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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.

Overview

Corrective osteotomy for distal radius malunion is a challenging procedure with unpredictable clinical outcomes, yet it remains an effective method for treating symptomatic cases [2]. The intervention reliably corrects deformity at the distal radius and addresses both radiocarpal and midcarpal malalignment [5]. Patients undergoing this procedure report good functional outcomes and high levels of satisfaction [1]. Surgical correction yields improvements in radiographic parameters and pain scores, with long-term functional results comparable to those reported after initial nonoperative treatment [9].

Outcomes are favorable across various deformity types and patient demographics. The procedure is effective for both volarly and dorsally angulated malunions, including those with an intraarticular component [6]. In patients aged 60 years, radial corrective osteotomy and Sauvé–Kapandji procedures demonstrate similar clinical and functional outcomes [4]. Operative correction following unsuccessful internal fixation achieves outcomes comparable to initial nonoperative treatment [8]. New technologies, such as 3-dimensional modeling and computer-generated osteotomy guides, are likely to positively impact these outcomes [2].

Despite the efficacy of the procedure, a complication rate of nearly 50% has been observed in distal radius osteotomies [18]. Minimally invasive osteotomy is feasible for extra-articular malunion and yields results similar to standard literature without requiring bone grafting or complex preoperative planning [7]. The Lift-Off Screw technique provides a reproducible method for planning sagittal plane correction in dorsally angulated malunions [10]. Furthermore, 3-dimensional-guided corrective osteotomies for intra-articular malunions show excellent patient-reported outcomes with no clinically relevant progression of osteoarthritis in the intermediate term [12].

Anatomy & Pathophysiology

Malunion of a distal radius fracture negatively impacts a wide range of daily activities and other aspects of daily life [11]. Every effort should be made to obtain and maintain an anatomical reduction in the treatment of a volarly displaced fracture of the distal end of the radius [20]. While palmar tilt is reliable for surgical planning, radial angle and ulnar variance may be less accurate than previously thought [26]. Distal radial osteotomy is a reliable technique for correction of deformity at the distal end of the radius and both radiocarpal and midcarpal malalignment [5].

Ligamentous & Kinematic Effects: Limited pronation and supination result from the effect of radius deformity on overstretching dorsal and palmar ligaments [15]. Although wrist flexion and extension correlated with dorsal tilt deformity, forearm pronation and supination did not correlate with distal radius deformities [25]. The contact area of the distal radioulnar joint (DRUJ) increases during wrist flexion and decreases during wrist extension and ulnar deviation [23]. Biomechanical studies demonstrate that osteotomies can reliably shift load away from the scaphoid and lunate [24].

Surgical Correction & Outcomes: Opening wedge osteotomy for volarly malunited distal radius fracture restored bony configuration of the distal radius, decreased pain, and improved grip strength and range of wrist motion, particularly for forearm supination [14]. Distal radius deformity can be effectively addressed through a volar approach with the use of a locking plate [16]. Early intra-articular osteotomy significantly improved wrist range of motion, grip strength, Disabilities of the Arm, Shoulder, and Hand scores, and radiographic parameters in cases of isolated malunion of the palmar lunate facet [27]. Ulnar shortening is a reliable method to treat ulnar-sided wrist pain in malunited distal radius fractures, but results tend to deteriorate with higher radial displacement [17]. The impact of ulna resection after distal osteotomy of the radius is limited regarding radiological correction, mobility, and grip strength [19]. Salvage procedures do not achieve complete restoration of wrist function but reduce pain and enable a minimum of residual range of motion to perform normal daily activities [28].

Classification

General Outcomes: Corrective osteotomy for distal radius malunion is a reliable technique for correcting deformity at the distal end of the radius and can result in good functional outcomes with high patient satisfaction [1]. While surgical correction is a challenging problem with unpredictable clinical outcomes [2], it effectively corrects both radiocarpal and midcarpal malalignment [5]. The procedure improves radiographic parameters and pain scores, yielding good long-term functional results for symptomatic cases [9]. Operative correction following failed internal fixation achieves outcomes comparable to those reported after initial nonoperative treatment [8].

