Many wrist fractures heal in ‘suboptimal’ position, either because they were not surgically fixed or because the surgical fixation did not turn out well. When a wrist fracture heals in poor position (called a ‘malunion’) it can lead to deformity, pain, stiffness, weakness, and dysfunction, especially in active individuals. If the malunion includes a malalignment inside of the wrist joint, this usually leads to arthritis.
The choice is between accepting the poor wrist position for life or having the bone ‘rebroken’ and fixed (or refixed, as the case may be) in a better position. This is called an osteotomy. As with many other things, if an osteotomy is going to be performed, it is better to perform it early rather than late. Early on, the original fracture line may be visible and it may be possible to reopen up the original fracture, which allows the wrist bone to be put into a fully normal position, or close to it. Once the fracture has healed and remodeled, this is no longer possible, and an approximation needs to be made. Performing the osteotomy early on is crucial if the malunion goes inside the joint, as surgery inside of a joint requires precision if the joint is to be made perfectly smooth again.
Once the osteotomy is made, it is then fixed with a plate in better position, just as a fresh distal radius fracture is plated. In order to ‘fill in the gaps’ in the bone created by the repositioning, bone graft is often needed for filler. Traditionally, this has been taken from the ‘hip’ (iliac crest), but it’s much less painful to take it from around the elbow. Bone taken from the body is much better for this purpose than bone taken from a cadaver, or synthetic bone, which are usually good enough for fresh fractures. Taking bone from around the elbow is not usually very painful, and rarely causes any problems.
After surgery, the wrist is immobilized for 1-2 weeks, depending primarily on the quality of the bone fixed. Then therapy is begun to regain motion. A splint is used as needed for 6 weeks.
Most patients who undergo osteotomy of a wrist fracture that has healed in poor position are extremely happy. This is a common, outpatient procedure, and should be considered in any active patient who is having problems from a wrist fracture that has healed in poor position.