Key Points
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Intraarticular malunion following distal radius fracture (DRF) leads to radiographic arthritis, but the effect on functional outcome is not well understood.
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Evidence evaluating operative and nonoperative treatment of intraarticular malunion is of low quality.
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Some small, retrospective case series suggest osteotomy will improve outcome after intraarticular DRF malunion.
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Surgery is challenging with high complication rate and need for re-operation.
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There is insufficient evidence to establish whether osteotomy for intraarticular malunion prevents the development of arthritis.
A 42-year-old, fit and well man was involved in a high-speed road traffic accident. He required an extended ICU admission and surgery for intraabdominal injuries. Following a good recovery from these injuries and discharge to a general surgical ward, he described pain in his dominant left wrist. Radiographs were obtained 3 weeks after his initial injury and these demonstrated a distal radius fracture with dorsal angulation and a depressed and rotated lunate fossa fragment with a 2 mm intraarticular step ( Fig. 1 ). What would be the optimal management for this patient?
Importance of the Problem
Persistent articular incongruity of the distal radius after fracture healing is known to lead to early degenerative changes of the radiocarpal joint. Cadaveric experiments have shown that an articular step affects the biomechanics of the joint with a step of 1 mm causing a significant increase in contact stresses. Despite the evidence that articular incongruity leads to radiologically proven arthritis, the correlation with symptoms and poor outcome is debatable. Studies by Trumble et al. and Chung et al. showed that residual articular displacement was associated with a poorer outcome. Others have shown minimal long term functional impairment.
Intraarticular malunion can be measured as a step and/or gap. Step is thought to be the most important parameter to affect functional outcome and many surgeons would recommend intervention for a step of 2 mm or more in younger patients. Correcting intraarticular malunion is challenging and involves the risk of rare but disastrous complications such as nonunion or avascular necrosis. Complexity of surgery is compounded by associated extra-articular malunion.
Main Question
What is the most effective treatment (operative vs nonoperative) for intraarticular malunion in terms of short-term outcomes and long-term consequences?
Current Opinion
Patients with an intraarticular step following DRF develop radiographic evidence of arthritis. However, this may not lead to significant functional impairment. Surgery to correct intraarticular displacement is complex with a risk of significant complications. It may be considered for younger patients with a significant intraarticular step taking into account the patient’s functional status and general health.
Finding the Evidence
We searched the Cochrane Database of systematic reviews, MEDLINE and EMBASE.
| The following MEDLINE search terms were used: (((distal ADJ3 (radius OR radial)) OR (wrist OR colles OR smith*)) ADJ3 fracture*).ti,ab |
| exp “RADIUS FRACTURES”/ |
exp “WRIST INJURIES”/
INTRA-ARTICULAR FRACTURES, ARTICULAR FRACTURES, MALUNITED, (malunited fracture*).ti,ab (abnormal union fracture*).ti,ab
| “CONSERVATIVE TREATMENT”/ |
| “FRACTURE HEALING”/ |
| TREATMENT OUTCOME/ |
| “SURGICAL PROCEDURES, OPERATIVE”/ |
Quality of the Evidence
Level IV: 14
Findings
No studies compared operative treatment with nonoperative treatment for intraarticular malunion following DRF. Fourteen studies were identified which report outcome following operative treatment for intraarticular malunion. All studies were retrospective case series and the largest case series involved 23 patients.
Ring et al. evaluated 23 patients at an average of 38 months after corrective osteotomy for an intraarticular malunion following DRF. Average articular incongruity was reduced from 4 to 0.4 mm. The rate of excellent or good results was 83% according to the rating systems of Fernandez and of Gartland and Werley. No patient had evidence of nonunion or avascular necrosis.
Buijze et al. assessed 18 patients at an average of 78 months after corrective osteotomy for a combined intra- and extra-articular malunion of the distal radius. All patients healed uneventfully, and final articular incongruity was reduced to 2 mm or less. Rate of excellent or good results was 72% according to the Mayo Modified Wrist Score. Hardware removal was required in 10 patients (56%), other complications occurred in 5 patients (28%), of which transient de Quervain tenosynovitis was the most common (3 patients, 17%).
Luo et al. evaluated seven consecutive patients with a mean age of 38 years who underwent corrective osteotomy for intraarticular malunion after DRF. Mean time from injury to corrective surgery was 10 weeks. At mean follow-up of 44 months, significant improvements in pain scores, QuickDASH, and grip strength were seen. One patient had evidence of degenerative change at final follow up but was asymptomatic. No significant complications were reported. The authors recommended that early corrective osteotomies should be considered in young patients with intraarticular distal radius malunions.
Arthroscopic assistance has been reported to help guide osteotomy and reduction by allowing direct visualization of the joint surface. In a study of 11 patients with intraarticular malunion following DRF, del Pinal et al. carried out an osteotomy from inside the joint outward under arthroscopic guidance. At follow-up ranging from 12 to 48 months, there were 4 excellent and 7 good results according to the Gartland and Werley score.
Correction of intraarticular malunions is desirable to prevent the development of radiocarpal degenerative evolution. Knirk and Jupiter showed a step of 2 mm or more led to a 100% incidence of radiological arthritis in 40 young adults at mean follow-up of 6.7 years.
Catalano et al. found 76% of patients with residual intraarticular displacement 7 years after internal fixation of DRF had evidence of arthritis which had progressed when reassessed after 15 years by radiographs and computerized tomography (CT) scans.
A total of 93% of the patients in Knirk and Jupiter’s study were symptomatic. However, 61% reported a good or excellent outcome, and only one patient who had bilateral fractures had to stop work due to their injury. The only functional limitation seen in the 15-year review of Catalano’s original study, was an insignificant reduction in wrist flexion.
Forward et al. retrospectively reviewed 40 young adults with intraarticular distal radius fractures at a mean of 38 years and found DASH (Disabilities of Arm, Shoulder, and Hand) scores were not different to population norms and functional impairment was less than 10% when assessed by the Patient Evaluation Measure. Kopylov et al. evaluated patients who had sustained a DRF 30 years, previously. Radiographic osteoarthritis was related to articular incongruity, but complaints were limited; 87% of patients reported no difference between their injured and uninjured sides.
Recommendations
In patients with an intraarticular displaced distal radius fracture, evidence suggests:
Conclusion
There is minimal evidence investigating outcome after interventions for intraarticular malunion following DRF. Some small, retrospective case series suggest osteotomy will improve outcome after intraarticular DRF malunion. Surgery is challenging with a high complication rate and common need for re-operation, notably hardware removal. Long-term evidence demonstrates that intraarticular malunion does lead to arthritis. Some studies have reported that this leads to poor functional outcome whereas other long-term studies have suggested functional impairment is minimal even in younger patients.
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