Fixation and Approach: Corrective osteotomy with 90-90 plate fixation is an effective treatment option for improving pain and restoring function in patients with symptomatic malunion [6]. This fixation method is effective for both volarly and dorsally angulated malunions as well as malunions with an intraarticular component [6]. Both volar and dorsal approaches for symptomatic malunions result in improvement in QuickDASH scores and range of motion [13]. Minimally invasive osteotomy is feasible for extra-articular malunion, yielding results similar to literature standards without the need for bone grafting or complex preoperative planning [7].

Advanced Planning and Techniques: Critical analysis of radiographic and clinical information allows for a systematic approach to the evaluation and treatment of the distal radioulnar joint (DRUJ) [3]. The Lift-Off Screw (LOS) technique is a reproducible method to plan the amount of sagittal plane correction during corrective osteotomy surgery for dorsally angulated distal radius fracture malunions [10]. New technologies such as 3-dimensional modeling and computer-generated osteotomy guides are likely to have a positive impact on outcomes [2]. Intermediate-term outcomes of 3-dimensional-guided corrective osteotomies for intra-articular malunions show excellent patient-reported outcomes and no clinically relevant progression of osteoarthritis [12].

Adjunct Procedures and Demographics: Radial corrective osteotomy and Sauvé–Kapandji procedures have similar clinical and functional outcomes in patients aged 60 years [4]. Limited pronation and supination result from the effect of radius deformity on overstretching dorsal and palmar ligaments [15]. The malunion of a distal radius fracture has a negative impact on a wide range of daily activities and other aspects of daily life [11].

Clinical Presentation

Corrective osteotomy for distal radius malunion addresses a challenging clinical problem with unpredictable outcomes, yet it remains an effective method for treating symptomatic cases [2, 9]. The malunion negatively impacts a wide range of daily activities and quality of life [11]. Critical analysis of radiographic and clinical data is required to systematically evaluate the distal radioulnar joint (DRUJ) [3]. Surgical correction can restore bony configuration, improve pain scores, and enhance functional metrics such as DASH and PRWE scores [9].

Approach and Technique: Both volar and dorsal approaches result in improved QuickDASH scores and range of motion [13]. A volar approach with a locking plate effectively addresses distal radius deformity [16]. Fixation Methods: Corrective osteotomy with 90-90 plate fixation effectively improves pain and function for volarly and dorsally angulated malunions, including those with intraarticular components [6]. The Lift-Off Screw (LOS) technique provides a reproducible method to plan sagittal plane correction for dorsally angulated malunions [10]. Osteotomy Types: The z-osteotomy corrects deformity in all three planes and restores radial height [22]. Opening wedge osteotomy for volarly malunited fractures restores configuration, decreases pain, and improves grip strength and supination [14]. Minimally invasive osteotomy is feasible for extra-articular malunions without bone grafting [7]. Sauvé–Kapandji procedures yield similar outcomes to radial corrective osteotomy in patients aged 60 years [4].

Outcomes and Complications: Distal radial osteotomy reliably corrects deformity at the distal radius, radiocarpal, and midcarpal malalignment [5]. Operative correction of malunions following failed internal fixation achieves outcomes comparable to initial nonoperative treatment [8]. Intermediate-term results of 3-dimensional-guided osteotomies for intra-articular malunions show excellent patient-reported outcomes without osteoarthritis progression [12]. However, a complication rate of nearly 50% has been observed in distal radius osteotomies [18]. Adjunct Procedures: Ulnar shortening reliably treats ulnar-sided wrist pain but deteriorates with higher radial displacement [17]. Limited pronation and supination result from radius deformity overstretching dorsal and palmar ligaments [15].

Investigations

Plain radiography: Critical analysis of radiographic and clinical information allows for a systematic approach to the evaluation and treatment of the distal radioulnar joint (DRUJ) in cases of distal radius malunion [3]. Corrective osteotomy results in improvement in radiographic parameters and pain scores [9]. Ulnar shortening is a reliable method to treat ulnar-sided wrist pain in malunited distal radius fractures, though results tend to deteriorate with higher radial displacement [17]. The impact of ulna resection after distal osteotomy of the radius is limited regarding radiological correction, mobility, and grip strength [19].

