This document reports on three cases of non-union of fractures of the lower end of the radius. Non-union of distal radius fractures is rare, with an incidence of around 0.2%. The cases presented had different clinical presentations and treatment histories, but all resulted in non-union of the radius. Early suspicion of potential non-union is important if x-rays at 6 weeks show a clear fracture line without signs of healing. Surgical treatment of non-union involves debridement, correction of any deformity, bone grafting and internal fixation. However, patient acceptance of corrective surgery can be poor given the minimal disability caused by the non-union in some cases.

1. Non union Lower end Radius
Vinod Naneria
Girish Yeotikar
Arjun Wadhwani
Choithram Hospital & Research Centre,
Indore , India

2. Purpose
• Reporting three cases of non-union of fracture
lower end radius.
• It is extremely rare condition
• Difficult to pinpoint the etiological cause.
• No single or multiple factors could be
indentified.
• None had any co-morbidity or risk factor.

3. Early suspicion?
• When x-rays at 6 weeks showing clear fracture
line with no attempt at union then it should
be suspected for possible non union.
A clear fracture line with no callous at 6 weeks

4. Cases in brief
• All the three patients have different
presentations.
• Cases one and two were initially treated
properly.
• Case one had failed open reduction and bone
grafting.
• Case two refused open reduction in small
district place hence waited for six months.
• Case three refused even initial treatment.

5. Introduction
• Distal radius fractures are the most frequent
ones on the upper limb.
• Account for 10 to 12% of all fractures of the
skeleton.
• Represent 74.5% of all fractures of the
forearm, with an approximate incidence of
1:10.000 individuals.

6. Incidence
• Watson-Jones reported 1 case in 3199 cases of
fracture distal radius in 1942.
• Barcon and Kurtzke reported incidence as
0.2% in a study of 2000 cases fractures of
lower end radius, in 1953.
Exact cause is not known
Soft tissue interposition?

7. General Risk factors:
• low-energy fractures,
• Impaction of metaphysis.
• DM, smoking, alcohol, collagen disorder,
• Obesity,
• Improper treatment
• Over distraction by ex fix
• Osteoporosis.

8. Recommonded Surgical principles
• Debridment of the nonunion, removing all
fibrous and synovial interposed tissues.
• Removing the sclerotic end caps,
• Intramedullary canal is opened on both sides.
• Deformity in the sagittal and coronal planes
should be corrected by an opening wedge.

9. Surgical principles
• Radial deviation deformity is corrected by
lengthening the Brachioradialis and Flexor
Carpi Radialis tendon.
• The use of Locking plates allows for more
points of fixation in case of small distal.
• There is usually a larger amount of bone in the
radial styloid portion of the distal fragment
that can be used for internal fixation.

10. Surgical principles
• Tri-cortical opening wedge graft will provide
intrinsic stability because of the tightening of
the soft tissue.
• Cancellous bone graft should be used.
• For severe shortening of the distal radius that
cannot be corrected, resection of the distal
ulna (Darrach procedure).

11. Wrist arthrodesis
• Insufficient bone for fixation.
• When there are fewer than 6 mm of bone
between the lunate facet of the distal radius
articular surface and the fracture site.
• Pre-existing arthrosis of radio-carpal joints.
• Failed attempt of fixation of non union.

12. Case one
• 42 years old female.
• Low energy trauma.
• Fracture lower end radius
• Treated conservatively by closed reduction
and pop casting in Dec 2012.

13. Dec 2012

14. March 2013
Close reduction and POP
Early sign

15. March 2013
Open reduction,
K-wire fixation
Bone grafting
POP cast

16. June 2013
Excision lower end ulna
Removal of K-wires

17. July 2013

18. Severe Palmer flexion and ulnar deviation deformity

19. Dorsal
Palmer/voral

20. Ulnar Radial

34. Palmer surface

36. Oct 2013
10 weeks
Post surgery
MP joint flexion ↑
Ex-fix removed
Physio-continue
Patient’s
satisfaction good
Wrist mobilization
started.

