Corrective osteotomy of radius malunion

Indications

Pain or functional impairment in the setting of radiocarpal or distal radioulnar joint (DRUJ) malalignment
There are no fixed radiographic criteria for correction, although symptoms often present with radial inclination of less than 10 degrees, volar or dorsal tilt greater than 20 degrees, ulnar variance greater than or equal to 2 mm, and articular incongruity greater than 2 mm.

Correction of malunion is not indicated in patients with advanced degenerative arthritis, fixed carpal malalignment, and limited functional capabilities.
In patients with fixed malalignment or advanced arthritis, salvage procedures should be considered.
For those with limited functional capabilities, malalignment is often well tolerated because these patients rarely put a high level of stress across the radiocarpal joint. Thus no intervention is required.
Deformity without pain, loss of motion, and decreased grip strength are not indications for correction.

The upper extremity is examined for deformity, wrist function, forearm mobility, finger mobility, grip strength, and instability of the DRUJ and carpal ligaments.
This patient presents after nonoperative treatment of a distal radius fracture with pain and difficulty with wrist flexion, extension, and supination ( Fig. 33.1 ).
In the absence of major nerve dysfunction, early surgical intervention at 6 to 12 weeks postinjury can be performed through an incompletely ossified fracture callous. This can minimize the development of soft-tissue contracture and joint stiffness and limit the duration of impact on the patient.

Standard imaging (anteroposterior, lateral, oblique) of the wrist is performed.
Patients may present with a malunion after nonoperative treatment ( Fig. 33.2 ). In other circumstances, a patient may present after attempted operative fixation. This will require any internal hardware to be removed ( Fig. 33.3 ).
Computed tomography (CT) imaging can provide more information concerning articular incongruity. Many radiographic programs provide three-dimensional (3D) reconstruction of CT images ( Fig. 33.4 ).

Anatomy of the malunion determines the approach used to correct the malunion. A volarly tilted malunion or incongruity of the volar cortex is treated through a volar approach. Dorsally tilted malunions are treated through either a volar or dorsal approach. Complex intraarticular malunions may require approaches from both sides.
Impacted malunions which require more than 1 cm of radial lengthening will often need an ulnar shortening osteotomy. This can be performed simultaneously or delayed until the final radial length is established.
X-rays from the time of the initial injury can help delineate the original fracture pattern.
X-rays of the opposite uninjured wrist can provide an example of the preinjury anatomy.
An osteotomy line is planned at the site of the prior fracture line. The osteotomy is made parallel to the joint surface in the sagittal plane. An opening wedge osteotomy is created in most circumstances because of fracture impaction ( Fig. 33.5 ).

The goal of radial malunion surgery is to restore preinjury form. Radiographically, those goals are defined by the appropriate ulnar variance, radial height, radial inclination, and volar tilt ( Fig. 33.6A–D ).
Volarly, the surgeon is cognizant of the location of the radial artery and median nerve at all times.
Dorsally, the surgery is approached between the extensor pollicis longus (EPL) and extensor digitorum communis (EDC). Dorsal sensory branches and veins are protected and retracted away. The EPL is mobilized and the Lister tubercle is removed for better plate contact to the radius.
Corrective osteotomies of distal radius malunions can be done through either a dorsal or volar approach.

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