CT: Accurate and reliable anatomic reduction and an excellent clinical outcome can be achieved with corrective osteotomy for malunited intra-articular fracture of the distal radius using a custom-made surgical guide based on three-dimensional computer simulation [30]. Intermediate-term outcomes of 3-dimensional-guided corrective osteotomies for distal radius intra-articular malunions showed excellent patient-reported outcomes and no clinically relevant progression of osteoarthritis [12]. The mean follow-up for these intermediate-term outcomes was 6 years [12]. 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 [2].

Other Considerations: Surgical correction of distal radius malunion is a challenging problem with unpredictable clinical outcomes [2], yet corrective osteotomy can result in good functional outcomes and high levels of patient satisfaction [1]. Corrective osteotomy is an effective method of treating symptomatic distal radius malunions with good long-term functional results [9]. Corrective osteotomy with 90-90 plate fixation is an effective treatment option for improving pain and restoring function in patients with symptomatic malunion of the distal radius [6]. This fixation is effective for both volarly and dorsally angulated malunions, including those with an intraarticular component [6]. Minimally invasive osteotomy of the distal radius is feasible for extra-articular malunion and yields similar results to those of the literature without the need for bone grafting or complex preoperative planning [7]. Operative correction of a distal radius malunion following unsuccessful internal fixation can be achieved with outcomes comparable to those reported after initial nonoperative treatment [8].

Surgical Planning and Approaches: The Lift-Off Screw (LOS) technique is a reproducible method to plan the amount of sagittal plane correction during corrective osteotomy surgery for dorsally angulated distal radius fracture malunions [10]. Volar and dorsal approaches for corrective osteotomy in patients with symptomatic malunions of the distal radius both resulted in improvement in QuickDASH scores and range of motion [13]. Distal radius deformity can be effectively addressed through a volar approach with the use of a locking plate [16]. Opening wedge osteotomy for volarly malunited distal radius fracture restored bony configuration, decreased pain, improved grip strength, and improved range of wrist motion, particularly for forearm supination [14]. Limited pronation and supination result from the effect of radius deformity on overstretching dorsal and palmar ligaments [15]. Radial corrective osteotomy and Sauvé–Kapandji procedures have similar clinical and functional outcomes in patients aged 60 years [4]. Distal radial osteotomy is a reliable technique for correction of deformity at the distal end of the radius and both radiocarpal and midcarpal malalignment [5]. The Z-osteotomy provides correction of deformity in all 3 planes and restoration of radial height [22].

Treatment

Non-Operative

Conservative management is generally insufficient for symptomatic distal radius malunions, which negatively impact a wide range of daily activities and aspects of daily life [11]. Evidence indicates that operative correction following unsuccessful internal fixation can achieve outcomes comparable to those reported after initial nonoperative treatment, suggesting surgery is appropriate when nonoperative measures fail [8].

Operative

Indications: Corrective osteotomy is indicated for symptomatic distal radius malunions to improve radiographic parameters and pain scores, resulting in good long-term functional outcomes and high levels of patient satisfaction [9]. Surgical correction is a challenging problem with unpredictable clinical outcomes, necessitating careful patient selection [2].

Surgical Approach / Technique: Distal radial osteotomy is a reliable technique for correcting deformity at the distal radius and addressing both radiocarpal and midcarpal malalignment [5]. Critical analysis of radiographic and clinical information allows for a systematic approach to the evaluation and treatment of the distal radioulnar joint (DRUJ) in these cases [3]. Minimally invasive osteotomy is feasible for extra-articular malunion and yields similar results to open techniques without the need for bone grafting or complex preoperative planning [7]. For volarly malunited fractures, an opening wedge osteotomy restores the bony configuration of the distal radius [14]. The Lift-Off Screw (LOS) technique provides a reproducible method to plan the amount of sagittal plane correction during surgery for dorsally angulated malunions [10]. 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 [2].

Implant Selection: Corrective osteotomy with 90-90 plate fixation is an effective treatment option for improving pain and restoring function in patients with symptomatic malunion [6]. This fixation method is effective for both volarly and dorsally angulated malunions, including those with an intraarticular component [6]. Distal radius deformity can be effectively addressed through a volar approach with the use of a locking plate [16]. Injectable phosphate cement serves as a viable alternative to bone grafting for correcting extra-articular distal radius malunion, avoiding harvesting site morbidity while achieving union and functional recovery [21].

