Nonunion of Distal Radius Fractures

Indications

Nonunited fractures of the distal radius. These fractures commonly have little cancellous bone. Nonunion commonly follows failed treatment with external fixation and percutaneously placed pins.

Pearl

Inspect the distal radioulnar joint (DRUJ) on preoperative radiographs. If the DRUJ appears salvageable prepare to use tricortical iliac crest bone graft to help fill the defect created by distal translation of the distal fragment. If the DRUJ does not appear salvageable, prepare the patient for distal ulna resection. In this case the radius can be shortened and grafted with cancellous bone.

Technique

Use a dorsal approach to the distal radius.

Open the retinaculum over the second through fourth extensor compartments as two opposing flaps (see Chapter 3, Fig. 3-1A,B).
Remove fibrous tissue and devascularized bone between the fracture fragments. Release the brachioradialis and any soft tissue attachments that may limit reduction of the fragment. Avoid stripping the radiocarpal ligaments (Fig. 10-1).
Decide whether the distal ulna can be preserved or should be resected. We recommend the surgeon consider stabilization of the resected distal ulna as described in Chapter 22.

Pearl

If the nonunion extends to the subchondral bone or into the joint, it may be necessary to open the dorsal capsule. A small window in the capsule can aid in reduction of the malunited fragment and confirm that hardware does not enter the radiocarpal joint.