38. After 6 months

39. Case two
• 50 years old female
• Low energy injury
• Sustained fracture lower end radius
• Pop cast for six weeks
• Progressively increasing deformity following
removal of plaster.
• X- rays after six months following fracture
showing non-union.

40. Established non union
Six month old injury

41. Surgery
• Volar exposure
• Removal of scar tissue and clearing of bone
ends.
• Release of soft tissue contractures.
• Shortening of ulna and plating.
• Plating of radius with bone grafting.

42. Feb 2013

43. April 2014

44. Sept 2013

45. Case three
• 40 years old Female,
• Sustained fracture lower end radius on 13th Sept
2014.
• Received no treatment.
• No co-morbidity.
• Chief complaint was deformity of wrist.
• X-rays on 11th Nov 2014 showing delayed union
• Clinically no disability.
• Patient refused corrective surgery.

46. 13th Sept 2014

47. 11th Nov 2014
Early sign of potential nonunion

49. Comments
• The disability is minimal
• Very little / no pain
• Cosmoses is only complaint
• Acceptance for surgery is poor
• Hence delayed / no treatment

50. References
• Fernandez DL, Ring D, Jupiter JB. Surgical management of delayed union and
nonunion of distal radius fractures. J Hand Surg 2001;26A:201e9.
• Chapman MW. Principles of treatment of non-unions and malunions. In: Chapman
MW, editor. Chapman’s Orthopedic Surgery. 3rd edition. Lippincott
• Williams and Wilkins; 2001. p. 847e66.
• Segalman KA, Clark GL. Un-united fractures of the distal radius. A report of 12
cases. J Hand Surg 1998;23A:914e8.
• Bacorn RW, Kurtzke JF. Colle’s fracture. A study of two thousand cases from the
New York State Workmen’s Compensation Board. J Bone Joint Surg 1953;35A:
643e58.
• McKee MD, Waddell JP. Non-union of distal radial fractures associated with distal
ulnar shaft fractures: a report of four cases. J Orthop Trauma 1997;11: 49e53.
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259e62.

51. References
• Harper WM, Jones JM. Non-union of Colle’s fracture: report of 2 cases. J Hand Surg
1990;15B:121e3.
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• Prommersberger KJ, Fernandez DL. Non-union of distal radius fractures. Clin Orthop
2004;419:51e6.
• Prommersberger KJ, Fernandez DL, Ring D, et al. Open reduction and internal fixation of un-united
fractures of the distal radius: does the size of the distal fragment affect the result?
Chir Main 2002;21:113e23.
• Kaempffe FA, Wheeler DR, Peimer CA, et al. Severe fractures of the distal radius: effect of
amount and duration of external fixator distraction on outcome. J Hand Surg
1993;18A:33e47.
• Orbay JL, Fernandez DL. Volar fixation for dorsally displaced fractures of the distal radius: a
preliminary report. J Hand Surg 2002;27A:205e15.
• Leung F, Zhu L, Ho H, et al. Palmar plate fixation of AO type C2 fracture of distal radius using
a locking plateda biomechanical study in a cadaveric model. J Hand Surg 2003;28B:263e6.
• Jakob M, Rikli DA, Regazzoni P. Fractures of the distal radius treated by internal fixation and
early function. A prospective study of 73 consecutive patients. J Bone Joint Surg
2000;82B:340e4.

52. DISCLAIMER
Information contained and transmitted by this presentation is
based on personal experience and collection of cases at
Choithram Hospital & Research centre, Indore, India. It is
intended for use only by the students of orthopaedic surgery.
Views and opinion expressed in this presentation are
personal. Depending upon the x-rays and clinical
presentations viewers can make their own opinion. For any
confusion please contact the sole author for clarification.
Every body is allowed to copy or download and use the
material best suited to him. I am not responsible for any
controversies arise out of this presentation. For any
correction or suggestion please contact naneria@yahoo.com