Rationale

Nonunion of the distal radius—long considered to be extremely rare^1,2—has been noted more frequently in recent years.^3–7 Although some authors have speculated that the advent of external fixation and other techniques for maintaining the length of the radius has created bony defects that can lead to nonunion,⁷ nonunion also is seen after internal fixation or nonoperative treatment (Figs. 54-1 through 54-3).^3–7 There seems to be an association with concomitant fracture or dislocation of the distal ulna (see Fig. 54-2).^4,5

FIGURE 54-1 A 42-year-old man was injured in a race car accident. A, A comminuted fracture of the distal radius was stabilized and distracted with an external fixator. B, The fracture failed to heal, his hand became stiff, and there was osteopenia related to disuse. C, After removing the external fixator and rehabilitating the hand, the fracture remained ununited. D, Débridement of the nonunion, autogenous cancellous bone grafting, and internal fixation achieved union. E, The use of a plate with fixed-angle metaphyseal screws enhanced the security of the fixation.

FIGURE 54-2 An elderly woman with fractures of the distal radius and ulna was treated in a cast. A, Synovial nonunions of both fractures with an ulnar deviation deformity ensued. B, Through a volar exposure, orthogonal plates (one volar, one direct radial) were applied. C, Good fixation of the radial styloid was achieved. D, The use of locking screws enhanced the security of fixation in the osteoporotic metaphyseal bone.

(Case Courtesy of J.B. Jupiter MD.)

FIGURE 54-3 A 75-year-old woman injured her wrist and believed that it was just a sprain. A, On presentation 6 weeks later, she had an unstable complex ununited fracture of the distal radius. B, This nonunion with associated complex articular injury was thought not to be amenable to attempts at repair and was salvaged with a wrist arthrodesis.

Although the cause and incidence of nonunion of the distal radius are uncertain, the need for operative treatment is clear. Most nonunions are synovial.^4–7 The wrist is usually deformed, unstable, and painful. Some patients have a severe radial deviation deformity reminiscent of congenital clubhand, which has been referred to as acquired or post-traumatic clubhand (Fig. 54-4).^8,9

FIGURE 54-4 Some nonunions of the distal radius are associated with a marked radial deviation deformity—the so-called post-traumatic radial clubhand.

Operative treatment can improve upper limb function in patients with nonunion of the distal radius by either fusing the wrist or healing the fracture. Improved implants and operative techniques have improved healing of the fracture, preserving some wrist motion.^5,6 Even small amounts of wrist motion can enhance upper limb function.¹⁰

Indications

Unstable ununited fractures are disabling and warrant operative treatment in all but the most severely infirm patients. A fracture of the distal radius that remains ununited in a distracted position (e.g., with external fixation) may heal after the fracture has been allowed to settle. Any fracture that remains unstable greater than 6 weeks after injury is likely to have healing problems and should be considered for operative treatment.

Contraindications

Concomitant infection should be treated with serial débridement and organism-specific parenteral antibiotics. Definitive treatment is delayed until the infection is eradicated. Very infirm, debilitated, or severely demented patients can be managed with a brace.

Operative Techniques