Clinical and functional outcome of malunited distal radius fractures: a single-centre observational study from a tertiary care hospital in Northern India

INTRODUCTION

Distal radius fractures are among the most prevalent skeletal injuries encountered in emergency and trauma settings, accounting for approximately one-sixth of all fractures presenting to orthopaedic departments.¹ They follow a bimodal epidemiological pattern: high-energy fractures in young adults and low-energy insufficiency fractures in elderly, osteoporotic individuals.² Despite advances in fracture fixation and rehabilitation, malunion remains a well-recognised complication, resulting from failure to achieve or maintain anatomical alignment. Malunion of the distal radius is defined as fracture healing in a non-anatomical position and is characterised by dorsal angulation, radial shortening, reduced radial inclination, and positive ulnar variance.³ These deformities collectively disrupt load transmission across the radiocarpal and distal radioulnar joints (DRUJ), alter carpal kinematics, and predispose patients to ulnocarpal impaction, DRUJ incongruity, and progressive degenerative arthritis.^4,5 The clinical sequelae include chronic pain, restricted wrist motion, diminished grip strength, cosmetic deformity, and significant limitations in activities of daily living consequences that are especially pronounced in manual labourers and younger, high-demand individuals.

Radiographic thresholds associated with inferior functional outcomes are well established in the literature: dorsal tilt exceeding 10-15°, radial shortening greater than 5 mm, radial inclination below 15°, and ulnar variance greater than 2 mm.⁶ Beyond these thresholds, both biomechanical derangement and patient-reported disability increase substantially.

Functional outcome assessment in distal radius malunion has evolved from purely clinician-derived scores such as the Gartland–Werley demerit score and the Modified mayo wrist score toward patient-reported outcome measures (PROMs).⁷ The DASH score and the PRWE score are now considered the standard instruments for evaluating wrist-specific disability and upper-limb function, owing to their established validity, reliability, and responsiveness.^8,9 While multiple international studies have characterised the radiological and functional burden of distal radius malunion, robust institution-specific data from tertiary care hospitals in North India remain limited. Uniform assessment protocols, consistent radiographic measurement practices and comparable rehabilitation environments within a single centre minimise heterogeneity and enhance interpretability of results.

The present study was therefore designed to systematically evaluate the clinical, radiological, and functional outcomes of malunited distal radius fractures at a tertiary care teaching hospital in Lucknow, Uttar Pradesh, using a standardised multimodal assessment framework. The specific objectives were to quantify radiographic deformity and its clinical correlates, to measure functional disability using validated PROMs, and to determine the strength of association between radiological parameters and functional outcome scores.

METHODS

Study design and setting

This was a hospital-based, single-centre, observational descriptive study conducted in the Department of Orthopaedic Surgery at Balrampur Hospital, a tertiary care teaching institution in Golaganj, Lucknow, Uttar Pradesh. The study was conducted over six months, from February 2025 to July 2025. Ethical approval was obtained from the Institutional Ethics Committee (IEC Ref. No. 18 18(-1) HB 2023), and the study was conducted in accordance with the ethical principles of the Declaration of Helsinki (revised 2013). Written informed consent was obtained from all participants prior to enrolment.

Participants

Patients presenting to the orthopaedics outpatient department or admitted during the study period with a diagnosis of malunited distal radius fracture were considered for inclusion. Inclusion criteria were: age ≥18 years; radiologically confirmed malunited distal radius fracture defined by at least one of the following dorsal tilt >10°, radial shortening>5 mm, radial inclination <15°, or positive ulnar variance; fracture union achieved at least three months prior to enrolment; and willingness to provide written informed consent.

Patients were excluded if they had acute or ununited distal radius fractures, pathological fractures, previous corrective surgery to the distal radius, associated ipsilateral upper-limb fractures affecting wrist or hand function, neurological disorders affecting upper-limb function, pre-existing inflammatory arthritis or pre-existing wrist deformity.

A total of 58 patients fulfilling the eligibility criteria were enrolled consecutively during the study period. No formal sample size calculation was performed; the cohort represents the complete eligible population presenting within the study window a strategy appropriate for this observational, single-centre design.

Clinical assessment

All evaluations were performed by the treating orthopaedic surgeon using standardised techniques. Pain was quantified on a 10-cm Visual analogue scale (VAS; 0 =no pain, 10=worst imaginable pain). Wrist range of motion was measured with a standard goniometer in six planes: palmar flexion, dorsiflexion, radial deviation, ulnar deviation, pronation and supination. Grip strength of the affected and contralateral wrists was measured using a calibrated hand dynamometer (three trials, mean recorded) and percentage deficit relative to the unaffected side was calculated. Visible deformity, localized tenderness and wrist instability were documented.

