SCIENTIFIC ARTICLE

Evaluation of Corrective Osteotomy of the Malunited

Distal Radius on Midcarpal and Radiocarpal
Malalignment
Filip Verhaegen, MD, Ilse Degreef, MD, Luc De Smet, MD, PhD

Purpose To quantify 2 patterns of carpal malalignment, midcarpal malalignment (type 1) and

radiocarpal malalignment (type 2), and to evaluate the effect of distal radius osteotomy on
these malalignment patterns.
Methods In a retrospective review, we studied 31 wrists treated with corrective osteotomy for
distal radius malunion after Colles’ fracture, in 31 patients (mean age, 44 y). The patients
were divided on the basis of effective radiolunate flexion (ERLF) into 2 patterns of carpal
malalignment as measured on preoperative radiographs. There were 20 patients with mid-
carpal malalignment (ERLF ⱕ 25°) and 11 with radiocarpal malalignment (ERLF ⬎ 25°).
Measurements of alignment were repeated after distal radius osteotomy and compared with
preoperative values.
Results Both groups had correction of radial tilt and ulnar variance with distal radius
osteotomy. In the midcarpal malalignment group, carpal alignment improved to normal
parameters. In the radiocarpal malalignment group, we observed a notable effect on the
ERLF. Neither age of the subject nor delay between fracture and osteotomy correlated with
improvement in carpal alignment.
Conclusions Distal radial osteotomy is a reliable technique for correction of the deformity at
the distal end of the radius and both radiocarpal and midcarpal malalignment. (J Hand Surg
2010;35A:57–61. © 2010 Published by Elsevier Inc. on behalf of the American Society for
Surgery of the Hand.)
Type of study/level of evidence Therapeutic IV.
Key words Carpus, distal radius fracture, instability, malunion, osteotomy.

after distal radius of carpal malalignment is correlated with functional

M
ALUNIONS ARE FREQUENT
1,2
fractures. Changes of carpal alignment in outcome.3 Two distinct patterns of carpal malalignment
malunion of the distal radius are considered have been observed. Type 1 is midcarpal malalignment,
to be an adaptive response of the carpus to loss of the in which the proximal carpus angulates dorsally in line
normal architecture of the distal radius. The incidence with the dorsally angulated articular surface of the distal
radius, with compensatory flexion of the midcarpus
From the Department of Orthopaedic Surgery, U.Z. Pellenberg, Lubbeek, Pellenberg, Belgium.
(capitate) in an unstable, zigzag pattern of the wrist4,5
Received for publication May 15, 2009; accepted in revised form September 25, 2009.
(Figs. 1A, 2). Type 2 is radiocarpal malalignment, with
No benefits in any form have been received or will be received related directly or indirectly to the
dorsal translation of the entire carpus with respect to the
subject of this article.
distal radius (Figs. 1B, 2). These 2 patterns of carpal
Correspondingauthor:LucDeSmet,MD,PhD,DepartmentofOrthopaedicSurgery,U.Z.Pellen-
berg, Weligerveld, 1, B-3212 Lubbeek (Pellenberg), Belgium; e-mail: luc.desmet@uz.kuleuven. malalignment are identified based on the effective ra-
ac.be. diolunate flexion (ERLF) measured on the radiographs.
0363-5023/10/35A01-0011$36.00/0 The ERLF measures the relationship between the axes
doi:10.1016/j.jhsa.2009.09.017
of the displaced distal radius and the lunate. In type 1,

