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Distal Radius Malunion (and Corrective Osteotomy)

Symptomatic distal radius malunion: deformity patterns and DRUJ consequences, planning (CT/3D guides), opening/closing-wedge corrective osteotomy and outcomes.

84 citationsUpdated Oct 2026

For patients: a plain-language version of this topic is available. See the patient guide.

Overview

Surgical correction of distal radius malunion is a challenging problem with unpredictable clinical outcomes [8]. While outcomes are generally good, they are not nearly as satisfactory clinically as the treatment of distal radius fractures that do not have malunion [6]. Corrective osteotomy is an effective method to treat symptomatic malunions, including in children, and can result in good functional outcomes and high levels of patient satisfaction [2, 3]. Osteotomy of the distal radius in cases of malunion gives favorable outcomes [5]. Operative correction through the malunion has become a well-accepted reconstructive procedure for symptomatic malunited extra-articular fractures of the distal radius [16]. Distal radial osteotomy is a reliable technique for correction of the deformity at the distal end of the radius and carpal malalignment [24]. The radiological result correlates with the functional outcome for malunited fractures of the distal end of the radius treated with corrective osteotomy [7].

To obtain optimal clinical outcomes, distal radius osteotomy must correct the rotational component of the malunion [38]. Surgery on the ulna to restore distal radioulnar joint anatomy is needed in some cases of distal radius malunion [38]. An accompanying ulnar styloid nonunion in patients with distal radius malunion has no apparent adverse effect on outcome or function after corrective radial osteotomy [1]. The operative correction of a distal radius malunion following an unsuccessful internal fixation can be achieved with outcomes comparable to those reported after initial nonoperative treatment [9]. New technologies such as 3-dimensional modeling and computer-generated osteotomy guides are likely to have a positive impact on the outcomes of surgical treatment for distal radius malunion [8].

Corrective osteotomy with 90-90 plate fixation is an effective treatment option for improving pain and restoring function for both volarly and dorsally angulated malunions, including malunions with an intraarticular component [11]. A simplified technique of distraction corrective osteotomy after distal radius malunion results in improved clinical and radiographic outcomes for patients [4]. A new modification of corrective osteotomy for distal radius malunion minimizes the need for bone grafting and addresses the constraining aspect of the extensor retinaculum [23]. Minimally invasive osteotomy of the distal radius for extra-articular malunion is feasible with similar results to those of the literature, without the need for bone grafting or complex preoperative planning [33]. Mini-invasive distal radius osteotomy is a feasible technique for treating extra-articular malunions [54]. Non-spanning external fixation is a successful technique for stabilization of corrective osteotomy of the distal radius for malunion [15]. Intramedullary nail fixation has been used in the treatment of distal radius malunion corrective osteotomy in more than 10 cases at one institution [13]. Simultaneous radial closing wedge and ulnar shortening osteotomies are indicated for patients with osteopenia for whom opening wedge osteotomy of the radius is inadequate [51].

Anatomy & Pathophysiology

Normal Anatomy and Biomechanics

The distal radius articular surface is biconcave, featuring distinct scaphoid and lunate facets [80]. The distal radioulnar joint (DRUJ) articulates with the ulna at the sigmoid notch [80]. Lister's tubercle, a small dorsal prominence, serves as a landmark for the dorsal approach to the wrist and is a cause of attritional rupture of the extensor pollicis longus after distal radius fracture [80]. The distal radial metaphysis possesses thin cortex, rendering it vulnerable to bending forces [80]. Additionally, the brachioradialis insertion on the radial styloid acts as a deforming force on the distal radius [80]. In a normal wrist with neutral ulnar variance, the distal radius bears 80% of the axial load [80]. Normal radiographic parameters for the distal radius include an average radial inclination of 22 degrees, radial height of 11 to 12 mm, and volar tilt of 11 to 12 degrees [37].

The carpal architecture consists of a proximal row comprising the scaphoid, lunate, and triquetrum, which function as a key intercalated segment between the forearm and the distal carpal row [43]. The distal carpal row consists of the trapezium, trapezoid, capitate, and hamate [43]. Ligamentous stability is provided by extrinsic palmar radiocarpal ligaments, including the transverse carpal, radioscaphocapitate, radioscapholunate, radial collateral, long radiolunate, and short radiolunate ligaments [75]. The extrinsic ulnocarpal ligaments include the ulnotriquetral, ulnolunate, and ulnocapitate ligaments [75]. Intrinsic ligaments connect individual carpal bones to one another and include the scapholunate, lunotriquetral, scaphocapitate, and triquetrocapitate ligaments [75]. The flexor carpi ulnaris and extensor carpi ulnaris muscles serve as dynamic stabilizers of the distal radioulnar joint [93]. Radio-ulno-carpal joint stability relies on the proper function of eight different anatomical structures and is modified by the degree of forearm rotation [121]. The forearm functions as a triarticular complex where the proximal, middle, and distal radioulnar joints work together to provide stability, mobility, and load transfer [123].

Malunion Definition and Epidemiology

Malunion is a common complication after distal radius fractures, occurring in up to 46% of cases [19]. It occurs commonly in distal radius fractures, particularly in elderly patients managed nonoperatively [31]. A recent definition of distal radius malunion includes radial inclination <10 degrees, volar tilt >20 degrees or dorsal tilt >20 degrees, radial height <10 mm, ulnar variance >2+ mm, and intra-articular incongruity or diastasis >2 mm [31]. No formal classification system for distal radius malunion exists due to a lack of consensus regarding its definition [31]. Distal radius malunions are generally described by morphological characteristics as dorsally displaced, volarly displaced, or intra-articular [31].

