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Diagnosing the Malunited Distal Radius


Key Points

  • The diagnosis of a malunited distal radius fracture (DRF) must take into account both clinical symptoms and radiographic findings

  • Standard radiographs of both the affected and contralateral wrist are usually sufficient to diagnose distal radius malunions, but CT scans can provide additional information for complex deformities

Panel 1: Case Scenario

A 72-year-old, right hand dominant, retired male presents to your office with chronic left wrist pain and decreased range of motion after conservative management of a distal radius fracture 10 years prior. Radiographs show a “malunited, impacted, intraarticular fracture of the left distal radius with dorsal tilt and decreased height and inclination of the distal radial articular surface ( Fig. 1 ).” How would you proceed with your evaluation in order to identify a symptomatic malunion of his prior distal radius fracture?

Fig. 1, (A–C) AP, lateral, and oblique radiographs of the left (affected) and right (normal) wrist demonstrating a malunited, impacted, intraarticular fracture of the left distal radius with dorsal tilt and decreased height and inclination of the distal radial articular surface. Scapholunate widening with DISI deformity. Moderate radioscaphoid narrowing and scattered moderate degenerative arthritis.

Importance of the Problem

Distal radius fractures (DRFs) are among the most common fractures managed by trauma surgeons, accounting for approximately 17% of all fractures managed in an orthopedic trauma unit. Malunion is fairly common following a DRF, with reported malunion rates of 23.6% and 10.6% after closed reduction with casting and surgical management, respectively. Patients with symptomatic malunion after a DRF demonstrate persistent disability at 1 year, 2 years, and 12–14 years after fracture treatment. Malunited DRFs alter the biomechanics of the distal radioulnar joint (DRUJ) as well as the radiocarpal, ulnocarpal, and midcarpal articulations, which may accelerate degenerative changes and produce pain as well as functional impairment. Carefully planned corrective osteotomies can significantly improve the radiographic and functional outcomes in these patients, and, therefore, it is paramount to recognize and appropriately diagnose this condition.

Main Question

For all patients who have sustained DRFs, how is a symptomatic malalignment of the radius most accurately diagnosed, both clinically and radiologically?

Current Opinion

The diagnosis of symptomatic distal radius malunion requires both clinical symptoms in addition to radiographic abnormalities. While plain radiographs are sufficient to diagnosis most distal radius malunions, computed tomography (CT) scans are extremely useful to diagnose rotational malunions as well as aid in surgical planning of the corrective osteotomies.

Finding the Evidence

We provide below a list of search algorithms used to construct this chapter:

  • Cochrane search: “distal radius”

  • PUBMED (clinical queries: systematic reviews): “distal radius”

  • PUBMED (Medline): “distal radius” AND “malunion”

  • Bibliography review of the selected articles

  • Articles that were not in the English were excluded.

  • Articles involving anything other than human subjects were excluded.

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