Radiological assessment

Standard posteroanterior and lateral radiographs of the affected wrist were obtained for all patients using uniform positioning and exposure protocols. Four radiographic parameters were measured by a single observer using established techniques: dorsal/volar tilt on the lateral view; radial height on the posteroanterior view; radial inclination on the posteroanterior view; and ulnar variance. These measurements were used both to confirm malunion status and to quantify the degree of deformity for correlation analysis.

Functional outcome assessment

Functional outcomes were assessed using four validated instruments administered at the time of enrolment: the DASH score (0-100; higher scores indicate greater disability); the PRWE score (0-100; higher scores indicate worse outcomes); the Modified mayo wrist score (100=perfect; ≥90 excellent, 80-89 good, 65-79 fair, <65 poor); and the Gartland–Werley demerit score.^7-9

Statistical analysis

Data were entered into Microsoft Excel 2019 and analysed using SPSS version 27.0 (IBM Corp., Armonk, NY). Continuous variables were expressed as mean±standard deviation (SD). Categorical variables were expressed as frequencies and percentages. Normality of distribution was assessed using the Shapiro–Wilk test. Associations between radiological parameters and functional outcome scores were examined using Pearson's correlation coefficient for normally distributed variables and Spearman's rank-order correlation for non-normally distributed variables. A two-tailed p value <0.05 was considered statistically significant throughout.

RESULTS

A total of 58 patients with radiologically confirmed malunited distal radius fractures were evaluated during the study period. Their demographic and injury characteristics are summarised in Table 1. The majority of patients were middle-aged adults (mean age 44.6±12.8 years), with a male predominance (62.1%). Falls on an outstretched hand (46.6%) and road traffic accidents (41.4%) were the leading mechanisms of injury. Radiological assessment revealed significant deformity across all measured parameters, as presented in Table 2.

Mean dorsal tilt (18.6°) substantially exceeded the clinically accepted threshold of 10-15°. Radial height loss (6.4 mm) and positive ulnar variance (+3.1 mm) similarly exceeded accepted acceptable limits. Table 3 shows the distribution of patients according to individual deformity criteria. Positive ulnar variance was the most frequently observed deformity (75.9%), followed by dorsal tilt exceeding 15° (70.7%). The majority of patients demonstrated multiple coexisting deformity components.

Clinical outcome measures are presented in Table 4. Palmar flexion and dorsiflexion were reduced compared with published normative values. The affected wrist demonstrated a mean grip strength of 19.8±4.6 kg versus 26.4±5.1 kg on the contralateral side, representing an approximately 25% deficit. The mean VAS pain score of 5.6±1.8 indicated moderate pain.

SD: Standard deviation.

SD: Standard deviation.

Values indicate number of patients satisfying each individual criterion; patients may fulfil multiple criteria simultaneously.

Functional outcome scores are shown in Table 5. Mean DASH (42.3±11.7) and PRWE (48.9±13.4) scores indicated moderate-to-severe functional disability. The mean Modified mayo wrist score of 63.8±12.1 placed the majority of patients in the 'fair' or 'poor' outcome category. Correlation analysis between radiological deformity parameters and functional outcome scores is presented in Table 6. Significant positive correlations were observed between dorsal tilt, radial shortening and ulnar variance with both DASH and PRWE scores, indicating that greater deformity was associated with worse functional outcomes. Radial inclination showed significant negative correlations, confirming that lower inclination values corresponded to higher disability scores.

SD: Standard deviation, VAS: Visual analogue scale.

DASH: Disabilities of the arm, shoulder and hand; PRWE: Patient-rated wrist evaluation; SD: Standard deviation.

DASH: Disabilities of the arm, shoulder and hand; PRWE: Patient-rated wrist evaluation; r: Pearson/Spearman correlation coefficient. p<0.05 considered statistically significant.

DISCUSSION

The present single-center study systematically characterized the radiological, clinical and functional burden of malunited distal radius fractures in a North Indian tertiary care setting. Our findings confirm that distal radius malunion is associated with substantial radiographic deformity, measurable deficits in wrist motion and grip strength, moderate-to-severe patient-reported disability, and a significant though not exclusive relationship between deformity magnitude and functional outcome. These findings are broadly concordant with both Indian and international literature.

