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Treatment of the Intraarticular Malunited Distal Radius


Key Points

  • Intraarticular malunion following distal radius fracture (DRF) leads to radiographic arthritis, but the effect on functional outcome is not well understood.

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

  • Some small, retrospective case series suggest osteotomy will improve outcome after intraarticular DRF malunion.

  • Surgery is challenging with high complication rate and need for re-operation.

  • There is insufficient evidence to establish whether osteotomy for intraarticular malunion prevents the development of arthritis.

Panel 1: Case Scenario

A 42-year-old, fit and well man was involved in a high-speed road traffic accident. He required an extended ICU admission and surgery for intraabdominal injuries. Following a good recovery from these injuries and discharge to a general surgical ward, he described pain in his dominant left wrist. Radiographs were obtained 3 weeks after his initial injury and these demonstrated a distal radius fracture with dorsal angulation and a depressed and rotated lunate fossa fragment with a 2 mm intraarticular step ( Fig. 1 ). What would be the optimal management for this patient?

Fig. 1, Radiographs demonstrating an intra and extra articular distal radius fracture malunion with loss of dorsal angulation and a depressed, rotated lunate fossa fragment.

Importance of the Problem

Persistent articular incongruity of the distal radius after fracture healing is known to lead to early degenerative changes of the radiocarpal joint. Cadaveric experiments have shown that an articular step affects the biomechanics of the joint with a step of 1 mm causing a significant increase in contact stresses. Despite the evidence that articular incongruity leads to radiologically proven arthritis, the correlation with symptoms and poor outcome is debatable. Studies by Trumble et al. and Chung et al. showed that residual articular displacement was associated with a poorer outcome. Others have shown minimal long term functional impairment.

Intraarticular malunion can be measured as a step and/or gap. Step is thought to be the most important parameter to affect functional outcome and many surgeons would recommend intervention for a step of 2 mm or more in younger patients. Correcting intraarticular malunion is challenging and involves the risk of rare but disastrous complications such as nonunion or avascular necrosis. Complexity of surgery is compounded by associated extra-articular malunion.

Main Question

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

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