Fracture characteristics and initial treatment contribute to the development of malunion, including failure to achieve or maintain accurate reduction or inadequate immobilization [37]. Malunion is more difficult to obtain and maintain in fractures with marked comminution, severe osteoporosis, or disruption of the distal radioulnar ligaments [37]. Older patients have a higher incidence of malunion, with a mean age of 60 years for patients with malunions compared to 51 years for those without [37]. Malunion remains a common cause of residual disability after distal radial fractures despite improvements in treatment since the early 1980s [37]. Not all distal radial malunions are symptomatic, especially in elderly patients with low functional demands [37].

Pathophysiology and Functional Consequences

Angulations of more than 20 degrees in either the palmar or dorsal directions, and radial inclination of less than 10 degrees, result in significant changes in load mechanics across the proximal wrist joint [19]. Malunion can result in functional deficits in the long term [19]. The purposes of radial osteotomy are to re-orientate the joint surface to achieve normal load distribution, re-establish the mechanical balance of the mid-carpal joint, and restore the anatomical relationships of the distal radioulnar joint [19]. Malunion of the distal radius or forearm fractures can result in incongruence in the distal radioulnar joint and subsequent cartilage damage [28]. Posttraumatic ulnar impaction syndrome usually occurs as a consequence of radial shortening, which is most frequently seen in malunited distal radius fractures [28].

Increased ulnar tilt of the distal end of the radius is considered a prearthrotic wrist deformity due to altered carpal kinematics and dynamic overload [64]. Radial shortening causes the greatest disturbance in kinematics and the most distortion of the triangular fibrocartilage [67]. Rotational malalignment of the wrist has significant effects on carpal, distal radial, and distal radioulnar joint measurements [69]. Significant changes in DRUJ joint area and ligament lengthening are found in distal radius malunion, despite insignificant changes in the pattern of radioulnar kinematics [101]. The contact area of the DRUJ increases during wrist flexion and decreases during wrist extension and ulnar deviation [96]. Changes in ulnar variance due to ulnar lengthening or radial shortening dramatically alter force transmission through the distal ulna [110]. Radial lengthening beyond native length is not detrimental to radial loading and further reduces distal ulnar loading [114]. Progressive ulnar shortening results in a decrease in distal ulnar loads with the generation of tensile loads [118].

The majority of hand placement and range of motion tasks can be accomplished with 70 percent of the maximal range of wrist motion [90]. Surgical correction of distal radius malunion rarely results in a normal wrist, with grip strength rarely exceeding 70% of the contralateral limb [31]. Wrist alignment is maintained over time following corrective osteotomy, but mild to moderate symptomatic wrist arthritis may develop [102].

Classification

No Formal System: No formal classification system for distal radius malunion exists [31]. This absence is likely due to a lack of consensus regarding the definition of a distal radius malunion [31]. Consequently, distal radius malunions are generally described by their morphological characteristics [31]. For simplicity of discussion, these malunions can be viewed as dorsally displaced, volarly displaced, or intra-articular [31]. Certain distal radius fractures have characteristics of more than one type of malunion [31].

Definitional Criteria: A recent article defines distal radius malunion using the following radiographic parameters: radial inclination <10 degrees [31], volar tilt >20 degrees or dorsal tilt >20 degrees [31], radial height <10 mm [31], ulnar variance >2+ mm [31], and intra-articular incongruity or diastasis >2 mm [31].

Other Considerations: The definition of malunion and its effect on functional outcome is debatable [31]. Most surgeons agree that treatment of malunion should focus on the symptomatic patient and not on radiographic appearance [31]. Some authors have argued that in cases of intra-articular malunion, early treatment may be warranted before there is evidence of degeneration [31]. None of the classification systems for distal radius fractures is ideal [137].

Dorsal Displacement: The most common type of symptomatic malunion encountered is that of the dorsally displaced distal radius malunion [31]. These malunions are often significantly dorsally angulated as well as shortened with respect to the radial shaft [31]. In dorsally displaced distal radius malunions, the distal radioulnar joint is often incongruous [31].

Volar Displacement: Malunion in flexion of the distal radius is rare [147]. In distal radius malunion in flexion, radial shortening does not contribute significantly to the deformity [147]. Palmar flexion exists without significant shortening in distal radius malunion in flexion [147]. There is always a decrease in the range of motion, especially prono-supination, in distal radius malunion in flexion [147]. Volar carpal subluxation relative to the radius is present in less than 1/3 of cases of distal radius malunion in flexion [147]. Adaptive carpus is very rare and independent of the volar displacement in distal radius malunion in flexion [147]. Pronation of the distal fragment results in distal radioulnar joint incongruity in distal radius malunion in flexion [147].

