Forearm Malunions: Corrective Osteotomies

Forearm Malunions: Corrective Osteotomies

Carley Vuillermin

Operative Indications

Symptomatic malunion without the potential to remodel (Figure 16.1)

  • Restricted range of motion

  • Pain—particularly functional pain not responsive to therapy

    • Pain at rest should prompt investigation as it is not common in an isolated malunion

  • Instability

    • Distal radioulnar joint (DRUJ) in diaphyseal malunions

    • Midcarpal joint in distal radial malunions

  • Nerve compression

  • Musculotendinous contracture or impingement

  • Combination of the above

Alternative Treatments

  • Natural history

    • Younger children with sufficient growth remaining may remodel marked deformities

      • Especially if distal, close to physis, and in plane of motion of joint

      • Diaphyseal and especially proximal forearm malunions are less likely to remodel

      • Rotational malunion will not remodel (Figure 16.2)

    • Mild degrees of deformity may be tolerated, so correction rarely performed in the absence of symptoms, restricted motion, instability, or activity-associated pain

Corrective Osteotomy (Figure 16.3)


  • Supine with radiolucent arm and hand table

Surgical Approach

  • Extensile exposures—most commonly a subcutaneous approach for the ulna and volar Henry approach to the radius.

  • Occasionally, a posterior approach to the radius may be indicated, however, not commonly

Preoperative Planning

  • This is essential

  • The more time spent here, the better the case will go and the more likely surgery will improve the patient’s problem

  • Determine the deformity, especially the apex and axis of deformity

    • Do plain radiographs adequately display the deformity?

    • Does the clinical examination match the radiographic findings?

    • Is there a soft-tissue component to the deformity that will not be seen on radiographs?

      • Long bone radiographs of entire forearm are better for diaphyseal and complex multiplanar deformity planning

      • Additional joint radiographs can more accurately quantify periarticular deformities

    • Is this a simple deformity or complex?

      • The deformity may be more complex when there are

        • multiple deformities/fractures

        • joint malalignment

        • incomplete remodeling

        • secondary growth arrest

    • Complex deformities benefit from 3D planning

      • Standard radiology 3D scans and proprietary options exist

    • Create an “on paper” template plan using either plain films and/or 3D reconstructions

      • Determine the location and magnitude of correction

      • Consider the effect of your correction on the DRUJ and ulna variance

  • Plan the appropriate fixation

    • Many metaphyseal deformities in the pediatric and adolescent population can be fixed with K-wires

    • 2.4- and 2.7-mm plates and screws can be good alternatives to 3.5-mm implants in the shaft in the younger patient

    • Anatomic specific implants commonly will not be suitable

Technique in Steps


  • Through planned ulna and/or radial approaches

  • Each osteotomy should be performed via a separate incision to minimize the risk of cross union

  • Longitudinally incise the periosteum for the length of the fixation if using a plate and screws; intramedullary or percutaneous wire fixation requires only subperiosteal elevation at osteotomy site

    • Only at the osteotomy site does the periosteum need to be elevated circumferentially

    • Additional subperiosteal elevation may be required to aid fragment mobility

  • Ensure the periosteum is kept intact—so a biologic envelop surrounds the osteotomy on closure

    • The intact periosteum also protects the adjacent tendons and neurovascular structures

Planning the Osteotomy in Operating Room After Surgical Exposure

  • Using your preoperative template, mark the osteotomy

    • Most commonly with K-wires and fluoroscopy

Keep Control of the Osteotomy at All Times

  • Periarticular osteotomies should have the articular fragment fixation with plate and distal screws or temporary fixation set prior to making the osteotomy

    • Fixation should be preset taking into account the corrected position of the distal fragment, so that the wires or plate will intersect the proximal fragment properly in corrected position

      • This requires biplanar thinking and planning

  • Diaphyseal osteotomies: As it can be hard to judge rotation after the osteotomy is performed, a longitudinal mark across the planned osteotomy site should be made

    • This is best with a true indentation in the bone rather than ink alone

      • Either an osteotome or careful use of a saw

      • Consider the placement of fixation and direction of any rotatory deformity correction so that these marks can be visualized after correction achieved

        • If a plate is to be used, commonly this mark can be along either the front or back edge of the plate

      • Place a line of surgical marker into the groove to help maintain visualization of the mark

    • Alternate methods of marking include a monopolar diathermy line or ink marker; however, these are more prone to be wiped away during the procedure

    • When possible, place one side of the fixation prior to performing the osteotomy

    • Screws partially inserted through the plate and removed make later fixation after manipulation of fragments into corrected position easier

      Remember, never lose control of your osteotomy

      • Most commonly, initial fixation in the proximal shaft for diaphyseal osteotomies is used as it is easier to secondarily manipulate the distal fragment and

      • Distal fixation in wrist periarticular and distal metaphyseal osteotomies

Perform the Osteotomy

  • Determine if a complete or incomplete osteotomy is required

    • Most commonly, a complete osteotomy is required in distal radius and forearm diaphyseal corrections

  • Oscillating saw

    • Irrigate while sawing, stop frequently to cool the blade, and clean the teeth

    • Preservation of biology and avoiding necrosis is essential regardless of the method chosen

    • At times, the only safe way to complete the osteotomy is with an osteotome

  • Drilling sequential holes and then using osteotome is an alternate lower energy technique

    • Most common for distal radial metaphyseal 3D deformity (Madelung deformity)

Complete the Correction and Fixation

Jun 9, 2022 | Posted by in Reconstructive surgery | Comments Off on Forearm Malunions: Corrective Osteotomies

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