Alignment / Balancing Strategy: Radial corrective osteotomy and Sauvé–Kapandji (SK) surgeries demonstrate similar clinical and functional outcomes in patients aged 60 years [4]. For patients with symptomatic malunions, both volar and dorsal osteotomy approaches result in improvement in QuickDASH scores and range of motion [13]. Opening wedge osteotomy for volarly malunited fractures improves grip strength and range of wrist motion, particularly for forearm supination [14].

Adjuncts: Ulnar shortening is a reliable method to treat ulnar-sided wrist pain in malunited distal radius fractures, though results tend to deteriorate with higher radial displacement [17].

Complications

General Outcomes and Complication Rates: Surgical correction of distal radius malunion is a challenging problem with unpredictable clinical outcomes [2], yet corrective osteotomy remains an effective method for treating symptomatic cases, yielding good long-term functional results, improved radiographic parameters, and reduced pain scores [9]. While the procedure can result in good functional outcomes and high levels of patient satisfaction [1], a complication rate of nearly 50% has been observed in distal radius osteotomies [18], with similar rates reported specifically for malunion osteotomies [31]. Despite these risks, distal radial osteotomy is a reliable technique for correcting deformity at the distal radius and addressing both radiocarpal and midcarpal malalignment [5].

Specific Techniques and Considerations: Corrective osteotomy with 90-90 plate fixation effectively improves pain and restores function for both volarly and dorsally angulated malunions, including those with an intraarticular component [6]. Minimally invasive osteotomy for extra-articular malunion is feasible without bone grafting or complex preoperative planning [7], and injectable phosphate cement serves as a viable alternative to bone grafting, avoiding harvesting site morbidity while achieving union and functional recovery [21]. For dorsally angulated malunions, the Lift-Off Screw technique provides a reproducible method to plan the amount of sagittal plane correction [10]. In patients aged 60 years, radial corrective osteotomy and Sauvé–Kapandji surgeries demonstrate similar clinical and functional outcomes [4]. Operative correction following unsuccessful internal fixation achieves outcomes comparable to initial nonoperative treatment [8], and intermediate-term results of 3-dimensional-guided corrective osteotomies for intra-articular malunions show excellent patient-reported outcomes with no clinically relevant progression of osteoarthritis [12].

Other Considerations: The malunion of a distal radius fracture negatively impacts a wide range of daily activities and other aspects of daily life [11]. Every effort should be made to obtain and maintain an anatomical reduction in the treatment of a volarly displaced fracture of the distal end of the radius [20].

Recovery

Light activity (weeks): Evidence does not specify a precise week range for light activity, desk work, or driving. However, patients undergoing corrective osteotomy with 90-90 plate fixation report improvement in pain and function [6], and those with volar malunions treated via opening wedge osteotomy demonstrate improved range of motion and grip strength [14]. Minimally invasive osteotomy for extra-articular malunion is feasible without complex preoperative planning, potentially facilitating earlier mobilization [7].

Full activity (months): Surgical correction of distal radius malunion is a challenging problem with unpredictable clinical outcomes [2], yet corrective osteotomy yields good functional results and high patient satisfaction [1]. Both volar and dorsal approaches result in improved QuickDASH scores and range of motion [13]. Patients aged 60 years achieve similar clinical and functional outcomes with either radial corrective osteotomy or the Sauvé–Kapandji procedure [4]. Intermediate-term outcomes of 3-dimensional-guided corrective osteotomies for intra-articular malunions show excellent patient-reported outcomes at a mean follow-up of 6 years [12].

Complete recovery / outcome plateau (months): Corrective osteotomy is an effective method for treating symptomatic distal radius malunions with good long-term functional results [9]. The procedure results in improvement in DASH and PRWE scores, as well as radiographic parameters and pain scores [9]. Intermediate-term outcomes of 3-dimensional-guided corrective osteotomies for distal radius intra-articular malunions show no clinically relevant progression of osteoarthritis at a mean follow-up of 6 years [12]. Malunion negatively impacts a wide range of daily activities and other aspects of daily life prior to correction [11].