Clinical Presentation

Epidemiology and Risk Factors

Malunion remains a common cause of residual disability following distal radial fractures, often resulting from failure to achieve or maintain accurate reduction or from inadequate duration or type of immobilization [37]. Reduction is most difficult to obtain and maintain in fractures characterized by marked comminution, severe osteoporosis, or disruption of the distal radioulnar ligaments [37]. Older patients exhibit a higher incidence of malunion than younger patients, with a mean age of 60 years for patients with malunions compared to 51 years for those without [37]. Forearm malunions may occur following either non-operative or operative treatment of acute fractures, as well as following deformity correction surgery [26].

Radiographic Parameters and Deformity

Radiographic measurement of alignment in an intact distal radius shows an average of 22 to 23 degrees of radial inclination, 11 to 12 mm of radial height, 11 to 12 degrees of volar tilt, and ± 2 mm of ulnar variance [37]. Malunions of the distal radius may be associated with extraarticular deformities, intraarticular malalignment, distal radioulnar joint incongruity or instability, or a combination of these features [37]. Extraarticular deformities include shortening and excessive dorsal or volar tilt of the distal radial articular surface [37].

Parameters likely associated with a poor functional outcome include intraarticular incongruity in the radiocarpal joint of more than 2 mm, a 1- to 2-mm step-off at the distal radioulnar joint, dorsal angulation of more than 20 degrees and radial inclination of less than 10 degrees, and the loss of sagittal tilt of 20 to 30 degrees [37]. Angulations of more than 20° in either the palmar or dorsal directions, and radial inclination of less than 10° resulted in significant changes in the load mechanics across the proximal wrist joint [19]. Fractures with more than 25 or 30 degrees of angulation in the frontal or sagittal plane or 6 mm or more of radial shortening were likely to become symptomatic [37]. Significant articular incongruity and radial shortening are more consistently correlated with the development of symptoms than are other measurements [37].

Specific deformity thresholds impact joint mechanics and function. More than 10 degrees of dorsal tilt leads to decreased wrist flexion [37]. Patients with constitutional joint laxity may develop midcarpal instability with a dorsal tilt of only 10 to 15 degrees [37]. Twenty to 30 degrees of dorsal tilt altered the force distribution across the radiocarpal joint and should be considered a prearthritic condition [37]. Six mm of radial shortening causes dysfunction of the distal radioulnar joint [37]. Malunion of distal radius or forearm fractures (angular and/or length discrepancy) can result in incongruence in the distal radioulnar joint and subsequent cartilage damage [28]. Significant changes to distal radioulnar joint mechanics as well as ligament lengthening with malunion of the distal radius may contribute to the dysfunction associated with these injuries [37].

Loss of normal anterior tilt following a distal radial fracture can lead to carpal malalignment, resulting in dorsiflexion of the lunate with compensatory flexion of the capitate [127]. Capitate shift is defined as the displacement of the capitate either dorsal or anterior to the longitudinal axis of the radius [127]. Capitate shift consistently demonstrated the strongest relationship with dorsal tilt and was the only parameter that was not influenced by age or the position of the wrist [127].

Clinical Symptoms and Functional Impact

Not all distal radial malunions are symptomatic, especially malunions in elderly patients with low functional demands [37]. Conversely, posttraumatic wrist deformities in younger, active patients may be sufficiently disabling to warrant surgical correction [37]. Malunion was found to be associated with higher arm-related disability regardless of age [37]. Malunion of a distal radial fracture can lead to impaired hand and wrist function [127], and carpal malalignment has a significant impact on functional outcomes [127].

Some malunited radius fractures that appear shortened may have just healed in malrotation [21]. Despite moderate deformities seen on plain radiographs, some patients may report deceptively severe symptoms and can benefit enormously from derotational osteotomy [21]. Ulnar impaction syndrome is characterised by ulnar-sided wrist pain increased by rotational or ulnar deviation loading and a long ulna relative to the radius [28]. Positive ulnar variance can be a permanent congenital condition or occur as dynamic relative radial shortening with pronation and forceful grip [28]. Posttraumatic ulnar impaction syndrome usually occurs as the consequence of radial shortening which in adults is most frequently seen in malunited distal radius fractures [28].

Symptomatic distal radioulnar joint incongruity and/or residual ulnocarpal abutment represent the most-likely reason for an unsatisfactory outcome after a corrective osteotomy is performed [42]. The surgical decision for corrective osteotomy is based on limitation of joint motion, grip strength, level of pain, degree of cosmetic deformity, together with radiographic findings including pre-arthritic deformity, carpal malalignment and an incongruent distal radioulnar joint [19].

Investigations

Radiographic Assessment and Measurements

Plain radiography: Standard evaluation of the distal radius requires posteroanterior (PA), lateral, and oblique views [106]. A true lateral view is mandatory to assess distal radioulnar joint alignment, defined by the pisiform overlying the volar third of the scaphoid [47]. Measurements must be taken on a true lateral view with the radius and ulna superimposed to avoid errors from forearm rotation; a 5-degree rotational change in the forearm results in a 1.6-degree change in volar tilt on the lateral radiographic view [106].

