The relationship between malunion and functional outcome following distal radius fracture (DRF) is not well understood.
Some patients tolerate malunion well, whereas others have poor functional outcome.
Evidence evaluating operative and nonoperative treatment of extraarticular malunion is largely of low quality.
Distal radius osteotomy is likely to improve symptoms in carefully selected patients with a symptomatic malunion following DRF.
Complication rate and need for re-operation is considerable.
Careful consideration and adequate patient counseling should be carried out before deciding optimum treatment for a patient with extraarticular DRF malunion.
A 67-year-old, fit and well woman slipped and fell onto her outstretched dominant right hand. Initial radiographs showed a distal radius fracture (DRF) with neutral angulation and slight shortening ( Fig. 1 ). This was treated in a plaster cast for 6 weeks with no further radiographs taken. After cast removal, the wrist was stiff, painful with an obvious dorsal deformity. After several months of hand therapy, the patient still described ongoing symptoms of pain, reduced grip strength, and was concerned about the appearance of the wrist. What would be the optimal management for this patient?
Importance of the Problem
DRFs are a very common injury and a huge burden on healthcare resources worldwide. Despite the frequency in which these injuries are encountered, there is still many unanswered questions regarding which fractures require intervention, optimum treatment methods, and long-term outcome. The evidence regarding fracture displacement and functional outcome after DRF is varied. Some studies have previously suggested only a small amount of displacement may lead to poor outcomes, whereas others have reported that significant displacement leads to minimal long-term functional problems. Increasing evidence has suggested that in older patients malunion is well tolerated.
Up to 24% of patients develop malunion following a conservatively treated DRF and 10% of those treated surgically. Unsatisfactory position in 58% of patients who underwent closed reduction of a displaced fracture has been reported, with 68% of those which were initially reduced satisfactorily subsequently displacing. Despite this, most patients make a satisfactory recovery with only a small number of patients suffering significant symptoms because of malunion. Which patients are most affected by malunion is not well understood. The commonest and most effective surgical intervention for a symptomatic malunion following a DRF is a distal radius osteotomy although the evidence base is limited. .
Key Question: What is the most effective treatment (operative vs nonoperative) for extraarticular malunion in terms of short-term outcomes and long-term consequences?
Many patients may tolerate extraarticular malunion well following DRF, especially the elderly and those with less functional demand. If symptomatic malunion occurs following DRF, then intervention such as distal radius osteotomy should be considered taking into account the patient’s functional status and general health.
Finding the Evidence
We searched Cochrane Database of systematic reviews, MEDLINE and EMBASE.
|(((distal ADJ3 (radius OR radial)) OR (wrist OR colles OR smith*)) ADJ3 fracture*).ti,ab|
|exp “RADIUS FRACTURES”/|
exp “WRIST INJURIES”/
|“SURGICAL PROCEDURES, OPERATIVE”/|
Quality of the Evidence
Level I: 1 (comparison of planning techniques not operative and conservative management)
Level IV: 40
No studies compare operative treatment with nonoperative treatment for extraarticular malunion following DRF. Forty-one studies were identified which report outcome following operative treatment for extraarticular malunion. One RCT reported outcome following osteotomy for extraarticular DRF but the aim of the study was to compare 3D computer-assisted planning with conventional two-dimensional (2D) planning for corrective osteotomy.
Thirty-nine of the studies reported on distal radius osteotomy with two describing ulnar shortening osteotomy. Thirty-seven studies were retrospective case series with three prospective series.
Most studies described new techniques such as the type of osteotomy, fixation method, use of different bone grafts, measurement or planning methods and supplemental procedures such as arthroscopy.
The decision about which DRF require surgical intervention is difficult. A huge amount of evidence on the subject has been produced but most of it is poor quality with conflicting findings. Significant variation in treatment currently exists. Recently, an international Delphi study has provided guidance about radiographic thresholds of intervention for different age groups ( Table 1 ). Guidance has also been produced by several national specialist groups. Despite this, malunion is not uncommon; however, the effect of this on a patient’s functional outcome appears variable.
Distal radius osteotomy is a well described and popular treatment for patients with a symptomatic malunion following DRF. The evidence identified is of low quality and heterogenous with a wide variety of techniques studied. There is no strong evidence regarding the optimum timing for surgery or surgical technique.
