Corrective Osteotomy with Orthogonal Plating and Nonstructural Bone Grafting for Treatment of Distal Radius Fracture Malunion or Deformity

Introduction: Substandard treatment of distal radius fractures (DRF) often result in malunions, which can have significantly debilitating effects for patients, including pain and loss of motion. The purpose of this study is to describe our institution's experience with corrective osteotomy of DRF malunions and other DR deformities, in conjunction with orthogonal volar and radial plating and nonstructural bone grafting.

Methods: We retrospectively reviewed the charts of all patients who underwent corrective osteotomy of the distal radius by one senior, fellowship-trained hand surgeons (RWC) from 2007 through 2014 using orthogonal (“90/90”) plate fixation and nonstructural bone grafting. Demographic data, injury history, prior treatment(s), and clinical exam values were recorded. Bivariate statistical analysis with independent t-test was utilized for comparison of pre- and postoperative wrist and forearm range of motion and grip strength. Secondary outcomes of complications and/or need for revision surgery were also recorded.

Results: Thirty-seven wrists in 37 (24 female, 13 male) patients satisfied inclusion in this study. Average age of all patients included was 53.0 ± 12.3 years. Aside from two patients treated for Madelung deformity, all other patients had sustained a prior fracture, of which 15 had been operated on previously, and 20 were initially treated nonoperatively. Volar tilt was initially present in 8 patients (35.3° ± 17.3°), with the remainder of patients presenting with dorsal tilt (26.5° ± 12.3°). Twenty procedures were performed on the nondominant extremity. The mean interval from initial injury or prior intervention to surgery was 14.4 ± 24.6 months. All patients went on to heal the osteotomy. Significant improvement was seen in flexion/extension arc (86.6° ± 25.4° preoperatively versus 102.3° ± 24.9° postoperatively; p = 0.016) and grip strength measured by dynamometer (36.8 ± 27.6 preoperatively versus 57.7 ± 25.4 postoperatively; p = 0.005). No significant difference was observed between pre- and postoperative forearm rotation. Thirteen patients underwent a subsequent operation at mean 8.5 ± 9.7 months from the index 90/90 fixation procedure: five patients had one or both plates removed due to symptomatic hardware, four patients underwent ulnar shortening osteotomies for persistent ulnar-sided wrist pain, two patients had tenolysis for tendon adhesions, two had revision carpal tunnel releases, and two patients had irrigation and débridement with wound closure for persistent drainage, though no signs of overt infection were noted.

Conclusions: Orthogonal plating and nonstructural bone grafting performed in conjunction with corrective osteotomy of distal radius malunion or deformity is an effective treatment option and allows for improved motion and pain, with an acceptably low rate of complications.