Normal radiographic parameters include an average radial height of 11 to 12 mm (normal range 8–18 mm) [106], average radial inclination of 22 to 23 degrees (normal range 12–30 degrees) [106], and average volar tilt of 11 to 22 degrees (normal range 0 to 28 degrees) [106]. Ulnar variance is defined as the vertical distance between lines drawn perpendicular to the long axis of the radius, one parallel to the medial corner of the radial articular surface and the other parallel to the most distal aspect of the ulnar head articular surface [106]. Carpal malalignment is assessed by drawing a line down the long axis of the capitate and a separate line down the long axis of the radius, which should overlap or intersect within the carpus in normal alignment [106]. The teardrop angle is measured on the lateral view as the angle between the radial shaft and the central axis of the teardrop, averaging 70 degrees in normal radii; a teardrop angle less than 45 degrees is associated with articular gap and step-off on CT [106]. Anteroposterior (AP) distance is measured on the lateral view as the distance between the apices of the dorsal and volar rims of the lunate facet [106].

Specific views include the dorsal tangential view, obtained by flexing the wrist with the forearm tangential to the C-arm beam to assess for dorsal cortical screw penetration [106], and the radial incline view, taken on the lateral view with the C-arm adjusted to match radial inclination to provide a view of the articular surface of the radius [106]. Radiographic parameters associated with distal radioulnar joint injury include fracture of the base of the ulnar styloid, widening of the distal radioulnar joint on AP wrist radiograph, dislocation of the ulna relative to the radius on a true lateral wrist radiograph, and more than 5 mm of radial shortening relative to the ulna [47]. Radial shaft fracture line obliquity greater than 30 degrees is a statistically significant predictor of distal radioulnar joint instability [47]. Clinicians should assess deterioration in fracture alignment on radiographic follow-up to identify potential need for surgery to avoid malunion in cases showing early secondary displacement [165].

Advanced Imaging and 3D Modeling

CT: CT scans are used for preoperative planning of intraarticular fractures [45]. CT is useful in the diagnosis of suspected carpal fractures and assessment of union [88]. Malunited diaphyseal fractures of both forearm bones showed complex deformities, suggesting that 3-dimensional modeling may be a more effective method than standard computed tomography or radiographs [163].

MRI: MRI is used to rule out injuries to carpal ligaments, such as lunotriquetral and scapholunate ligaments, or to the triangular fibrocartilage complex [45]. MRI is useful in detecting suspected fractures and avascular necrosis of the carpus [88].

3D Modeling: 3D imaging is useful in reconstructive procedures for malunions and nonunions [88]. Measurements made on both plain radiographs and 3-dimensional computer bone models are accurate for evaluating the deformity in extraarticular distal radius malunions [60]. Computer-assisted 3D preoperative planning of corrective osteotomy for extra-articular distal radius malunion provides satisfactory clinical and radiological results with minimal residual malalignment [152]. The severity of the initial fracture and time taken from injury to corrective osteotomy correlate with the ability to correct radiographic parameters in dorsally angulated malunions of the distal radius [22].

Clinical Examination and Diagnostic Tests

Clinical Examination: The most constant and dependable sign of carpal injury is well-localized tenderness [103]. Tenderness in the anatomical snuffbox is indicative of scaphoid injury [103]. Tenderness distal to Lister's tubercle is indicative of scapholunate and lunate injury [103]. Tenderness at the dorsal margin, fingerbreadth distal to the ulnar head, is indicative of triquetal, lunotriquetral ligament, and triquetrohamate ligament injury [103].

Special Tests: The scaphoid shift test involves pressure applied over the scaphoid tubercle while moving the wrist from radial to ulnar deviation, with a positive result indicated by a "clunk" as the scaphoid subluxates dorsally [103]. The midcarpal shift test involves pressure applied over the dorsum of the capitate while moving the wrist from radial to ulnar deviation, with a positive result indicated by a "clunk" as the lunate reduces from the palmarflexed position [103]. The lunotriquetral ballottement test involves fixing the lunate and displacing the triquetrum palmarly and dorsally, with a positive result indicated by pain [103]. The lunotriquetral shear test involves dorsally directed pressure to the pisiform and palmarly directed pressure to the lunate, with a positive result indicated by reproducing the patient's pain along with palpable crepitation or clicking [103].

Other Considerations: Live/video fluoroscopic evaluation of the wrist provides diagnostic clarity for dynamic instability with sensitivities reported between 86% and 95% and specificity between 80% and 97% for diagnosing scapholunate ligament injury [88]. Ultrasound scanning provides an additional tool for the detection and visualization of carpal ligaments [88]. Critical analysis of radiographic and clinical information allows for a systematic approach to the evaluation and treatment of the distal radioulnar joint in cases of distal radius malunion [29].

Treatment

Non-Operative

The provided evidence does not detail specific conservative management protocols such as weight loss, physical therapy, NSAIDs, or injections. However, operative indications are predicated on the presence of symptoms rather than radiographic appearance alone [31].

Operative

Indications: Treatment of distal radius malunion prioritizes the symptomatic patient over radiographic appearance [31]. Corrective osteotomy is indicated for clinically determined symptomatic malunion to restore normal radiocarpal and distal radioulnar relationships [31]. In the elderly population, operative indications are based on symptomatology because radiographic outcomes do not consistently correlate with functional or subjective metrics [31]. Malunions in elderly patients are often well tolerated functionally and do not justify osteotomy [140]. Conversely, early corrective osteotomies should be considered in young patients with intra-articular distal radius malunions before considering salvage procedures such as partial or complete wrist arthrodesis [41]. In cases of intra-articular malunion, early treatment may be warranted before there is evidence of degeneration [31]. Malunion can result in decreased grip strength, limitations in range of motion, pain, and cosmetic deformity which is unacceptable to patients [31].

