View/Download PDF
Case Report
doi: 10.4103/jmsr.jmsr_27_17

Skin necrosis following ilizarov application in an adolescent with radial club hand

Abdulrahman D Algarni, Muhammad Asif, Saleh Alharby
 Department of Orthopedic Surgery, King Saud University, Riyadh, Saudi Arabia

Corresponding Author:
Abdulrahman D Algarni
Department of Orthopedic Surgery, King Saud University, Riyadh
Saudi Arabia
Received: 28-Sep-2017, Accepted: 11-Dec-2017
How to cite this article:
Algarni AD, Asif M, Alharby S. Skin necrosis following ilizarov application in an adolescent with radial club hand. J Musculoskelet Surg Res 2018;2:31-33
Copyright: (C)2018 Journal of Musculoskeletal Surgery and Research


Congenital radial club hand is a well-recognized congenital malformation of the upper extremity. It is characterized by radial deviation of the hand and shortening of the forearm. Soft-tissue distraction with an Ilizarov fixator followed by ulnar centralization in a staged approach for the Type IV radial club hand is well described in the literature. In this report, we describe a unique complication following Ilizarov application for soft-tissue distraction in a patient with Type IV radial club hand. A longitudinal skin necrosis appeared at the radial side of the forearm and hand that healed spontaneously after the cessation of distraction.
Keywords: Club hand, complication, Ilizarov, necrosis, skin


Congenital radial club hand or longitudinal radial deficiency is a well-recognized congenital malformation. It represents a “failure of formation of parts” anomaly of the upper extremity. It is a rare condition, occurring 1 in every 30,000–100,000 live births, with a slightly increased incidence in boys.[1] In 50% of the cases, it is bilateral and is frequently asymmetrical.[2] It is characterized by radial deviation of the hand along with significant shortening and bowing of the forearm. There is hypoplasia of bone and soft tissues including nerves and vasculature on the radial aspect of the forearm and hand. The thumb may be absent, and the ulna is typically 60% of the normal length.[2]

Conventionally, the radial club hand has been classified by Bayne and Klug according to the severity of one of the four types based on the length of radius present. Bayne and Klug Type IV, the most severe form, is clinically the most common type.[3]

The treatment of the radial club hand varies considerably with the extent of the deformity and the age of the patient.[1],[2] Several authors described the concept of gradual soft-tissue distraction with an Ilizarov fixator followed by ulnar centralization in a staged manner for Bayne and Klug Type IV radial club hand.[4],[5],[6],[7],[8],[9],[10],[11] In our report, we used the Ilizarov technique as a multistage procedure for soft-tissue stretching, centralization, and lengthening of the ulna. A thin longitudinal band-like painful ulceration-necrosis of the skin and the soft tissues appeared at the radial aspect of the forearm and the hand. To the best of our knowledge, this complication has never been reported before. We aim at presenting this rare complication encountered during the soft-tissue stretching in a case of Type IV radial club hand. The patient and the family gave an informed consent after we informed them that anonymous data and pictures concerning his case would be submitted for publication.

Case Report

An 11-year-old boy has the right club hand with completely absent radius and thumb (Bayne and Klug Type IV). On examination, the wrist was stiff, in slight flexion and radially deviated with a minimal motion from the resting position and a limited forearm pronation/supination from a neutral position. The hand-forearm angle was +76 as measured on the AP forearm radiograph according to the method described by Manske et al.,[12] where the angle is formed by a line drawn through the third metacarpal bone intersecting the distal ulna bisector line and reflects the amount of radial deviation, indicated as a positive number, or ulnar deviation, indicated as a negative number, of the hand [Figure - 1]a.