Pillukat et al. prospectively reviewed 48 patients who underwent corrective osteotomy for malunion following DRF. Seventeen patients were aged 65 years and over and 31 were aged less than 65. Range of motion, grip strength, pain, and radiographic parameters improved in both groups, although the younger age group had greater improvement. They concluded that osteotomy was beneficial for all age groups but older patients may not gain as much benefit. In a separate nonrandomized study, Pillukat et al. prospectively studied 34 consecutive patients with extraarticular DRF malunion and compared outcome for those who underwent early correction (less than 14 weeks following injury) and later correction. At 2 year follow-up, Mayo scores improved significantly in both groups. The only difference between the groups was less requirement for bone grafting in those corrected early. Jupiter and Ring felt earlier reconstruction was technically simpler and resulted in a reduced period of disability when comparing 10 patients who underwent osteotomy at a mean time of 8 weeks following injury with 10 who underwent surgery at 40 weeks following injury.
El-Karef et al. prospectively assessed the outcomes of 26 symptomatic patients with malunited DRF. A staged reconstructive approach was used and outcome measured using the Fernandez score. Satisfactory functional scores were achieved by 20 of the 26 patients after distal radial osteotomy alone, and 24 of the 26 after subsequent ulnar shortening osteotomies and arthroscopy after 54 months. In their RCT comparing patient-reported outcome measures (PROMs) after corrective osteotomy for malunited DRF with and without 3-dimensional planning and use of patient-specific surgical guides, Buijze et al. found a trend toward a minimal clinically important difference in PROMs in favor of 3D-assisted group, although it did not attain significance because of (post-hoc) insufficient power. Radiographic analysis showed minimal significant differences in the mean residual volar angulation and radial inclination, in favor of 3D planning and guidance. However, both groups gained significant improvement in DASH and PRWE scores.
Mulders et al. retrospectively reviewed 48 patients who underwent corrective osteotomy at a median of 27 months. VAS pain scores decreased significantly from 6.5 preoperatively to 1.0 postoperative and grip strength recovered to 85% of the uninjured side. Postoperatively, they found a median PRWE score of 18.5 (IQR 6.5–37.0) and a DASH score of 10.0 (IQR 5.8–23.3), which is equal to the estimated score of the general population. Preoperative scores were not available. Eighteen patients (38%) had a complication for which additional treatment was required.
Disseldorp et al. retrospectively reviewed 132 corrective osteotomies of DRF malunions at mean follow-up of 92 months (range 13–252 months). All but two osteotomies healed within 4 months and no nonunions occurred. Radiographic parameters improved significantly after surgery. They did not collect PROM data. Wound or soft tissue complications occurred in 21 (15.9%) patients. Seventy-three (55.3%) patients subsequently underwent metalwork removal because of complications, functional impairment, or pain.
There is minimal evidence regarding outcome after nonoperative treatment of extraarticular DRF malunion. Concern exists regarding the development of arthritis or problems related to carpal malalignment and altered wrist kinematics. Forward et al. assessed patients 38 years following nonoperative management of a DRF. Sixty-six patients were examined who had sustained an extraarticular DRF. Patient evaluation measure score was 5% less than the uninjured side, with range of movement 98% and grip strength 96% of the uninjured side.
There is evidence that older patients tolerate malunion well with satisfactory functional outcome despite imperfect position. Anzurat et al. prospectively graded DRF in patients aged over 50 as acceptable or unacceptable reduction according to radiographic parameters. At 6 months follow-up, there was no difference in SF12 and DASH scores between the groups. Several metaanalyses have reported no improvement in functional outcome when comparing surgical intervention and closed reduction in older patients despite superior radiological outcome with surgery.
There is a vast amount of evidence investigating outcome after DRF and DRF osteotomy but the majority is low quality. Multiple studies that suggest osteotomy will improve outcome after DRF malunion. There are few high quality studies using PROMs but the evidence from lower quality studies generally suggests a benefit from osteotomy. Many variables are not well understood such as surgical approach, adjunct procedures, use and type of bone graft, and timing of surgery. Complication rate and need for re-operation is considerable. There is evidence that older patients tolerate malunion well. Therefore, careful consideration and adequate patient counseling should be carried out before deciding optimum treatment for a patient with DRF malunion.