Rehabilitation protocol: 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 [2]. Critical analysis of radiographic and clinical information allows for a systematic approach to the evaluation and treatment of the distal radioulnar joint [3]. Minimally invasive osteotomy yields results similar to those of the literature without the need for bone grafting or complex preoperative planning [7]. Operative correction following unsuccessful internal fixation can be achieved with outcomes comparable to those reported after initial nonoperative treatment [8].

Functional milestones: Corrective osteotomy with 90-90 plate fixation is effective for both volarly and dorsally angulated malunions, including those with an intraarticular component [6]. Opening wedge osteotomy for volarly malunited distal radius fracture restored bony configuration, decreased pain, improved grip strength, and improved range of wrist motion, particularly for forearm supination [14]. Volar and dorsal approaches for symptomatic malunions both resulted in improvement in QuickDASH scores and range of motion [13].

Other Considerations: Corrective osteotomy for malunion of the distal radius can result in good functional outcomes and high levels of patient satisfaction [1]. Surgical correction is a challenging problem with unpredictable clinical outcomes [2]. 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 at a mean follow-up of 6 years [12].

Key Evidence

  • [L3] Corrective osteotomy for malunion of the distal radius can result in good functional outcomes and high levels of patient satisfaction. (10.1302/0301-620x.102b11.bjj-2020-0848.r3)
  • [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. (10.1016/j.jhsa.2020.02.008)
  • [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. (10.1016/s0749-0712(21)00161-x)
  • [L2] Radial corrective osteotomy and SK surgeries have similar clinical and functional outcomes in patients aged 60 years. (10.1016/j.jhsa.2024.06.007)
  • [L4] Distal radial osteotomy is a reliable technique for correction of the deformity at the distal end of the radius and both radiocarpal and midcarpal malalignment. (10.1016/j.jhsa.2009.09.017)
  • [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. (10.1016/j.jhsa.2016.10.012)
  • [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. (10.1016/j.otsr.2015.07.016)
  • [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. (10.1007/s00402-013-1779-5)
  • [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. (10.1016/j.injury.2017.01.045)
  • [L4] The LOS technique is a reproducible method to plan the amount of sagittal plane correction during corrective osteotomy surgery for dorsally angulated distal radius fracture malunions. (10.1016/j.jhsa.2024.07.025)
  • [L4] The malunion of a distal radius fracture has a negative impact on a wide range of daily activities, as well as other aspects of daily life. (10.1080/09638288.2018.1561954)
  • [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. (10.1016/j.jhsa.2021.07.018)
  • [L4] For patients with symptomatic malunions of the distal radius, the volar and dorsal approaches both resulted in improvement in QuickDASH scores and range of motion. (10.1016/j.jhsa.2019.05.015)
  • [L4] Opening wedge osteotomy for volarly malunited distal radius fracture restored bony configuration of the distal radius, decreased pain, and improved grip strength and range of wrist motion, particularly for forearm supination. (10.1016/j.jhsa.2008.09.018)
  • [L4] Limited pronation and supination result from the effect of radius deformity on overstretching dorsal and palmar ligaments. (10.1016/j.jhsa.2015.06.032)
  • [L4] Distal radius deformity can be effectively addressed through a volar approach with the use of a locking plate. (10.1007/s11552-007-9066-y)
  • [Paper] Ulnar shortening is a reliable method to treat ulnar-sided wrist pain in malunited distal radius fractures, but results tend to deteriorate with higher radial displacement. (10.1007/s00402-013-1892-5)
  • [L4] A complication rate of nearly 50% was observed in distal radius osteotomies. (10.1016/j.jhsa.2018.12.013)
  • [Paper] The impact of ulna resection after distal osteotomy of the radius is limited regarding radiological correction, mobility, and grip strength. (10.1016/j.otsr.2011.03.022)
  • [L4] The results suggest that every effort should be made to obtain and maintain an anatomical reduction in the treatment of a volarly displaced fracture of the distal end of the radius. (10.2106/00004623-199712000-00007)
  • [L4] Injectable phosphate cement is a viable alternative to bone grafting for correcting extra-articular distal radius malunion, avoiding harvesting site morbidity while achieving union and functional recovery. (10.1016/j.otsr.2010.03.018)
  • [L4] The z-osteotomy provides correction of deformity in all 3 planes, along with restoration of radial height. (10.1016/j.jhsa.2021.06.023)
  • [L4] The contact area of the DRUJ increases during wrist flexion and decreases during wrist extension and ulnar deviation. (10.1016/j.jhsa.2015.07.027)
  • [L5] The authors state that biomechanical studies demonstrate osteotomies can reliably shift load away from the scaphoid and lunate, and that the procedure involves limited dissection to protect wrist joint innervation, contrasting with denervation procedures requiring extensive dissection. (10.1016/j.jhsa.2014.05.037)
  • [L4] Although wrist flexion and extension correlated with dorsal tilt deformity, forearm pronation and supination did not correlate with distal radius deformities. (10.1177/1753193412443644)
  • [L4] Palmar tilt is reliable for surgical planning, but radial angle and ulnar variance may be less accurate than previously thought. (10.1177/1753193412451383)
  • [L4] Early intra-articular osteotomy significantly improved wrist range of motion, grip strength, Disabilities of the Arm, Shoulder, and Hand scores, and radiographic parameters. (10.1016/j.jhsa.2010.07.036)
  • [L5] Salvage procedures do not achieve complete restoration of wrist function but reduce pain and enable a minimum of residual range of motion to perform normal daily activities. (10.1007/s00402-020-03369-8)
  • [Case_report] This initial account indicates that accurate and reliable anatomic reduction and an excellent clinical outcome can be achieved with this technique. (10.1016/j.jhsa.2008.02.008)
  • [L4] There was a complication rate of nearly 50%. (10.1016/j.jhsa.2016.07.037)