Surgical Approach / Technique: Corrective osteotomy of the distal radius to reconstruct the natural anatomy is the foundation of treatment [18]. The type of osteotomy selected depends on surgeon preference, experience, and the unique deformity of the distal radius, such as excessive volar or dorsal angulation, loss of radial length or inclination, or intraarticular displacement [18]. Corrective osteotomies can be performed via either a dorsal or palmar approach [25]. A successful corrective osteotomy for the treatment of complex intra- and extra-articular distal radius malunions can improve wrist function [20].

Implant Selection: Corrective osteotomy with 90-90 plate fixation is an effective treatment option for improving pain and restoring function for both volarly and dorsally angulated malunions, including those with an intraarticular component [11]. Corrective osteotomy and fixed-angle volar plate fixation provide satisfactory union rates and clinical and radiological outcomes even without bone graft, irrespective of the osteotomy type, size, or location [35].

Alignment / Balancing Strategy: To obtain optimal clinical outcomes, distal radius osteotomy must correct the rotational component of the malunion [38]. In severe malunions with marked radial shortening where length restoration is impossible, corrective osteotomy can be performed to correct sagittal plane deformity while an ulnar shortening osteotomy is performed to achieve congruency of the distal radioulnar joint [31].

Adjuncts: Surgery on the ulna to restore DRUJ anatomy is needed in some cases to obtain optimal clinical outcomes [38]. Ulna shortening osteotomy has proven efficacy in ulnar impaction syndrome with 96% of patients considering themselves cured or improved [12]. The main hallmark of the ulnar shortening osteotomy technique using a sliding-hole plate is that there is no need to remove the plate to create the osteotomy, which avoids possible complications of malalignment and malangulation [151].

Other Considerations: The timing of operative intervention for symptomatic malunion remains controversial due to insufficient evidence comparing "early" (before full healing) versus "late" (following consolidation) corrective osteotomy [31]. Recent data support intervention as early as 6 weeks, resulting in a technically less challenging case and a shorter overall period of patient disability [31]. A simplified technique of distraction corrective osteotomy after distal radius malunion results in improved clinical and radiographic outcomes [4]. Minimally invasive osteotomy of the distal radius for extra-articular malunion is feasible with similar results to the literature, without the need for bone grafting or complex preoperative planning [33]. A less invasive technique for a dorsal single-cut open-wedge osteotomy can correct an extrarticular rotational malunion of the distal radius [19]. Corrective osteotomy with callus filling at the fracture site for malunion after distal radius fracture is a rare technique that achieved a favorable postoperative outcome [34].

Outcomes and Limitations: Corrective osteotomy is an effective method of treating symptomatic distal radius malunions with good long-term functional results, measured with the DASH and PRWE score, and improvement in radiographic parameters and pain scores [30]. Surgical correction of distal radius malunion is a challenging problem with unpredictable clinical outcomes, but new technologies such as 3-dimensional modeling and computer-generated osteotomy guides are likely to have a positive impact on the outcomes of surgical treatment [8]. Operative treatment of inadequately or imperfectly treated fractures of the distal radius can improve wrist and hand function substantially, but rarely restores the limb to normal [32]. Surgical procedures designed to correct malunions of the distal radius rarely result in a normal wrist [31]. In comparison to the contralateral limb, deficits are often still appreciated after corrective osteotomy, particularly with respect to range of motion and grip strength, which rarely exceeds 70% of the contralateral limb [31].

Complications

Overall Complication Burden: A complication rate of nearly 50% was observed in distal radius osteotomies [141]. The outcomes of distal radius malunion treatment are not nearly as satisfactory clinically as the treatment of distal radius fractures that do not have malunion [6].

Hardware and Fixation Risks: Surgeons should be fully aware of the increased risks when using dorsal plate fixation after corrective osteotomy for dorsally angulated distal radial malunions [63]. One in 3 patients will undergo a reoperation after ulna shortening osteotomy, most often due to hardware irritation or nonunion of osteotomy [148].

Functional Deficits: Deficits in range of motion and grip strength are often still appreciated after corrective osteotomy, with grip strength rarely exceeding 70% of the contralateral limb [31]. In cases of marked radial shortening, it is often impossible to restore length [31].

Arthritis and Long-term Sequelae: It remains unknown whether the more accurate correction that can be achieved with a drilling guide might potentially reduce development of arthritis, a sequel that has been described to have a high prevalence after conventional corrective osteotomy [27].

Other Considerations: The results of operative correction of a distal radius malunion following an unsuccessful internal fixation can be achieved with outcomes comparable to those reported after initial nonoperative treatment [9].

Recovery

Light activity (weeks): The provided evidence does not specify a typical week range for the resumption of desk work, driving, or light activities of daily living following corrective osteotomy or ulnar shortening.

Full activity (months): The evidence does not define a specific month range for the return to manual work, sport, or full range of motion and strength.

Complete recovery / outcome plateau (months): The evidence does not establish a specific month range for the stabilization of pain, strength, and final functional outcomes.

Rehabilitation protocol: The provided evidence does not detail specific physical therapy phasing, immobilisation duration, weight-bearing or range-of-motion progression schedules, or timing for sling and brace removal.