Figure 1: Plain radiographs of the right forearm and the hand showing (a) the preoperative radial club hand deformity (hand-forearm angle: +76°) and (b) immediate postoperative radiographs following application of Ilizarov fixator

Before surgery, the patient and his family were counseled regarding the commitment and stamina required to have this procedure. Ilizarov fixator was applied to the right forearm and hand to gain soft-tissue stretching and wrist centralization. The Ilizarov fixator consisted of two full rings. The transfixion wires were placed in the proximal ulna and distally in the metacarpals. The ring was fixed to the proximal ulna by two 1.5-mm Ilizarov smooth wires and two 3-mm olive wires. Distally, the ring was fixed to the metacarpals by one 1.5-mm Ilizarov smooth wires and two 3-mm olive wires in a radial to ulnar direction. The two rings were connected by two threaded rods with the hinge on the convex side at the level of the apex of the angular deformity [Figure - 1]b. No bony shortening or carpal resection was performed.

On the 2nd postoperative day, the distraction was started at the usual rate of 1 mm daily (quarter-turn four times). At the 5th postoperative day, we noticed a painful band-like necrosis of skin along the radial aspect of the forearm [Figure - 2]. Therefore, the distraction was halted for 2 weeks until the lesion spontaneously healed and then resumed at a slower pace (half-millimeter daily). Before discharge, the patient and his family were instructed to clean the wire sites daily with alcohol swabs, and any pin tract infection was treated accordingly. The patient was followed in the clinic at 2-week intervals, looking for clinical and radiological progress, and for any complication. The Ilizarov fixator was removed after 2 months, and the forearm was temporarily splinted for 3 months.

Figure 2: Clinical photograph showing the ulceration-necrosis at the radial side of the forearm and hand with Ilizarov fixator in situ at 5th postoperative day (white arrow)

At the most recent 3-year follow-up, the patient had a good hand function with no recurrence of the deformity and radiographs revealed a hand-forearm angle of +6° [Figure - 3].

Figure 3: Plain radiographs of the right forearm and hand at the most recent 3-year follow-up (hand-forearm angle: +6°)


The introduction of the Ilizarov method has allowed the possibility of gradual distraction with neohistogenesis. Initial reports have described, the use of the Ilizarov fixator for only ulnar lengthening in the radial club hand.[5],[6] Several authors later have described the use of the Ilizarov fixator for soft-tissue distraction preceding centralization of the ulna.[3],[4],[7],[8] The authors reported excellent results using the Ilizarov fixator in a staged approach for Bayne and Klug Type IV radial club hand. They cited significant correction of the deformity and better functional position of the hand while minimizing the overall complications.

Several soft-tissue procedures have been described for the treatment of the radial club hand. These include z-plasty, dorsal-rotation flap, Evans bilobed flap, and microvascular joint transfer.[13],[14],[15],[16],[17],[18],[19] Although these single-stage procedures subject the patient to a single operation, it is associated with a higher rate of ulnar growth plate injuries, radial neurovascular injuries, ulnar shortening, and wound complications.[2] In a late-presenting patient with severe deformity as in the presented case, an Ilizarov technique is more effective than a soft-tissue procedure.[10],[11]

Complications, including nocturnal pain, early or delayed consolidation, joint contracture or stiffness, nerve palsy, pin track infection, and skin inversion, have been reported in the literature using the Ilizarov technique.[20] In our patient, we noticed a unique complication in the form of a longitudinal necrotic band of skin at the radial aspect of the forearm and the hand. It appeared in the early phase of distraction and healed spontaneously when the distraction was paused. We do not know whether distraction at a slower pace from the outset could have been successfully prevented this complication. In our view, we propose that stretching of the severely contracted soft tissues, combined with reduced blood supply of the inherently underdeveloped vasculature on the hypoplastic radial side of the club hand have contributed to the pathogenesis of this lesion.

In conclusion, we recommend that distraction using Ilizarov fixator should be closely monitored and preferably carried out at a slow pace in Type IV congenital radial club hand.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

Author contributions

ADA edited the initial manuscript, wrote both the revised and the final manuscript and was the corresponding author, MA collected the data and wrote the initial manuscript, and the senior author SA provided the case material and supervised the whole work. All authors have critically reviewed and approved the final draft and are responsible for the content and similarity index of the manuscript.

