Distal Radius Malunions
Many Distal Radius Fractures heal in ‘suboptimal’ position, either because they were not surgically fixed or because the surgical fixation did not turn out well. When a Distal Radius Fracture heals in poor position it is called a ‘malunion’. Distal Radius Malunions can lead to deformity, pain, stiffness, weakness, and dysfunction, especially in active individuals. If the malunion includes a step-off of the joint surface, it usually leads to arthritis.
The choice is between accepting the poor wrist position for life or having the bone ‘re-broken’ and fixed (or re-fixed, as the case may be) in a better position. This is called an ‘osteotomy’. As with many other things, if an osteotomy is going to be performed, it is better to perform it early rather than late. Early on, the original fracture line may be visible and it may be possible to reopen up the original fracture, which allows the wrist bone to be put into a fully normal position, or close to it. Once the fracture has healed and remodeled, this is no longer possible, and only an approximation can be made. Performing the osteotomy early on is crucial if the malunion affects the joint surface, as surgery inside of a joint requires precision if the joint surface is to be aligned again.
Similar to a fresh Distal Radius Fracture, after the osteotomy is moved into better position, the bone fragments are fixed with a plate (please see the Distal Radius Fracture section for further description and an X-ray). In order to ‘fill in the gaps’ between the bone fragments created by the repositioning, bone graft is often needed for filler. Traditionally, bone graft was taken from the ‘hip’ (iliac crest), but it’s much less painful to take it from around the elbow. Bone taken from the patient’s body is much better for this purpose than bone taken from a cadaver, or synthetic bone, which are usually good enough for other procedures. Taking bone from around the elbow is not usually very painful, and rarely causes any problems.
After surgery, the wrist is immobilized for 1-2 weeks, depending primarily on the degree of osteoporosis. Then hand therapy is started to regain motion. A removable splint is then used as needed for another month.
Most patients who undergo osteotomy of a Distal Radius Fracture that has healed in poor position are extremely happy. This is a fairly common outpatient procedure, and should be considered for any active patient who is having problems from a Distal Radius Fracture that has healed in poor position.