Functional milestones: Validated patient-reported outcome trajectories and specific benchmark scores are not detailed in the evidence. However, intermediate-term outcomes for 3-dimensional-guided corrective osteotomies of intra-articular malunions demonstrated excellent patient-reported outcomes [171]. Multiple-level osteotomies of the radius and ulna with rigid internal fixation resulted in near-normal forearm rotation at 12-month follow-up [172].

Other Considerations: Corrective osteotomy with 90-90 plate fixation is an effective treatment for improving pain and restoring function in both volarly and dorsally angulated malunions, including those with an intraarticular component [11]. Good clinical results observed 10 years after radial shortening osteotomy are likely to remain stable at 20 years [14]. A critical analysis of radiographic and clinical information allows for a systematic approach to evaluating and treating the distal radioulnar joint (DRUJ) in cases of distal radius malunion [29]. Minimally invasive osteotomy for extra-articular malunion is feasible and yields results similar to the literature without the need for bone grafting or complex preoperative planning [33]. In adults with malunited forearm fractures, corrective osteotomy leads to better function and improved range of motion, with good outcomes achievable even with a long delay between injury and surgery [39]. Ulnar shortening osteotomy with a dorsally placed plate for ulnar impaction syndrome yields similar postoperative functional scores and complications compared with other plate placements [40]. Double bone forearm osteotomy in adolescence provides long-lasting functional improvement and long-term correction of distal radioulnar and radiocarpal subluxations [52]. In a series of 81 distal radius fractures, 20 per cent had unsatisfactory results, and damage to the ulnar collateral mechanism adversely affects clinical results despite a good anatomical result [56]. Ulnar shortening osteotomy achieved excellent long-term results in most cases [59]. Intra-articular malunions are time-sensitive, as delaying treatment for more than 3 months can result in irreversible cartilage damage [167]. The results of early and late reconstruction of malunited distal radius fractures are comparable [168]. The author reports difficulty with delayed union following transverse osteotomy of the ulna and fixation with a 3.5 mm dynamic compression plate [169]. Delayed-onset ulnar neuropathy at the wrist can occur 12 to 30 years after conservatively treated distal radius fractures with malunion and DRUJ arthritis [170]. Intermediate-term outcomes of 3-dimensional-guided corrective osteotomies for distal radius intra-articular malunions showed no clinically relevant progression of osteoarthritis [171]. Radial shortening osteotomy provides decade-long improvement in 75% of patients and seems to be a reasonable treatment for symptomatic Kienböck’s disease [166].