Colen DL, Lin IC, Levin LS, Chang B. Radial longitudinal deficiency: Recent developments, controversies, and an evidence-based guide to treatment. J Hand Surg Am 2017;42:546-63.
[Google Scholar]
Vilkki SK. Management of congenital radial longitudinal deficiency: Controversies and current concepts – An important correction of the donor site. Plast Reconstr Surg 2014;134:328e-9e.
[Google Scholar]
Bayne LG, Klug MS. Long-term review of the surgical treatment of radial deficiencies. J Hand Surg Am 1987;12:169-79.
[Google Scholar]
Farr S, Petje G, Sadoghi P, Ganger R, Grill F, Girsch W, et al. Radiographic early to midterm results of distraction osteogenesis in radial longitudinal deficiency. J Hand Surg Am 2012;37:2313-9.
[Google Scholar]
Sabharwal S, Finuoli AL, Ghobadi F. Pre-centralization soft tissue distraction for bayne type IV congenital radial deficiency in children. J Pediatr Orthop 2005;25:377-81.
[Google Scholar]
Pickford MA, Scheker LR. Distraction lengthening of the ulna in radial club hand using the ilizarov technique. J Hand Surg Br 1998;23:186-91.
[Google Scholar]
Kawabata H, Shibata T, Masatomi T, Yasui N. Residual deformity in congenital radial club hands after previous centralisation of the wrist. Ulnar lengthening and correction by the ilizarov method. J Bone Joint Surg Br 1998;80:762-5.
[Google Scholar]
Nanchahal J, Tonkin MA. Pre-operative distraction lengthening for radial longitudinal deficiency. J Hand Surg Br 1996;21:103-7.
[Google Scholar]
Goldfarb CA, Murtha YM, Gordon JE, Manske PR. Soft-tissue distraction with a ring external fixator before centralization for radial longitudinal deficiency. J Hand Surg Am 2006;31:952-9.
[Google Scholar]
Taghinia AH, Al-Sheikh AA, Upton J. Preoperative soft-tissue distraction for radial longitudinal deficiency: An analysis of indications and outcomes. Plast Reconstr Surg 2007;120:1305-12.
[Google Scholar]
Kanojia RK, Sharma N, Kapoor SK. Preliminary soft tissue distraction using external fixator in radial club hand. J Hand Surg Eur Vol 2008;33:622-7.
[Google Scholar]
Manske PR, McCarroll HR Jr., Swanson K. Centralization of the radial club hand: An ulnar surgical approach. J Hand Surg Am 1981;6:423-33.
[Google Scholar]
Watson HK, Beebe RD, Cruz NI. A centralization procedure for radial clubhand. J Hand Surg Am 1984;9:541-7.
[Google Scholar]
VanHeest A. Wrist centralization using the dorsal rotation flap in radial longitudinal deficiency. Tech Hand Up Extrem Surg 2010;14:94-9.
[Google Scholar]
Evans DM, Gateley DR, Lewis JS. The use of a bilobed flap in the correction of radial club hand. J Hand Surg Br 1995;20:333-7.
[Google Scholar]
Vuillermin C, Wall L, Mills J, Wheeler L, Rose R, Ezaki M, et al. Soft tissue release and bilobed flap for severe radial longitudinal deficiency. J Hand Surg Am 2015;40:894-9.
[Google Scholar]
Qazi UA, Rehman Orakzai IU, Rashid M. The bilobed flap – A better option for soft tissue release in the management of radial club hand. J Pak Med Assoc 2017;67:698-700.
[Google Scholar]
Vilkki SK. Vascularized metatarsophalangeal joint transfer for radial hypoplasia. Semin Plast Surg 2008;22:195-212.
[Google Scholar]
de Jong JP, Moran SL, Vilkki SK. Changing paradigms in the treatment of radial club hand: Microvascular joint transfer for correction of radial deviation and preservation of long-term growth. Clin Orthop Surg 2012;4:36-44.
[Google Scholar]
Velazquez RJ, Bell DF, Armstrong PF, Babyn P, Tibshirani R. Complications of use of the ilizarov technique in the correction of limb deformities in children. J Bone Joint Surg Am 1993;75:1148-56.
[Google Scholar]

Fulltext Views

PDF downloads
Show Sections