What treatment options are available for a nonunion wrist fracture with apex-volar deformity and ulnar positive variance after 6 weeks of splinting?

Treatment Options for Nonunion Wrist Fracture with Apex-Volar Deformity and Ulnar Positive Variance

Surgical fixation is strongly recommended for this nonunion wrist fracture with apex-volar deformity >25 degrees and ulnar positive variance, as conservative management has failed and these radiographic parameters indicate significant deformity requiring correction. 1

Understanding Your Diagnosis

• Nonunion means your wrist fracture has failed to heal properly after 6 weeks of splinting 2
• Apex-volar deformity >25 degrees indicates significant angulation of the fracture that exceeds acceptable parameters (normal volar tilt should be 8.5-15.5 degrees) 3
• Ulnar positive variance means the ulna is longer than the radius at the wrist joint, which can cause ulnar impaction syndrome and pain 4

Recommended Treatment Approach

Primary Treatment: Surgical Intervention

• Surgical fixation is indicated for fractures with postreduction radial shortening >3 mm, dorsal tilt >10°, or intra-articular displacement 1
• For nonunion with significant deformity, surgical reconstruction is necessary to restore proper alignment and function 2

Specific Surgical Options:

1. Combined Corrective Osteotomy:

   • Radial closing-wedge osteotomy to correct the apex-volar deformity
   • Simultaneous ulnar shortening osteotomy to address the ulnar positive variance
   • Internal fixation with volar locking plate for the radius 3

2. Open Reduction and Internal Fixation (ORIF):

   • With bone grafting to promote healing of the nonunion site
   • Volar locking plate fixation to stabilize the fracture 2, 5

3. Ulnar Shortening Procedure:

   • Can be performed as a standalone or combined procedure
   • Uses a sliding-hole dynamic compression plate to achieve proper ulnar length 4

Expected Outcomes

• Most distal radius nonunions can be successfully treated with reconstruction surgery even when the distal fragment is small 2
• Correction of both the radial deformity and ulnar variance is critical for optimal functional results 3
• Following proper surgical correction, patients typically experience:
  • Improved wrist function
  • Decreased pain
  • Better grip strength 4

Potential Complications

• Hardware irritation may occur in some patients (reported in 6 of 27 patients in one study) 4
• Persistent instability of the distal radioulnar joint if not properly addressed 6
• Risk of malrotation or angulation if surgical technique is not optimal 4

Rehabilitation Considerations

• Early motion is typically allowed immediately after surgery to prevent stiffness 3
• Active finger motion exercises are important to prevent stiffness, which is one of the most functionally disabling adverse effects of hand fractures 7
• Regular radiographic follow-up will be needed to ensure proper healing 7

Important Considerations

• Wrist fusion (arthrodesis) should be reserved as a last resort when reconstruction is not possible 2
• The rarity of distal radius nonunions means there is limited consensus on optimal treatment, but preserving wrist motion should be prioritized when possible 2, 5
• Nonunion in distal radius fractures is often associated with unstable situations, such as concomitant fracture of the distal radius and ulna, or inadequate immobilization 2