Key Evidence

• [L3] An accompanying ulnar styloid nonunion in patients with distal radius malunion has no apparent adverse effect on outcome or function after corrective radial osteotomy. [1] (10.1016/j.jhsa.2012.12.006)
• [L4] Corrective osteotomy is an effective method to treat symptomatic malunions of the distal radius in children with good functional outcomes. [2] (10.1055/s-0039-3402082)
• [L3] Corrective osteotomy for malunion of the distal radius can result in good functional outcomes and high levels of patient satisfaction. [3] (10.1302/0301-620x.102b11.bjj-2020-0848.r3)
• [L4] This simplified technique of distraction corrective osteotomy after distal radius malunion results in improved clinical and radiographic outcomes for patients. [4] (10.1055/s-0041-1726293)
• [L4] Osteotomy of the distal radius in cases of malunion gives favorable outcomes. [5] (10.1016/s1297-3203(03)00028-3)
• [L5] The outcomes of distal radius malunion treatment have generally been good but are not nearly as satisfactory clinically as the treatment of distal radius fractures that do not have malunion. [6] (10.1097/00130911-200012000-00002)
• [L3] The study demonstrates that the radiological result correlates with the functional outcome for malunited fractures of the distal end of the radius treated with corrective osteotomy. [7] (10.1054/jhsb.2001.0693)
• [L5] Surgical correction of distal radius malunion is a challenging problem with unpredictable clinical outcomes, but new technologies such as 3-dimensional modeling and computer-generated osteotomy guides are likely to have a positive impact on the outcomes of surgical treatment. [8] (10.1016/j.jhsa.2020.02.008)
• [L4] The results of this study suggest that the operative correction of a distal radius malunion following an unsuccessful internal fixation can be achieved with outcomes comparable to those reported after initial nonoperative treatment. [9] (10.1007/s00402-013-1779-5)
• [L4] For patients with symptomatic malunion of the distal radius, corrective osteotomy with 90-90 plate fixation is an effective treatment option for improving pain and restoring function for both volarly and dorsally angulated malunions, including malunions with an intraarticular component. [11] (10.1016/j.jhsa.2016.10.012)
• [L4] Ulna shortening osteotomy has proven efficacy in ulnar impaction syndrome with 96% of patients considering themselves cured or improved. [12] (10.1016/j.otsr.2021.102970)
• [L4] At our institution, we have used this intramedullary nail fixation in the treatment of distal radius malunion corrective osteotomy in more than 10 cases. [13] (10.1097/bth.0b013e318187bb45)
• [L4] Good clinical results observed in patients 10 years after radial shortening osteotomy are likely to remain stable at 20 years after surgery. [14] (10.1016/j.jhsa.2025.04.018)
• [L2] It is also a successful technique for stabilization of corrective osteotomy of the distal radius for malunion. [15] (10.1016/j.hcl.2005.04.006)
• [L5] Operative correction through the malunion has become a well-accepted reconstructive procedure for symptomatic malunited extra-articular fractures of the distal radius. [16] (10.1097/01.bth.0000126572.28568.88)
• [L5] [18] (10.5435/00124635-200701000-00004)
• [L4] [19] (10.1177/1753193414551910)
• [L4] A successful corrective osteotomy for the treatment of complex intra- and extra-articular distal radius malunions can improve wrist function. [20] (10.1016/j.jhsa.2012.07.013)
• [L4] [21] (10.1177/1753193408097324)
• [L4] The severity of the initial fracture and time taken from injury to corrective osteotomy correlate with the ability to correct radiographic parameters in dorsally angulated malunions of the distal radius. [22] (10.1016/j.jhsg.2023.06.008)
• [L5] The new modification of corrective osteotomy for distal radius malunion minimizes the need for bone grafting and addresses the constraining aspect of the extensor retinaculum. [23] (10.1097/01.bth.0000231582.78147.6f)
• [L3] Distal radial osteotomy is a reliable technique for correction of the deformity at the distal end of the radius and carpal malalignment. [24] (10.1055/s-0034-1384823)
• [L3] Corrective osteotomies of distal radius malunions can be done in either way. [25] (10.1055/s-0032-1326725)
• [L4] [26] (10.1007/s11552-014-9635-9)
• [L3] [27] (10.1177/1753193411433227)
• [L4] [28] (10.1007/bf00434545)
• [L5] Critical analysis of radiographic and clinical information allows for a systematic approach to the evaluation and treatment of the DRUJ in cases of distal radius malunion. [29] (10.1016/s0749-0712(21)00161-x)
• [L3] Corrective osteotomy is an effective method of treating symptomatic distal radius malunions with good long-term functional results, measured with the DASH and PRWE score, and improvement in radiographic parameters and pain scores. [30] (10.1016/j.injury.2017.01.045)
• [L4] Operative treatment of inadequately or imperfectly treated fractures of the distal radius can improve wrist and hand function substantially, but rarely restores the limb to normal. [32] (10.1097/01.blo.0000152442.66083.ff)
• [L4] The short series confirms the feasibility of minimally invasive osteotomy of the distal radius for extra-articular malunion with similar results to those of the literature, without the need for bone grafting or complex preoperative planning. [33] (10.1016/j.otsr.2015.07.016)
• [L5] Corrective osteotomy with callus filling at the fracture site for malunion after distal radius fracture is a rare technique, but it achieved a favorable postoperative outcome. [34] (10.1142/s2424835518720323)
• [L4] Corrective osteotomy and fixed-angle volar plate fixation for distal radius malunion provide satisfactory union rates and clinical and radiological outcomes even without bone graft, irrespective of the osteotomy type, size, or location. [35] (10.1016/j.jhsg.2024.09.001)
• [L4] To obtain optimal clinical outcomes, distal radius osteotomy must correct the rotational component of the malunion, and surgery on the ulna to restore DRUJ anatomy is needed in some cases. [38] (10.1016/j.otsr.2015.12.010)
• [L4] Corrective osteotomy in adults with malunited forearm fractures leads to better function and improvement in range of motion, with good outcomes achievable even with a long delay between injury and surgery. [39] (10.1177/1753193410380585)
• [L4] Similar postoperative functional scores and complications were seen in patients undergoing an ulnar shortening osteotomy with a dorsally placed plate for ulnar impaction syndrome, compared with other plate placement localizations. [40] (10.1055/s-0037-1608636)
• [L4] Early corrective osteotomies should be considered in young patients with intra-articular distal radius malunions before considering salvage procedures such as partial or complete wrist arthrodesis. [41] (10.1177/1558944718793972)
• [L4] Symptomatic distal radioulnar joint incongruity and/or residual ulnocarpal abutment represent the most-likely reason for an unsatisfactory outcome after a corrective osteotomy is performed. [42] (10.1097/00130911-200203000-00006)