Radiological deformity and its clinical relevance

In the present cohort, the majority of patients demonstrated dorsal tilt exceeding 15°, radial shortening greater than 5 mm and positive ulnar variance all surpassing widely accepted thresholds for clinically relevant malunion.⁶ Andreasson et al reported comparable radiographic profiles in patients presenting for corrective osteotomy and demonstrated that greater dorsal tilt and radial shortening correlated with worse pre-operative functional scores.¹¹ Similarly, Mulders et al, in a systematic review and meta-analysis, confirmed that unacceptable radiographic alignment following distal radius fractures was associated with inferior functional outcomes.¹² The high prevalence of positive ulnar variance (75.9%) in our series likely reflects the contribution of radial shortening to altered load distribution at the DRUJ and ulnocarpal articulation, a mechanism well described in biomechanical studies.^4,5

Clinical outcomes: range of motion, grip strength and pain

Patients demonstrated reduced wrist range of motion across all planes and an approximately 25% reduction in grip strength relative to the contralateral side findings consistent with prior reports of altered load transmission and capsular contracture following malunion. Grewal and MacDermid documented analogous deficits in wrist motion and grip strength in patients with residual deformity after distal radius fractures, with impairments being more pronounced in younger, high-demand individuals.¹³ Indian series echo these findings: Venkat et al reported substantial pre-operative reductions in wrist motion and grip strength in a single-centre cohort undergoing corrective osteotomy.¹⁴ The mean VAS pain score of 5.6±1.8 observed in our cohort indicates moderate baseline pain, likely reflecting a combination of radiocarpal arthritis and DRUJ incongruity that commonly develops beyond accepted deformity thresholds.

Patient-reported functional disability

Mean DASH (42.3±11.7) and PRWE (48.9±13.4) scores in this study indicate moderate-to-severe functional disability. Belloti et al reported comparable pre-operative PRWE scores in patients undergoing corrective osteotomy, with significant improvement following surgery.¹⁵ The Modified Mayo wrist score distribution predominantly in the 'fair' and 'poor' categories corroborates the substantial functional burden observed on PROMs. Dutta et al, in an Indian series, similarly reported poor-to-fair functional outcomes in patients with untreated distal radius malunion, with meaningful improvement only after corrective osteotomy.¹⁶ Collectively, these comparisons validate the severity of functional impairment documented in the present study and support the case for timely intervention in symptomatic patients with significant deformity.

Radiological–functional correlation

A central finding of this study is the moderate but statistically significant correlation between radiological deformity parameters and DASH and PRWE scores (r=0.39-0.51). This is consistent with the current understanding that radiographic deformity is an important but incomplete determinant of patient-reported disability. Mulders et al highlighted that the radiographic functional relationship is modulated by patient age, activity demands, and soft-tissue adaptation.¹² Schmidt et al, in a prospective cohort of 366 patients with one-year follow-up, demonstrated non-linear relationships between radiographic parameters and functional outcomes, reinforcing the necessity of integrating PROMs with objective imaging findings in clinical decision-making.¹⁷ The moderate correlation coefficients observed in our cohort (r≈0.4-0.5) affirm this complexity: while deformity predicts disability, it does not fully explain it underscoring the value of multimodal outcome assessment.

Limitations

Several limitations of this study merit acknowledgement. First, the observational design without a control arm precludes causal inference. Second, the six-month recruitment window at a single centre may limit generalisability to broader populations. Third, intra- and inter-observer reliability of radiographic measurements was not formally assessed. Fourth, patient-level covariates such as occupational demand, hand dominance, and duration of malunion were not systematically analysed as independent predictors of functional outcome. Fifth, the Gartland–Werley score was administered without longitudinal follow-up, limiting assessment of outcome trajectory. Future prospective, multi-centre studies with longer follow-up including pre- and post-intervention comparative data would substantially strengthen the evidence base in this population.

CONCLUSION

Malunited distal radius fractures produce significant radiological deformity, measurable deficits in wrist motion and grip strength and moderate-to-severe functional disability as quantified by validated patient-reported outcome measures. In this cohort, deformity parameters particularly dorsal tilt, radial shortening, and positive ulnar variance correlated significantly with DASH and PRWE scores, confirming the functional relevance of radiographic malunion beyond its imaging characteristics. These findings are most pronounced in middle-aged, high-demand individuals and provide institution-specific evidence relevant to patient counselling, treatment prioritisation, and surgical planning at tertiary care centres in North India. Integrated assessment combining objective radiological measurements with patient-reported outcome instruments is essential for informed clinical decision-making. Early recognition of unacceptable fracture alignment and timely corrective intervention remain the most effective strategy for preventing long-term functional morbidity.

ACKNOWLEDGEMENTS

Support and guidance were gratefully acknowledged from the Department of Orthopaedics, including the academic supervision and departmental leadership that contributed to the successful completion of the study.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee (IEC Ref. No. 18 18(-1)HB 2023)

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