See Also

References

[1] Patient-reported outcomes after corrective osteotomy for a symptomatic malunion of the distal radius. The Bone & Joint Journal. 2020. DOI: 10.1302/0301-620x.102b11.bjj-2020-0848.r3

[2] Distal Radius Malunion. The Journal of Hand Surgery. 2020. DOI: 10.1016/j.jhsa.2020.02.008

[3] A SYSTEMATIC APPROACH TO HANDLING THE DISTAL RADIO-ULNAR JOINT IN CASES OF MALUNITED DISTAL RADIUS FRACTURES. Hand Clinics. 1998. DOI: 10.1016/s0749-0712(21)00161-x

[4] Comparative Analysis of Radial Corrective Osteotomy and Sauvé–Kapandji Procedure for Malunited Distal Radius Fractures in Older Adults. The Journal of Hand Surgery. 2024. DOI: 10.1016/j.jhsa.2024.06.007

[5] Evaluation of Corrective Osteotomy of the Malunited Distal Radius on Midcarpal and Radiocarpal Malalignment. The Journal of Hand Surgery. 2010. DOI: 10.1016/j.jhsa.2009.09.017

[6] Orthogonal Plate Fixation With Corrective Osteotomy for Treatment of Distal Radius Fracture Malunion. The Journal of Hand Surgery. 2017. DOI: 10.1016/j.jhsa.2016.10.012

[7] Minimally invasive osteotomy for distal radius malunion: A preliminary series of 9 cases. Orthopaedics & Traumatology: Surgery & Research. 2015. DOI: 10.1016/j.otsr.2015.07.016

[8] Corrective osteotomy of the distal radius following failed internal fixation. Archives of Orthopaedic and Trauma Surgery. 2013. DOI: 10.1007/s00402-013-1779-5

[9] Corrective osteotomy is an effective method of treating distal radius malunions with good long-term functional results. Injury. 2017. DOI: 10.1016/j.injury.2017.01.045

[10] Validation of the Lift-Off Screw Technique in Patients Undergoing Corrective Osteotomy for Malunited Distal Radius Fractures. The Journal of Hand Surgery. 2025. DOI: 10.1016/j.jhsa.2024.07.025

[11] Life has become troublesome – my wrist bothers me around the clock: an interview study relating to daily life with a malunited distal radius fracture. Disability and Rehabilitation. 2019. DOI: 10.1080/09638288.2018.1561954

