Non-articular malunions of the distal radius: evaluation and techniques ofcorrection

Malunion remains the most common complication following fracture of the dis tal radius. Deformities can be observed in all three planes with displaceme nt in dorsal or palmar tilt, translation, shortening and axial rotation. Pr eoperative evaluation requires a comparative analysis with clinical, radiol ogical and scanographic assessment. The functional consequences affect the radiocarpal and distal radio-ulnar j oints and the carpus. Biomechanical aspects include changes in pressure for ces on the distal radius and ulna, and displacement of the centers of rotat ion. If present, associated lesions should be evaluated. The degree of clinical acceptance depends on each patient, but generally fu nctional outcome is closely correlated with the anatomic result. Limits of radiological acceptance should be defined at 20 degrees dorsal tilt, 5 degr ees radial inclination, and a - 4 mm distal radio-ulnar index. Corrective osteotomy is performed on the radius, with or without a compleme ntary ulnar procedure. Closing wedge and re-orientation osteotomies are no longer used. Opening wedge osteotomy with or without lengthening is preferr ed, generally with an access on the same side as the sagittal tilt. The ost eotomy should be performed just above the distal radio-ulnar joint. A tempo rary external fixator provides the best way to check peroperative correctio ns. Bone grafts may be harvested from the radius or the iliac crest. Pins a nd cast are sufficient to immobilize the dorsal tilt corrections. In case o f volar tilt, an internal plate fixation is best. Depending on the status of the distal radio-ulnar joint, a conservative (sh ortening osteotomy, wafer procedure) or non-conservative (Darrach-Moore, Ka pandji-Sauve...) procedure should be performed on the ulna. If needed, asso ciated lesions of the carpus must be treated. Surgical correction is mainly indicated in case of a functionally unaccepta ble deformation, but should be discussed if the radiographical limits have been overrun. The goal of such corrective procedures is to recover anatomic al restitution.