CASE SERIES OF COMPLICATIONS ASSOCIATED WITH WRIST CENTRALIZATION IN RADIAL CLUBHAND.

...................................................................................................................... Introduction:Congenital longitudinal deficiency is divided into radial and ulnar deformities. Radial is more common than ulnar. Radial club hand is a congenital deformity of partial or complete absence of radius due to malformation of preaxial border of the upper limb. It is characterized by deviation of radius and short forearm. More than half of radial clubhand occur bilaterally, and the incidence is more in males.


ISSN: 2320-5407
Int. J. Adv. Res. 6(3), 1114-1117 1115 feet. Local examination of the upper limbs revealed he had bilateral good shoulder and normal contour and movement, but there was obvious bilateral shortening of the forearm and radial deviation of both wrists and bowing of ulna on both sides with complete absence of the thumb on both sides. Forearm x-ray showed revealed he had bilateral complete absence of radius and also bilateral complete absence of the thumb.
Patient was diagnosed with grade IV radial clubhand. The managment began immediately with stretching exercises and brace supplementation then centralisation of wrist after 1 year of age. 18 months later, centeralisation of the right ulnar bone with the right was done, and the patient tolerated the procedure without complication then he was put on slab postoperatively. Follow-up was 2 months after the date of discharge, and there was migration of K-wire that protroded from the distal part of the wrist. It came from metacarpal bone for which the K-wire was removed under aspetic technique in the clinic. Meanwhile, he was put in splinting because there was 30% of callus formation around the osteotomy part which was done during wrist centralisation. He was seen again in clinic after 8 months, and the follow-up x-ray revealed completely healed bone but the deformity recurred for which the parents were offerred to redo centralisation of the right wrist. Surgery was redone in October/2012, and he was put in above right elbow cast and bivalved. Patient was admitted on October/2017 for removal of k-wire of right hand and forearm due to the breakage of k-wire.

Case 2:-
15-year-old Saudi female a product of spontaneous delivery, full term birth weight was 2.5 kg. Patient was referred to king Faisal specialist research center from Asir central hospital she was diagnosed at birth with syndromic bilateral club hand. She had type 4 isolated radial club hand. Patient had no family history of same condition. All of her siblings were doing well. Past surgical history tracheoesophageal fistula repair. Patient was born with one kidney On examination generally she looked good, right upper limb showed shoulder muscle atrophy, but normal joint. Elbow range of motion between 10 to 110 degrees. Supination and pronation 0 and bowing of ulna and shortening. The wrist is subtle and the right thumb is absent.
This patient underwent external fixator application for traction at the right forearm on June 2006. She was discharged. After that patient underwent removal of external fixators and centralization of the right wrist on September/2007. Postoperatively patient was doing well no complications. She had a follow up after 6 weeks This procedure failed to reach full correction due to distal circulation compromise.
Patient had recurrent deformity because the k-wire was accidentally removed and the progress was lost. Patient was admitted on October/2007 for a redo of her right radial clubhand. She was doing well postoperatively Patient was put on full cast above the elbow at 90 degrees. Patient was admitted electively for k-wire removal of right hand on March/2010. Patient developed maluinon of the ulna bone and no further treatment was done for her.

Discussion:-
Radial clubhand is a congenital deformity of partial or complete absence of radius due to malformation of preaxial border of the upper the limb, and characterized by deviation of radius and short upperlimbs 12 . Half of radial clubhand occur bilaterally 3 . Radial clubhand is considered as the most common longitudinal malformation, although its is rare condition. It occures once in every 20,000 livebirths, and it is slightly more common in males 4 . The deformities can be either associated with multiple congenital defects or syndromes such as VACTREL, or sporadic and less commonly inherited 5 .
Radial clubhand deformity was classified by Bayne into four grades according to the radiological findings: grade I: short radius with the presence of the distal growth plate; grade II: hypoplastic radius with absence of the distal growth plate; grade III: partial absence of the radius, and the most severe grade IV: complete absence of the radius with abnormal ulnar curvature 6 .
Selection of treatment modality of radial clubhand is based on the severity of the deformity, and the age. For type I and II, which considered mild types, treatment modality bone lengthing with temporary external fixation of the wrist, or conservatively by splinting 7 .
Surgical correction by hand centralisation is the treatment of choice for radial clubhand in type III and IV 8 . It is usually done after 1 year of age, and delaying the intervention will make it more complex and challenging to correct 9 . Piror to surgery, muscle stretching is beneficial in correction of ulnar malalignment for successful centralisation, starting immediately after birth then splinting after maturity of the forearm, but conservative treatment is not helpful in late presentation or after two to three years of age 10 . Unfortunately, more than 45% of