Copyright 1997 by The Journal of Bone and Joint Surgery, Incorporated Corrective Osteotomy for Malunited, Volarly Displaced Fractures of the Distal End of the Radius* BY KEVIN SHEA, M.D.f, BOSTON, DIEGO L. FERNANDEZ, M.D4, AARAU, SWITZERLAND, JESSE B. JUPITER, M.D.§, AND CLAUDE MARTIN, JR., M.D.§, BOSTON, MASSACHUSETTS Investigation performed at Massachusetts General Hospital, Boston, and Kantonspital, Aarau ABSTRACT: Twenty-five patients who had had an opening-wedge osteotomy for the treatment of a mal- united, volarly displaced fracture of the distal end of the radius were studied retrospectively. The indications for the operation were pain and functional limitations rather than the degree of anatomical deformity. Fifteen patients were men and ten were women; their average age was forty-six years (range, twenty-one to eighty- four years). Preoperative radiographs revealed an average ul- nar inclination of 14 degrees, an average ulnar variance of five millimeters, and an average volar inclination of 24 degrees. Extension of the wrist averaged 25 de- grees; flexion of the wrist, 53 degrees; supination of the forearm, 41 degrees; and pronation of the forearm, 64 degrees. The average grip strength was a force of seventeen kilograms compared with a force of forty kilograms in the contralateral hand. At an average of sixty-one months (range, eighteen to 114 months) after the osteotomy, supination of the forearm had improved to an average of 69 degrees and pronation had improved to an average of 75 degrees (p < 0.05 for both). Extension of the wrist had improved to an average of 55 degrees, and grip strength had im- proved to a force of thirty kilograms (p < 0.05 for both). Volar inclination averaged 5 degrees; ulnar variance, zero millimeters; and ulnar inclination, 22 degrees. A reoperation was performed in eleven patients. Seven pa- tients had removal of the hardware only, two had a procedure involving the distal radioulnar joint, one had a procedure because the site of the osteotomy had not healed, and one had a median-nerve release. The functional result was rated as very good in ten patients, good in eight, fair in three, and poor in four. *No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study. tDepartment of Orthopaedic Surgery, University of Utah, 50 North Medical Drive, Salt Lake City, Utah 84132. The e-mail ad- dress is kshea74283@aol.com. tOrthopaedische Chirurgie F. M. H., Mittelstrasse 54, CH 3012 Bern, Switzerland. §Orthopaedic Hand Service, Massachusetts General Hospital, WACC 527, 15 Parkman Street, Boston, Massachusetts 02114. The e-mail address for Dr. Jupiter is jupiter@al.mgh.harvard.edu. Malunion following a volarly displaced fracture of the distal metaphysis of the radius (a Smith fracture) impairs the normal function of the radiocarpal and dis- tal radioulnar joints 1 " 31534 . An increase in the volar in- clination of the radiocarpal articular surface, combined with a loss of normal ulnar inclination in the frontal plane, causes a decrease in grip strength, a decrease in extension and ulnar deviation of the hand and wrist, and a cosmetic deformity. In addition, shortening of the ra- dius relative to the distal end of the ulna, combined with a pronation deformity of the distal fragment, invariably results in incongruence and instability of the distal ra- dioulnar joint. Such deformity adversely affects rotation of the forearm , - 4 • 10 ' ,5 • 16 ' 2,, . Although there is considerable information in the literature regarding the indications for, and the tech- niques and results of, corrective osteotomy for the treat- ment of malunited, dorsally displaced fractures of the distal end of the radius 2 ' 3 ' 5 "- 9 ' 12 - 162 "' 22 ' 26 ' 27 - 30 ' 31 - 35 , there have been few reports concerning osteotomy for the treat- ment of volarly displaced malunions of the distal end of the radius 1416 . In the current study, we evaluated the results of corrective osteotomy for a volarly angulated, post-traumatic deformity of the distal end of the radius in twenty-five patients. Materials and Methods We retrospectively reviewed the experience of the two senior ones of us (D. L. F. and J. B. J.) at Kanton- spital in Aarau, Switzerland, and at Massachusetts Gen- eral Hospital in Boston, Massachusetts, with regard to corrective osteotomy for the treatment of malunited, volarly angulated fractures of the distal end of the ra- dius in twenty-five consecutive patients from 1986 to 1995. All patients had been managed initially at other institutions and later were referred to us because of a residual deformity. The indications for the osteotomy were pain or func- tional limitations rather than the degree of anatomical deformity. The preoperative functional problems in- cluded painful or limited supination of the forearm, loss of extension of the wrist due to volar displacement of the distal radial fragment, and loss of grip strength that adversely affected the patient's capacity to return to his or her preinjury occupation. The criteria for exclusion 1816 THE JOURNAL OF BONE AND JOINT SURGERY