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Treatment of the Extraarticular Malunited Distal Radius


Key Points

  • The relationship between malunion and functional outcome following distal radius fracture (DRF) is not well understood.

  • Some patients tolerate malunion well, whereas others have poor functional outcome.

  • Evidence evaluating operative and nonoperative treatment of extraarticular malunion is largely of low quality.

  • Distal radius osteotomy is likely to improve symptoms in carefully selected patients with a symptomatic malunion following DRF.

  • Complication rate and need for re-operation is considerable.

  • Careful consideration and adequate patient counseling should be carried out before deciding optimum treatment for a patient with extraarticular DRF malunion.

Panel 1: Case Scenario

A 67-year-old, fit and well woman slipped and fell onto her outstretched dominant right hand. Initial radiographs showed a distal radius fracture (DRF) with neutral angulation and slight shortening ( Fig. 1 ). This was treated in a plaster cast for 6 weeks with no further radiographs taken. After cast removal, the wrist was stiff, painful with an obvious dorsal deformity. After several months of hand therapy, the patient still described ongoing symptoms of pain, reduced grip strength, and was concerned about the appearance of the wrist. What would be the optimal management for this patient?

Fig. 1, Radiographs demonstrating an extraarticular distal radius fracture malunion with shortening and neutral angulation.

Importance of the Problem

DRFs are a very common injury and a huge burden on healthcare resources worldwide. Despite the frequency in which these injuries are encountered, there is still many unanswered questions regarding which fractures require intervention, optimum treatment methods, and long-term outcome. The evidence regarding fracture displacement and functional outcome after DRF is varied. Some studies have previously suggested only a small amount of displacement may lead to poor outcomes, whereas others have reported that significant displacement leads to minimal long-term functional problems. Increasing evidence has suggested that in older patients malunion is well tolerated.

Up to 24% of patients develop malunion following a conservatively treated DRF and 10% of those treated surgically. Unsatisfactory position in 58% of patients who underwent closed reduction of a displaced fracture has been reported, with 68% of those which were initially reduced satisfactorily subsequently displacing. Despite this, most patients make a satisfactory recovery with only a small number of patients suffering significant symptoms because of malunion. Which patients are most affected by malunion is not well understood. The commonest and most effective surgical intervention for a symptomatic malunion following a DRF is a distal radius osteotomy although the evidence base is limited. .

Main Question

Key Question: What is the most effective treatment (operative vs nonoperative) for extraarticular malunion in terms of short-term outcomes and long-term consequences?

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