A 50-year-old woman with dominant right hand, with a history of left distal radius fracture, went to the orthopedics clinic 5 weeks after she fell on the ground. When she was initially injured, she was told that she had a fracture of the distal radius, but she was not in a hurry to follow up because her professional demand was not high. At the first visit, there was no significant movement of the fracture site, and the patient was not interested in surgical intervention. Subsequently, she lost follow-up until 3 months after the injury. At that time, she reported a painless period after her last visit, followed by new left ulnar pain, which mainly occurred during pushing and pulling activities. Upon examination, the patient's radial tenderness was found to be minimal. On the ulnar side, there is significant tenderness in the extensor carpi ulnaris muscle. The range of motion test showed that the wrist extension was reduced by 20° compared with the contralateral side.

X-rays showed healing of the distal radius fracture, which was shortened by 3 mm compared to the contralateral side, the volar angle was 26°, and the radial inclination increased by 9° (Figures 1 and 2). Compared with the neutral ulnar variation of the uninjured wrist, the patient’s ulnar variation was 2 mm.

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After X-rays showed that the deformity of the distal radius had normal ulnar variation, the patient discussed surgical options, including distal radius osteotomy, ulnar shortening osteotomy, and distal ulna resection. The patient finally chose to undergo a distal radius osteotomy to correct the malunion. Five months after the injury, the patient underwent a volar opening wedge osteotomy of the left distal radius and internal fixation with a volar locking plate. At 6 weeks after the operation, she switched to a movable short arm wrist support and began to bear weight at 8 weeks after the operation. At the last follow-up 20 weeks after the operation, the patient was painless and non-tender, and recovered 50° wrist flexion and 50° wrist extension. X-rays showed bone healing, neutral tilt and radial tilt improved to 31° (Figure 3).

Distal radius fractures account for 3% of all upper limb fractures, and there are nearly 640,000 distal radius fractures in the United States each year. Malunion of the distal radius is associated with poor functional outcomes, leading to an increased incidence of surgical treatment of these injuries. Paul J. MacKenney, MD, FRCS (Tr & Orth) and his colleagues reported that nearly one-third of patients who received in situ cast fixation and two-thirds of patients who received closed reduction and cast treatment, if not transferred For surgical treatment. In addition, approximately 20% of patients undergoing non-surgical treatment experience dysfunction, which negatively affects their clinical results. Although the definition of malunion varies, Muhanned Ali, MD, and colleagues describe it as a dorsal angle greater than 10°, an orthoulnar deviation of 3 mm, and/or a radial tilt less than 15°.

Regardless of non-surgical treatment or surgical treatment, the malunion of the distal radius is a potential undesirable result. For all people who treat distal radius fractures, it is important to understand the management principles. Improper restoration of the direction of the articular surface before injury will cause the radius to shorten, which in turn leads to disorders of the radius and ulna, which leads to disruption of the biomechanics of the radioulnar joint. Specifically, ulnar wrist pain is common when the distal radius is deformed and may be due to triangular fibrocartilage injury, distal radioulnar joint (DRUJ) incoordination, or secondary ulnar impaction syndrome. A study by Andrew K. Palmer, MD, and colleagues showed that an increase of only 2.5 mm of the radius and ulna variance can increase the strength of the ulnar wrist joint by 42%.

A variety of surgical options can solve the problem of abnormal healing of the distal radius. For most patients, corrective radius osteotomy is the main treatment. However, depending on the degree of deformity healing and the functional requirements of the patient, ulnar shortening osteotomy and distal ulna resection are alternative options for the treatment of ulnar wrist pain.

If the articular surface is intact or the damage is minimal, the corrective distal radius osteotomy is the preferred method to treat most deformities of the distal radius. By restoring the anatomical parameters of the distal radius, secondary benefits include restoring DRUJ consistency, restoring carpal alignment, and reducing ulnar carpal impaction. Corrective osteotomy options include open and closed wedge osteotomies. Open wedge osteotomy has the advantage of restoring the radial length of the distal end. Open wedge osteotomy has traditionally adopted the use of bone grafts or bone graft substitutes, but this concept has been challenged by recent literature, which suggests that bone grafts are not necessary. In a study by Kagan Ozer, MD, and colleagues, there were no differences in the maintenance of radiation alignment, healing time, healing rate, or DASH score when comparing patients who received or did not receive a bone graft at the open time. Another option is a closed wedge osteotomy, which allows direct bone-to-bone contact. Because it shortens the already short radius, it usually requires an accompanying ulna shortening osteotomy.

For elderly patients with malunion of the distal radius and patients with lower functional requirements, it is an option to solve the symptomatic carpal ulnar side, which is associated with shorter operation time, fewer complications, and fewer hardware removals. The incidence and more reliable corrections are related to radioulnar variance. Distal ulna resection (Darrach surgery) involves the removal of the ulnar head and is associated with instability of the back and palm at the proximal end of the ulna and loss of grip. This is usually reserved for refractory cases or low-demand patients.

The patient in this case underwent a wedge osteotomy of the distal radius without a bone graft. At the follow-up, she showed signs of healing, the ulnar impaction syndrome was resolved, and her flexion and extension arc returned to 100°.

The main points are as follows:

Fracture of the distal radius is a common injury. If treated non-surgically, it may lead to malunion and cause severe disability;

Treatment of malunion of the distal radius includes different osteotomy options with or without bone grafting, but it is important to consider the 3D nature of this issue; and

The main treatment option should be radial osteotomy to restore the natural anatomy, but ulnar surgery may be suitable for a subgroup of patients.

Disclosure: Erdman is a committee member of the Orthopedic Trauma Association. Ghiassi owns Carbofix stock options and is a member of the editorial/management board of the Journal of Hand Surgery. The Nakata and Nicholson reports did not have relevant financial disclosures.

Editor's note: This article was updated on April 13, 2020 to correct the order of appearance of Figure 1 and Figure 3.

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