The aim of the radial closing-wedge osteotomy is to correct the volar tilt angle in the sagittal plane to within a normal range of 8.5° to 15.5°¹⁶. Plan the amount of bone wedge to be removed using radiographs of the injured wrist. The angle of the bone wedge to be removed corresponds to the dorsal tilt plus the normal volar tilt of the radius (30° + 8° = 38° in the patient shown in Fig. 1). Determine the amount of volar cortex to be removed using tracings of the radiograph (8 mm in the patient in Fig. 1 [lateral radiograph]). To improve radial inclination, the distance between the two osteotomy lines is 1 mm shorter on the radial side than on the ulnar side (Fig. 1 [posteroanterior radiograph]).

The aim of the ulnar shortening osteotomy is to restore ulnar variance to within a normal range of −2.5 to 0.5 mm¹⁶, irrespective of the radiographs of the uninjured wrist. The amount of bone to be removed with the distal osteotomy corresponds to the positive ulnar variance measured on the preoperative radiographs (7 mm in the patient shown in Fig. 1 [posteroanterior radiograph]) and that to be removed with the proximal osteotomy is determined from intraoperative radiographs after reduction and internal fixation of the distal part of the radius.

Place the patient in a supine position with the hand on an arm-table, apply a tourniquet to the upper arm, and inflate it to 250 mm Hg. Use regional or general anesthesia.

Make an 8-cm longitudinal skin incision over the radial edge of the flexor carpi radialis muscle.

Expose the pronator quadratus muscle through the interval between the flexor carpi radialis and the radial artery. Incise the pronator quadratus longitudinally along the radial border of the distal part of the radius at its insertion, leaving a small cuff of tissue that can be repaired during closure.

Mark two osteotomy lines, leaving enough room to place a volar locking plate on the distal fragment (Fig. 2-A). Determine the distance between the two lines using tracings of the radiographs (8 mm in the patient shown in Fig. 1). Direct the distal osteotomy approximately parallel to the joint surface with an oscillating saw, taking care to avoid a complete osteotomy of the dorsal cortex (Fig. 2-B). Then complete the proximal osteotomy and remove the wedge of bone (Fig. 2-C).

Reduce the distal fragment, keeping the dorsal cortex as a hinge. Complete reduction of the distal fragment is usually unsuccessful until the ulnar osteotomy is completed.

Make a 10-cm longitudinal skin incision along the distal third of the ulna. Open the interval between the extensor carpi ulnaris and flexor carpi ulnaris and expose the ulna subperiosteally dorsally.

Fit a 3.5-mm six-hole LCP to the distal part of the ulna with three distal screws. Ensure that the plate is parallel to the bone along its whole length.

Mark the site of the osteotomy at the middle of the plate and make an aligning mark proximal to the plate (Fig. 3-A).

Remove the plate and resect the estimated section of ulna, which is equivalent to the ulnar variance, with transverse osteotomies (Fig. 3-B).

Reapproximate and hold together the two fragments of the radius with a 1.8-mm Kirschner wire (Fig. 4).

Confirm the position of the radius with regard to volar tilt and radial inclination on fluoroscopic views. The acceptable range of volar tilt is 1° to 21° and that of radial inclination is 13° to 30°¹⁷.

Secure permanent fixation with a volar locking plate (Video 1; see Appendix).

Reapply the 3.5-mm six-hole LCP to the distal ulnar fragment with three screws. Realign the hand and wrist rotationally, using the previously made longitudinal aligning mark. Use a reduction forceps to hold the plate temporarily against the proximal fragment. If it is difficult to close the osteotomy, fix an AO compression device (Synthes, Paoli, Pennsylvania) to the proximal fragment with a unicortical screw, having engaged the mobile arm in the most proximal plate-hole (Fig. 5-A). Tighten the compression device to close the osteotomy site.

Evaluate residual ulnar positive variance, which is usually 3 to 4 mm, with fluoroscopy. For the proximal ulnar osteotomy, loosen the AO compression device and release the plate from the proximal fragment. It is not necessary to unscrew the plate from the distal fragment. Shorten the ulna further as needed by removing additional bone from the proximal fragment (Fig. 5-B).

Again, clamp the plate to the proximal fragment and fix the AO compression device. Reapply compression until the two fragments of the ulna abut (Fig. 6), and confirm this with fluoroscopic views.

Insert the proximal screws and remove the compression device. If more compression is desired, use the off-center drill guide.

Repair the pronator quadratus muscle and close the wound in layers.

Apply a volar short-arm plaster splint until the soft tissues heal. Finger motion is encouraged immediately after the operation.

Schedule the first postoperative clinic visit at ten to fourteen days for wound inspection and suture removal, at which time the hand therapist can supply the patient with a removable static volar wrist splint and start the rehabilitation program.

Obtain radiographs every month postoperatively until union is achieved. After complete union of both radial and ulnar osteotomy sites has occurred, allow the patient to resume full normal activities. We do not recommend plate removal unless the patient has irritation from the implants.

Extra-articular distal radial malunion.

Reduced wrist motion or pain with the activities of daily living.

No absolute criteria for the degree of deformity were used.

Advanced degenerative changes or substantial incongruity of the distal radioulnar or radiocarpal joint.

Reduction of the distal part of the radius after radial closing-wedge osteotomy is rarely accomplished unless the ulnar osteotomy is performed.

True-positive ulnar variance is difficult to evaluate until dorsal angulation of the radius is restored.

Ulnar variance should be restored to within a normal range of −2.5 to 0.5 mm¹⁶, irrespective of the radiographs of the uninjured wrist. The uninjured wrist may not provide a better reference than normal values obtained from a database^16,18.

What technique have you found to be effective in achieving normal ulnar variance with ulnar shortening osteotomy?

True-positive ulnar variance is difficult to evaluate on preoperative radiographs as dorsal angulation gives a false impression of shortening of the radius. Ulnar shortening osteotomy should be performed in two stages. In the distal osteotomy, a wafer of bone that corresponds to the ulnar variance should be removed. Following correction and internal fixation of the distal radial fragment, the residual ulnar variance should be evaluated on intraoperative radiographs. If normal ulnar variance has not yet been achieved, the ulna should be further shortened by removing additional bone from the proximal fragment.

The first cut of the ulnar osteotomy (Step 3) can be made before the radial osteotomy. This allows the bone to overlap, which may help to determine how much of the ulna needs to be resected. In our experience, however, the amount of overlap is smaller than the amount of ulna requiring resection to establish the normal ulnar variance.

What prophylactic measures have you found to be effective in minimizing the risk of delayed union after ulnar shortening osteotomy?

The plate should be attached to the distal fragment with screws prior to the osteotomy, as the distal fragment is very mobile after the osteotomy and it is difficult to screw the plate to it.

Any kind of compression device can be used to close the osteotomy site.

The total amount of the ulna to be resected may reach >10 mm. It is sometimes difficult to close the osteotomy site even if a compression device is used. In such cases, the interosseous membrane attached to the distal fragment of the ulna should be released. Undue tension may result in a fracture of the distal fragment or loosening of the plate.