Abstract
Background
Distal radius fractures (DRF) account for up to 18% of adult fractures, with malunion
occurring in up to 25% of conservatively managed cases and 10% of surgically managed
cases. Symptomatic malunion can lead to significant morbidity, including loss of forearm
rotation, adaptive carpal instability, and arthritis. Corrective osteotomy is a key
surgical intervention, yet there is no consensus on the optimal surgical approach,
fixation technique, or necessity of bone grafting.
Case Description
The purpose of this systematic review is to evaluate surgical outcomes of distal radius
osteotomy for extra-articular malunion, compare volar and dorsal approaches, and assess
the need for bone grafting.
Literature Review
A search of PubMed (2000–2023) was conducted using predefined search terms to identify
relevant studies. A total of 17 studies met inclusion criteria, which required primary
data on DRF malunion correction, comparative analyses of volar versus dorsal approach,
bone graft necessity, and patient-reported outcomes. Data on complication rates, patient
satisfaction, and clinical questionnaire scores were analyzed.
Volar plate fixation outcomes were assessed in 10 studies, with 5 using bone grafting
and 5 without. Both the groups demonstrated significant improvement in patient-reported
outcome measures (PROMs), radiographic measures, and grip strength. Four studies without
bone grafting reported zero cases of nonunion, while one study was discontinued due
to persistent malunion in 20% of cases. Bone grafting, including autologous and synthetic
options, was associated with similar functional and radiographic outcomes. Two studies
directly compared volar and dorsal approaches. Both the approaches demonstrated significant
improvements in range of motion and patient-reported outcomes. However, the volar
approach resulted in significantly greater wrist flexion (p = 0.012) and fewer hardware-related complications compared with dorsal plating. Three
studies assessed the necessity of bone grafts and showed mixed results. While some
demonstrated successful outcomes without grafting, others reported improved union
rates with cancellous grafts. One study found no difference between autologous and
synthetic grafts.
Clinical Relevance
Corrective osteotomy for DRF malunion significantly improves patient outcomes, with
volar plate fixation trending toward better outcomes over dorsal plating. Bone grafting
may not be essential for all cases, particularly when stable fixation is achieved
with cortical bony contact. Further high-quality comparative studies are needed to
refine surgical decision-making.
Keywords
distal radius fracture - structural bone graft - autologous bone graft - extra-articular
malunion - corrective osteotomy
