Nonunion of Distal Radius Fractures

Key Points

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While the cause of nonunion is often multifactorial, both injury (open fracture, severe comminution, soft tissue interposition) and patient (diabetes, smoking, obesity, substance abuse, malnutrition, peripheral vascular disease, social situation) factors play a role.
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Treatment is based on the history of previous surgical attempts, the status of the radiocarpal joint, and the status of the distal radioulnar joint.
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Commonly utilized methods include orthogonal plating, nonvascularized bone grafting, vascularized bone grafting, modified Sauve-Kapandji procedure, and radiocarpal arthrodesis.

Panel 1: Case Scenario

A 67 year-old, right-handed female with a history of poorly controlled type II diabetes and cerebral palsy with associated spasticity presented to an outside hospital following a ground level fall with a closed distal radius fracture ( Fig. 1 A and B). Closed reduction and casting was attempted, however she was referred to our clinic approximately 3 months status post injury with concern for nonunion with associated loss of reduction, shortening, radial deviation, and volar subluxation ( Fig. 1 C and D). What is the most effective approach for management of this clinical scenario?

Importance of the Problem

Distal radius fractures are a commonly encountered injury in orthopedic surgery, representing the most common upper extremity fracture encountered in the emergency department and accounting for approximately 20% of all fractures occurring in adults. Common complications include median nerve neuropathy, extensor pollicis longus tendon rupture, flexor pollicis longus tendon rupture, radiocarpal arthrosis, infection, and malunion. A less commonly observed complication of distal radius fractures is nonunion of the fracture site, estimated to occur in 0.03%–1.6% of cases ( Fig. 2 ).

Though rare, nonunions can be a devastating complication, resulting in severe pain and functional limitation. Additionally, even those that are able to be successfully treated often require multiple operative interventions, resulting in increased health care costs, time away from work, and risk of infection or other complications.

Main Question

What is the most effective management of a distal radius fracture nonunion?

Current Opinion

Nonunion of a distal radius fracture is historically a topic of debate. Some argue for definitive treatment in the form of arthrodesis while others attempt fixation in order to preserve function.

Finding the Evidence

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Cochrane search: “distal rad*” AND “nonunion”
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Pubmed (Medline): “distal rad*” AND “nonunion.”
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Bibliography review of eligible articles.
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Articles that were not in English were excluded.
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Articles involving nonhuman subjects were excluded.

Quality of the Evidence

Level IV:

Case series: 7
Case report: 8

Findings

Fifteen studies were identified for inclusion in this review. Seven of 15 selected studies were case series ( Table 1 ), and the remaining eight were case reports ( Table 2 ). Segalman et al. (1998) evaluated 10 females and 1 male with nonunion after distal radius fracture and found that all had significant associated co-morbidities, most notably diabetes, peripheral vascular disease (PVD), psychiatric disease, alcoholism, and/or morbid obesity. They ultimately recommended that wrist arthrodesis be performed in those with < 5 mm of subchondral bone distal to the nonunion site in order to decrease complication and failure rates. From 1990 to 1997, Smith et al. (1999) identified 5 patients with an average age of 44 years and nonunion of a distal radius fracture. All were treated with open reduction, internal fixation (ORIF), and iliac crest bone autograft. Two achieved union with the index procedure, and one required a second ORIF before achieving union. Two patients ultimately were treated with wrist arthrodesis after an average of 3 additional procedures. All five patients were noted to be active smokers. In a study of 10 patients with nonunion, Fernandez et al. (2001) noted that patients typically presented with gross malalignment, pain, and severely limited function. Forty percent of their cohort was found to have arthrosis of the distal radioulnar joint (DRUJ) requiring either a Bowers hemiresection with interposition or a Darrach procedure. Of note, cases in which a Darrach procedure was utilized also had extreme angular deformity and shortening at the nonunion site. A 100% union rate was achieved by 3 months and 7/10 functional outcomes were rated as excellent or good after undergoing ORIF with either a volar or dorsal approach.

Table 1

Case Series.

Study	N ^a	Complications	Average Age (Years)	Union Rate ^b
Segalman 1998	6 (arthrodesis cohort)	NR ^c	58.7	6/6
Segalman 1998	3 (ORIF cohort)	NR ^c	41.7	3/3
Smith 1999	5	NR ^c	44	3/5
Fernandez 2001	10	4	46	10/10
Eglseder 2002	10	4	47.75	8/10
Prommersberger 2002	10 (small fragment cohort)	5	53	10/10
Prommersberger 2002	13 (large fragment cohort)	4	56	12/13
Mithani 2014	8	1	68	8/8
Henry 2017	6	1	52	6/6