[12] Intermediate-Term Outcome of 3-Dimensional Corrective Osteotomy for Malunited Distal Radius Fractures With a Mean Follow-Up of 6 Years. The Journal of Hand Surgery. 2022. DOI: 10.1016/j.jhsa.2021.07.018

[13] Outcomes and Complications Following Volar and Dorsal Osteotomy for Symptomatic Distal Radius Malunions: A Comparative Study. The Journal of Hand Surgery. 2020. DOI: 10.1016/j.jhsa.2019.05.015

[14] Corrective Osteotomy for Volarly Malunited Distal Radius Fracture. The Journal of Hand Surgery. 2009. DOI: 10.1016/j.jhsa.2008.09.018

[15] Three-Dimensional Analysis of Malunited Distal Radius Fractures with Limitation of Forearm Rotation. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2015.06.032

[16] Corrective Osteotomy for Deformity of the Distal Radius Using a Volar Locking Plate. HAND. 2007. DOI: 10.1007/s11552-007-9066-y

[17] Ulnar shortening osteotomy for malunited distal radius fractures: results of a 7-year follow-up with special regard to the grade of radial displacement and post-operative ulnar variance. Archives of Orthopaedic and Trauma Surgery. 2013. DOI: 10.1007/s00402-013-1892-5

[18] Complications of Corrective Osteotomies for Extra-Articular Distal Radius Malunion. The Journal of Hand Surgery. 2019. DOI: 10.1016/j.jhsa.2018.12.013

[19] Is distal ulna resection influential on outcomes of distal radius malunion corrective osteotomies?. Orthopaedics & Traumatology: Surgery & Research. 2011. DOI: 10.1016/j.otsr.2011.03.022

[20] Corrective Osteotomy for Malunited, Volarly Displaced Fractures of the Distal End of the Radius. The Journal of Bone & Joint Surgery*. 1997. DOI: 10.2106/00004623-199712000-00007

[21] Extra-articular distal radius malunion: The phosphate cement alternative. Orthopaedics & Traumatology: Surgery & Research. 2010. DOI: 10.1016/j.otsr.2010.03.018

[22] Z-Corrective Osteotomy in Malunited Extra-Articular Fractures of Distal Radius. The Journal of Hand Surgery. 2022. DOI: 10.1016/j.jhsa.2021.06.023

[23] In Vivo Contact Characteristics of Distal Radioulnar Joint With Malunited Distal Radius During Wrist Motion. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2015.07.027

[24] Vascularized Bone Grafting and Distal Radius Osteotomy for Scaphoid Nonunion Advanced Collapse: Myth and Reality. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2014.05.037

[25] Three-dimensional deformity analysis of malunited distal radius fractures and their influence on wrist and forearm motion. Journal of Hand Surgery (European Volume). 2012. DOI: 10.1177/1753193412443644

[26] Comparison of three dimensional and radiographic measurements in the analysis of distal radius malunion. Journal of Hand Surgery (European Volume). 2012. DOI: 10.1177/1753193412451383

[27] Corrective Osteotomy for Isolated Malunion of the Palmar Lunate Facet in Distal Radius Fractures. The Journal of Hand Surgery. 2010. DOI: 10.1016/j.jhsa.2010.07.036

[28] Salvage procedure after malunited distal radius fractures and management of pain and stiffness. Archives of Orthopaedic and Trauma Surgery. 2020. DOI: 10.1007/s00402-020-03369-8

[30] Corrective Osteotomy for Malunited Intra-Articular Fracture of the Distal Radius Using a Custom-Made Surgical Guide Based on Three-Dimensional Computer Simulation: Case Report. The Journal of Hand Surgery. 2008. DOI: 10.1016/j.jhsa.2008.02.008

[31] Complications of Distal Radius Malunion Osteotomies. The Journal of Hand Surgery. 2016. DOI: 10.1016/j.jhsa.2016.07.037