©  Published by Elsevier, Inc. on behalf of the ASSH. 䉬 57

58 CORRECTIVE OSTEOTOMY AND CARPAL MALALIGNMENT
FIGURE 1: A Midcarpal malalignment; B radiocarpal mala-
lignment.
FIGURE 2: A B C Schematic presentation of midcarpal
malalignment. A Normal alignment, B midcarpal or adaptive
malalignment, C radiocarpal malalignment.
the lunate is in line with the distal radius; in type 2, the
lunate tends to be in flexion. Thus the ERLF measures
the real flexion of the lunate. Gupta et al6 described the
ERLF as a measurement to distinguish type 1 from type
2 malalignment: type 1 has a value of less than 25°, and
type 2 of more than 25°.6 Abnormal alignment and
motion of the carpal bones leads to mechanical over-
load of the radiocarpal and midcarpal joints, which can
cause ligament attenuation, synovitis, and progressive
dynamic instability.5,7 It is not clear, however, whether
each of these malalignments evolves differently.
The purpose of this survey was to quantify 2 patterns
of carpal malalignment following distal radius mal-
union: midcarpal (type 1) and radiocarpal (type 2), and
to evaluate the effect of a distal radius osteotomy on
these malalignment patterns.
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MATERIALS AND METHODS
Patients
We included 31 patients in this retrospective study. The
inclusion criteria were: (1) malunion of a Colles frac-
ture treated with distal radius osteotomy, and (2) avail-
ability of a full complement of radiologic films (preop-
erative and follow-up anteroposterior and lateral
radiographs). There were 11 men and 20 women. The
average age was 44 years (range, 16 –76 y); 21 were
operated on the left wrist and 10 on the right. Average time
between trauma and corrective surgery was 3 years and 10
months (range, 3 mo to 30 y). The mean time of radiologic
follow-up was 7 months (range, 6–18 mo). There were 20
patients with a midcarpal malalignment (type 1) and 11
with a radiocarpal malalignment (type 2).
Surgical technique
The senior author performed all surgeries, using tech-
niques described by Fernandez8: 22 had an opening
wedge osteotomy with interposition of corticocancel-
lous iliac-crest graft (1 in combination with Sauvé-
Kapandji and 1 with a Darrach procedure); 1 had an
opening wedge osteotomy with interposition of cancel-
lous graft from the proximal ulna, and 8 had a closing
wedge osteotomy (4 in combination with a Sauvé-
Kapandji procedure and 4 combined with ulnar short-
ening osteotomy). The approaches were volar in 21
patients (14 with an opening and 7 with a closing wedge
osteotomy) and dorsal in 10 (9 with an opening and 1
with a closing wedge osteotomy). For the ulnar proce-
dures, an additional incision was used.
Evaluation
Preoperatively and at the final clinical assessment, we
took standard anteroposterior and lateral radiographs.
On the anteroposterior radiographs, 3 measurements
were used to evaluate the malunion: radial inclination,
radial height (or length), and ulnar variance, which were
measured according to standard techniques.9,10 The
presence or absence of an ulnar styloid fracture was
noted. On the lateral radiographs, we took 5 measure-
ments: dorsal tilt, scapholunate angle, radiolunate angle
(RLA), radioscaphoid angle, and capitolunate angle.
We used standard techniques of measurements here, as
well.4,9,10
We calculated ERLF by the formula: ERLF ⫽ Dor-
sal tilt ⫹ 11° (mean volar tilt) ⫹ RLA. ERLF measures
the movement of the lunate that has occurred as a result
of fracture displacement.11 Patients were divided into 2
groups based on the ERLF. The first group (group 1;
n ⫽ 20, mean age 42 y) had ERLF less than or equal
to 25°, corresponding to type 1 or midcarpal mal-
 CORRECTIVE OSTEOTOMY AND CARPAL MALALIGNMENT 59

TABLE 1. Radiographic Findings at Preoperative and Final Examination

Follow-Up Value
Parameter Normal Value (⫾SD) Preoperative Value (⫾SD) (⫾SD) p Value

Dorsal tilt† 10° (⫾6°) –12 (⫾14°) 6° (⫾10°) .003*

Radial inclination† 22° (⫾3°) 18 (⫾8°) 21° (⫾8°) .009*
Radial height (mm)‡ 8 (⫾14) 9 (⫾3) 10 (⫾4) .006*
Ulnar variance (mm)㛳 Neutral 2 (⫾3) 0 (⫾2) .002*

Values are given as the mean.

*Significant.
†Normal value from Stoffelen et al.10
‡Normal values from Gupta et al.6
㛳Normal value as mentioned by Bushnell and Byrum.9

alignment. The second group (group 2; n ⫽ 11, mean

age 46 y) had ERLF more than 25°, corresponding to
type 2 or radiocarpal malalignment.
Statistical analysis
We used a paired samples t-test to determine if differ-
ences between preoperative and follow-up measure-
ments for each angle were significant. The level of
significance was set at p ⬍ .05.