• [L4] Our procedure is indicated for patients with osteopenia for whom opening wedge osteotomy of the radius is inadequate. [51] (10.1016/j.jhsa.2003.12.001)
• [L4] Double bone forearm osteotomy in adolescence brought long-lasting functional improvement and provided long-term correction of distal radioulnar and radiocarpal subluxations. [52] (10.1054/jhsb.1999.0304)
• [L4] This short series validates the feasibility of mini-invasive distal radius osteotomy for treating extra-articular malunions. [54] (10.1016/j.hansur.2017.10.191)
• [L4] [56] (10.1016/s0020-1383(75)80004-0)
• [L4] Ulnar shortening osteotomy achieved excellent long-term results in most cases. [59] (10.1016/j.jhsa.2012.09.011)
• [L4] Despite small differences, measurements made on both plain radiographs and 3-dimensional computer bone models are accurate for evaluating the deformity in extraarticular distal radius malunions. [60] (10.1016/j.jhsa.2020.03.009)
• [L1] Surgeons should be fully aware of the increased risks when using dorsal plate fixation after corrective osteotomy for dorsally angulated distal radial malunions. [63] (10.1177/17531934241254962)
• [L4] The condition is considered a prearthrotic wrist deformity due to altered carpal kinematics and dynamic overload. [64] (10.1053/jhsu.2001.26033)
• [L5] Radial shortening caused the greatest disturbance in kinematics and the most distortion of the triangular fibrocartilage. [67] (10.1016/0363-5023(93)90098-n)
• [L4] Rotational malalignment of the wrist has significant effects on carpal, distal radial and distal radioulnar joint measurements. [69] (10.1177/1753193408090393)
• [L4] The majority of the hand placement and range of motion tasks that were studied in this project could be accomplished with 70 percent of the maximal range of wrist motion. [90] (10.1016/0363-5023(91)90006-w)
• [L4] The flexor carpi ulnaris and extensor carpi ulnaris muscles serve as dynamic stabilizers of the distal radioulnar joint. [93] (10.1177/17531934231168299)
• [L4] The contact area of the DRUJ increases during wrist flexion and decreases during wrist extension and ulnar deviation. [96] (10.1016/j.jhsa.2015.07.027)
• [L4] Despite previous findings of insignificant changes in the pattern of radioulnar kinematics, significant changes in DRUJ joint area and ligament lengthening were found. [101] (10.1002/jor.20322)
• [L4] Wrist alignment was maintained over time but 13 patients presented mild to moderate symptomatic wrist arthritis. [102] (10.1177/1753193409357373)
• [L5] Changes in ulnar variance of a forearm due to ulnar lengthening or radial shortening do, however, dramatically alter the force transmission. [110] (10.1016/0363-5023(92)90342-m)
• [L5] Radial lengthening beyond the native length was not detrimental to radial loading and further reduced distal ulnar loading; achieving at least native ulnar variance seems to be appropriate to restore normal biomechanical loading based on this in vitro study. [114] (10.1016/j.jhsa.2019.03.017)
• [L5] A progressive decrease in distal ulnar loads with generation of tensile loads was observed with sequential ulnar shortening. [118] (10.1016/j.jhsa.2019.04.007)
• [L5] The radio-ulno-carpal joint (RUCJ) is a complex multifactorial phenomenon where stability rests on the proper function of eight different anatomical structures and is modified by the degree of forearm rotation, rather than relying solely on the TFCC. [121] (10.1177/17531934211042316)
• [L5] The conventional concept of the forearm as part of either the elbow or wrist is outdated; a more relevant concept describes the forearm as a triarticular complex where the proximal, middle, and distal radioulnar joints work together to provide stability, mobility, and load transfer. [123] (10.1177/1753193410396976)
• [L4] [127] (10.1177/17531934231159786)
• [L5] None of the classification systems for distal radius fractures is ideal. [137] (10.1016/j.hansur.2016.02.012)
• [L5] Recent studies show that malunions in elderly patients are well tolerated functionally and do not justify osteotomy. [140] (10.1016/j.hansur.2016.03.013)
• [L4] A complication rate of nearly 50% was observed in distal radius osteotomies. [141] (10.1016/j.jhsa.2018.12.013)
• [L4] [147] (10.1016/j.main.2005.10.002)
• [L3] One in 3 patients will undergo a reoperation after ulna shortening osteotomy, most often due to hardware irritation or nonunion of osteotomy. [148] (10.1177/1558944719828004)
• [L3] The main hallmark of the technique is that there is no need to remove the plate to create the osteotomy, which avoids possible complications of malalignment and malangulation. [151] (10.1097/00130911-200309000-00004)
• [L3] This procedure provides satisfactory clinical and radiological results with minimal residual malalignment. [152] (10.1016/j.hansur.2020.02.009)
• [L4] Malunited diaphyseal fractures of both forearm bones showed complex deformities, which suggests that 3-dimensional modeling may be a more effective method than standard computed tomography or radiographs. [163] (10.1016/j.jhsa.2013.03.052)
• [L3] Clinicians should assess deterioration in fracture alignment on radiographic follow-up and be aware of the potential need for surgery to avoid malunion in cases showing early secondary displacement. [165] (10.1177/17531934221146063)
• [L4] Radial shortening osteotomy provides decade-long improvement in 75% of patients and seems to be a reasonable treatment for symptomatic Kienböck’s disease. [166] (10.1177/1753193413512222)
• [L5] Intra-articular malunions of the distal radius are time sensitive, as delaying treatment for more than 3 months can result in irreversible cartilage damage. [167] (10.1016/j.hcl.2017.07.004)
• [L3] The results of early and late reconstruction of malunited fractures of the distal end of the radius are comparable. [168] (10.2106/00004623-199605000-00014)
• [L5] The author reports difficulty with delayed union following transverse osteotomy of the ulna and fixation with a 3.5 mm dynamic compression plate. [169] (10.1016/0363-5023(93)90070-j)
• [L4] Delayed-onset ulnar neuropathy at the wrist can occur 12 to 30 years after conservatively treated distal radius fractures with malunion and DRUJ arthritis. [170] (10.1016/j.jhsa.2009.11.005)
• [L4] The intermediate-term outcome of 3-dimensional-guided corrective osteotomies for distal radius intra-articular malunions showed excellent patient-reported outcomes and no clinically relevant progression of osteoarthritis. [171] (10.1016/j.jhsa.2021.07.018)
• [L4] Multiple-level osteotomies of the radius and ulna with rigid internal fixation allowed early range of motion and resulted in near-normal forearm rotation at 12-month followup. [172] (10.1097/blo.0b013e31805c7405)

See Also

• Distal Radius Fracture
• Scapholunate Ligament Injury

References

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