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Considerations for the public: By using one of our public licenses, a licensor grants the public permission to use the licensed material under specified terms and conditions. If the licensor's permission is not necessary for any reason--for example, because of any applicable exception or limitation to copyright--then that use is not regulated by the license. Our licenses grant only permissions under copyright and certain other rights that a licensor has authority to grant. Use of the licensed material may still be restricted for other reasons, including because others have copyright or other rights in the material. A licensor may make special requests, such as asking that all changes be marked or described. Although not required by our licenses, you are encouraged to respect those requests where reasonable. More considerations for the public: wiki.creativecommons.org/Considerations_for_licensees

Creative Commons Attribution-NonCommercial 4.0 International Public License

By exercising the Licensed Rights (defined below), You accept and agree to be bound by the terms and conditions of this Creative Commons Attribution-NonCommercial 4.0 International Public License ("Public License"). To the extent this Public License may be interpreted as a contract, You are granted the Licensed Rights in consideration of Your acceptance of these terms and conditions, and the Licensor grants You such rights in consideration of benefits the Licensor receives from making the Licensed Material available under these terms and conditions.

Section 1 -- Definitions.

a. Adapted Material means material subject to Copyright and Similar Rights that is derived from or based upon the Licensed Material and in which the Licensed Material is translated, altered, arranged, transformed, or otherwise modified in a manner requiring permission under the Copyright and Similar Rights held by the Licensor. For purposes of this Public License, where the Licensed Material is a musical work, performance, or sound recording, Adapted Material is always produced where the Licensed Material is synched in timed relation with a moving image.

b. Adapter's License means the license You apply to Your Copyright and Similar Rights in Your contributions to Adapted Material in accordance with the terms and conditions of this Public License.

c. Copyright and Similar Rights means copyright and/or similar rights closely related to copyright including, without limitation, performance, broadcast, sound recording, and Sui Generis Database Rights, without regard to how the rights are labeled or categorized. For purposes of this Public License, the rights specified in Section 2(b)(1)-(2) are not Copyright and Similar Rights.

d. Effective Technological Measures means those measures that, in the absence of proper authority, may not be circumvented under laws fulfilling obligations under Article 11 of the WIPO Copyright Treaty adopted on December 20, 1996, and/or similar international agreements.

e. Exceptions and Limitations means fair use, fair dealing, and/or any other exception or limitation to Copyright and Similar Rights that applies to Your use of the Licensed Material.

f. Licensed Material means the artistic or literary work, database, or other material to which the Licensor applied this Public License.

g. Licensed Rights means the rights granted to You subject to the terms and conditions of this Public License, which are limited to all Copyright and Similar Rights that apply to Your use of the Licensed Material and that the Licensor has authority to license.

h. Licensor means the individual(s) or entity(ies) granting rights under this Public License.

i. NonCommercial means not primarily intended for or directed towards commercial advantage or monetary compensation. For purposes of this Public License, the exchange of the Licensed Material for other material subject to Copyright and Similar Rights by digital file-sharing or similar means is NonCommercial provided there is no payment of monetary compensation in connection with the exchange.

j. Share means to provide material to the public by any means or process that requires permission under the Licensed Rights, such as reproduction, public display, public performance, distribution, dissemination, communication, or importation, and to make material available to the public including in ways that members of the public may access the material from a place and at a time individually chosen by them.

k. Sui Generis Database Rights means rights other than copyright resulting from Directive 96/9/EC of the European Parliament and of the Council of 11 March 1996 on the legal protection of databases, as amended and/or succeeded, as well as other essentially equivalent rights anywhere in the world.

l. You means the individual or entity exercising the Licensed Rights under this Public License. Your has a corresponding meaning.

Section 2 -- Scope.

a. License grant.

1. Subject to the terms and conditions of this Public License, the Licensor hereby grants You a worldwide, royalty-free, non-sublicensable, non-exclusive, irrevocable license to exercise the Licensed Rights in the Licensed Material to:

a. reproduce and Share the Licensed Material, in whole or in part, for NonCommercial purposes only; and

b. produce, reproduce, and Share Adapted Material for NonCommercial purposes only.

2. Exceptions and Limitations. For the avoidance of doubt, where Exceptions and Limitations apply to Your use, this Public License does not apply, and You do not need to comply with its terms and conditions.

3. Term. The term of this Public License is specified in Section 6(a).

4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.