RESULTS
Radiographs demonstrated an improvement in the dor-
sal tilt, radial inclination, ulnar variance, and radial
length (Table 1). The average preoperative dorsal tilt
was 12° (standard deviation [SD] ⫾14°). Postopera-
tively, the average volar tilt was – 6° (SD ⫾10°) (p ⫽
.001). The radial inclination improved from 18° (SD ⫾8°)
to 21° (SD ⫾8°) (p ⫽ .009). The ulnar variance
improved from an average of 2 mm (SD ⫾3 mm) to
0 mm (SD ⫾2 mm) (p ⫽ 0.001). The preoperative
radial length was 9 mm (SD ⫾3 mm). Postopera-
tively, it improved to 10 mm (SD ⫾4 mm) (p ⫽
.006). There was no significant difference between
volar and dorsal approached wrists (p ⫽ .4 for dorsal
tilt correction, p ⫽ .8 for correction of radial incli-
nation, and p ⫽ 1.0 for ulnar variance correction).
There were 12 patients with an associated fracture of
the ulnar styloid.
The 20 subjects in group 1 with ERLF less than or
equal to 25° (type 1 or midcarpal malalignment) had a
mean preoperative ERLF of 0.8° [SD ⫾16°]). Preop- FIGURE 3: A Midcarpal–adaptive malalignment. B Correction
after osteotomy of the distal radius. C Radiocarpal malalignment.
eratively, the 11 subjects in group 2 with ERLF more
D Correction after osteotomy of the distal radius.
than 25° (type 2 or radiocarpal malalignment) had a
mean ERLF of 33° (SD ⫾6°) (Fig. 3A, B). Postopera-
tively, 4 patients in group 2 had an ERLF greater than
25°; all had a persistent dorsal tilt due to incomplete In group 1 there was a significant improvement (p ⬍
correction. Two had a dorsal approach and two had a .05) in the dorsal tilt, radial height, and ulnar variance
volar approach (Table 2). postoperatively (Table 3). Radial inclination preopera-

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60 CORRECTIVE OSTEOTOMY AND CARPAL MALALIGNMENT

TABLE 2. Patients Grouped According to ERLF

Group Preoperative Dorsal Tilt Mean Age Mean Value ERLF

ERLF ⱕ 25° (group 1) 20 patients 10° (SD) 42 patients 1° (SD 16)

ERLF ⬎ 25° (group 2) 11 patients 17° (SD) 46 patients 33° (SD 6)

TABLE 3. Radiographic Findings for Group 1 (ERLF < 25°) at Preoperative and Final Examination
Parameter Normal Value (⫾SD) Preoperative Value (⫾SD) Follow-Up Value (⫾SD) p Value

Dorsal tilt 10° (⫾6°) –10° (⫾15°) 7° (⫾11°) .002*

Radial inclination 22° (⫾3°) 18° (⫾7°) 21° (⫾6°) .08
Radial height (mm) 8–14 8 (⫾3) 10 (⫾4) .04*
Ulnar variance (mm) Neutral 2 (⫾2) 0 (⫾2) .003*
Scapholunate angle 50 (⫾7°) 63° (⫾13°) 56° (⫾10) .02*
Radiolunate angle 10° (⫾6°) ⫺20° (⫾18°) ⫺7° (⫾18°) .005*
Capitolunate angle 12° (⫾2°) –10° (⫾18°) 0° (⫾15°) .004*
Radioscaphoid angle 60° (⫾4°) 43° (⫾18°) 48° (⫾15°) .1
ERLF 0° 1° (⫾16°) ⫺3° (⫾20°) .5

Values are given as the mean. Normal values for the carpal angles are from Stoffelen et al.10
*Significant.

tively was 18° (SD ⫾7°) and postoperatively was 21°
(SD ⫾6°) (p ⫽ .08). There was also significant im-
provement in the scapholunate angle, RLA, and capi-
tolunate angle. The preoperative scapholunate angle of 63°
(SD ⫾13°) was reduced to an average of 56° (SD ⫾10°)
(p ⫽ .02). Twelve patients in this group had a
scapholunate angle exceeding 60° preoperatively.
The radioscaphoid angle did not show a significant
change between the preoperative and follow-up radio-
graphs. The RLA preoperatively was –20° (SD ⫾18°) and
improved to –7° (SD ⫾18°) (p ⫽ 0.005). The average
preoperative capitolunate angle was 10° (SD ⫾18°); post-
operatively, it was 0° (SD ⫾15°) (p ⫽ .004).
In group 2, there was a significant improvement in
radial tilt and ulnar variance (Table 4, Fig. 3C, D). The
average preoperative radial inclination was 19° ⫾ 9°;
postoperatively, it was 23° ⫾ 10° (p ⫽ .06). Preoper-
atively, radial height measured 10 ⫾ 3 mm; postoper-
atively, this was 11 ⫾ 4 mm (p ⫽ .08). Postoperatively,
all 4 radiographic parameters were considered to be
normal values. The effect on the carpal angles was not
significant. The average preoperative ERLF of 33° (SD
⫾6°) decreased to 9° (SD ⫾15°) (p ⫽ .008). If the 4
patients with residual dorsal angulation after surgery
were excluded, the ERLF was reduced to normal: pre-
operatively at 33° (SD ⫾7°) and postoperatively at 2°
(SD ⫾12°) (p ⫽ .002).
There were no significant associations between pa-
tients’ ages, dorsal tilt and radial shortening, and type of
carpal malalignment (p ⬎ .1).
There was no significant correlation between the
interval between fracture and osteotomy and type of
carpal malalignment (p ⫽ .5).
DISCUSSION
An osteotomy of a distal radius malunion can restore
volar tilt, ulnar variance, radial inclination, and radial
height. However, the effect on radiocarpal and midcar-
pal malalignment is less clear.
Abnormal alignment and motion of the carpal bones
leads to mechanical overload of the radiocarpal and
midcarpal joints. This overload can cause ligament at-
tenuation, synovitis, and progressive dynamic instabil-
ity.5,7 In 1984, Taleisnik and Watson5 reported 13 pa-
tients with symptoms of midcarpal pain and instability
after malunited fractures of the distal radius. They per-
formed a corrective osteotomy in 3 patients. They dem-
onstrated that a corrective osteotomy can result in relief
of symptoms and that osteotomy corrected the radiolu-
nate and lunocapitate relationship. Minami and Ogino12
reported 1 case of midcarpal instability after a mal-
united fracture of the distal radius, in which an osteot-
omy resulted in complete relief of symptoms. McQueen
and Wakefield13 noted a restoration of carpal alignment

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 CORRECTIVE OSTEOTOMY AND CARPAL MALALIGNMENT 61

TABLE 4. Radiographic Findings for Group 2 (ERLF > 25°) at Preoperative and Final Examination
Parameter Normal Value (⫾SD) Preoperative Value (⫾SD) Follow-Up Value (⫾SD) p Value

Dorsal tilt 10° (⫾6°) –17° (⫾10°) 4° (⫾10°) .005*

Radial inclination 22° (⫾3°) 19° (⫾9°) 23° (⫾10°) .06
Radial height (mm) 8–14 10 (⫾3) 11 (⫾4) .08
Ulnar variance (mm) Neutral 3 (⫾3) 0 (⫾1) .002*
Scapholunate angle 50 (⫾7°) 51° (⫾9°) 51° (⫾11) 1
Radiolunate angle 10° (⫾6°) 5° (⫾10°) ⫺3° (⫾11°) .6
Capitolunate angle 12° (⫾2°) 14° (⫾11°) 14° (⫾13°) .9
Radioscaphoid angle 60° (⫾4°) 57° (⫾11°) 53°(⫾10°) .3
ERLF 0° 33° (⫾6°) ⫺9° (⫾15°) .008*

Values are given as the mean.

*Significant.

in 21 of 23 patients who underwent a distal radial
osteotomy using nonbridging external fixation for dor-
sal malunion. Carpal malalignment was defined as the
displacement on a lateral view of the longitudinal axis
of the capitate either dorsal or volar to the longitudinal
axis of the radius.14 Other studies failed to confirm
these findings. In a series of 122 cases, Sennwald et al15
could not obtain good clinical results with radial osteot-
omy in cases with carpal instability. Radiologic out-
comes did not correlate with the clinical outcomes.
Measurements of radiologic outcomes for our cohort
of patients with distal radius malunions were analyzed
statistically. Based on the work of Gupta et al6 we could
clearly make a distinction between 2 types of carpal
(mal)alignment in malunited distal radius fractures. We
were able to demonstrate that a radial osteotomy has a
beneficial effect on the carpal alignment in patients with
the midcarpal malalignment pattern; for the radiocarpal
malalignment pattern, this is still a matter of debate.
Neither the approach— dorsal or volar—nor the type of
correction— opening or closing wedge—seemed to
make a difference in restoring the carpal alignment. In
the first group, the preoperative and postoperative
ERLF was considered normal. In the second group,
there was a significant effect on the ERLF, but it could
not be completely restored. The incomplete correction
is mainly due to the incomplete correction of the dorsal
tilt in the radial osteotomy.
Clearly, 2 patterns exist of carpal malalignment in
malunited distal radius fractures. Longitudinal surveys
are necessary to evaluate the effect of each on the
evolution of the biomechanics and degeneration of the
wrist. We could not evaluate such an effect in this
study. Regardless, both patterns can be effectively cor-
rected with an osteotomy of the distal radius.
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