Misalignments after fractures of the hand

What does a misalignment after a fracture mean?

We speak of a misalignment (malunion) when a broken bone grows together in a changed position. This can affect axis, rotation, length or the articular surface. This must be distinguished from nonunion (lack of bone healing).

• Axis deviation: e.g. B. Tilting of the spoke end dorsally/volarly
• Rotation error: fingers cross when making a fist (“scissoring”)
• Change in length: shortening/lengthening, etc. with influence on the DRUJ
• Intra-articular step/incongruence: Unevenness in the articular surface
• Combined deformities: Multiple levels affected at the same time

Possible consequences include pain under strain, reduced grip strength, tendon friction or snapping, premature cartilage wear and functional limitations in rotation (twisting movements) and power grips.

Hand and wrist anatomy – why alignment matters

The hand consists of 27 bones that work in a finely coordinated network: the radius and ulna form the wrist with the carpus, followed by the metacarpal bones and fingers. Articular surfaces, ligaments and tendons depend on precise alignment.

• Distal radius: Normal volar inclination (~10–12°) and ulnar inclination (~22–23°) ensure joint mechanics.
• DRUJ (distal radioulnar joint): responsible for pronation/supination; sensitive to differences in length of the radius and ulna.
• Scaphoid: keystone of the carpus; Mishealing changes the kinematics of the entire series.
• Metacarpus/fingers: Even small rotation errors significantly disrupt the gripping function.

If this geometry gets out of alignment, this will result in changed loads, tendon friction and premature wear. Therefore, the assessment of even minor misalignments is clinically relevant.

Causes and risk factors

Misalignments arise from the injury itself or from secondary tilting during healing. The type of fracture, bone quality and the stability of the initial treatment have an influence.

• Insufficient reduction or premature sagging under a cast/splint
• Unstable osteosynthesis or high fragment fragmentation
• Osteoporosis, smoking, metabolic disorders
• Delayed diagnosis (e.g. scaphoid), multiple injuries
• Infections (osteomyelitis) as a hindrance to healing

The initial phase after the break is crucial: regular checks detect any sagging in good time and can enable countermeasures.

Typical complaints

• Pain on exertion and at rest, often radial, ulnar or dorsal
• Restriction of movement, especially rotational movements (pronation/supination)
• Loss of strength, unsteady grip, early fatigue
• Visible deformity, step formation, edges
• Snapping/crunching (crepitation), tendon irritation
• Painful sensations or numbness due to nerve irritation
• Crossing fingers when closing a fist is an indication of rotational errors

Not every misalignment hurts. Functional relevance is crucial: What hinders you at work, in everyday life or in sport?

Diagnostics: clinically sound, imaging-precise

At the beginning there is an anamnesis and functional examination: visual axis, rotation test of the fingers, grip strength, tendon gliding, stability of the DRUJ and neurovascular status.

• X-ray in two planes, if necessary special lateral image (true lateral) and comparison images
• CT for precise assessment of axes, steps and complex misalignments; 3D analysis possible
• MRI if ligament/cartilage damage is suspected (e.g. TFCC, scapholunate instability)
• Functional tests (e.g. painful DRUJ compression, ballottement) complement the findings

The combination of clinical picture and imaging enables individual, targeted therapy planning. In complex cases, 3D planning including patient-specific cutting templates can be useful.

Conservative therapy: when it makes sense

Slight misalignments without relevant joint level and with tolerable symptoms can often be easily managed non-surgically. The aim is to relieve pain, gain function and avoid consequential damage.

• Individual splint/orthosis provision for relief and stabilization
• Hand therapy/occupational therapy: mobility, coordination, targeted strengthening, scar and edema management
• Adapted stress and workplace management, aids in everyday life
• Medication for pain and inflammation as needed
• Targeted infiltrations (e.g. DRUJ, radiocarpal) in selected cases for symptomatic relief

We treat it conservatively if it means your personal functional goals can be achieved. In the case of progressive symptoms, significant axial/rotational misalignment or intra-articular steps, surgical correction becomes more important.

Surgical options: correction with a sense of proportion

Surgery is indicated when misalignments cause pain, instability, loss of function, or increase the risk of premature joint wear. The corrective osteotomy realigns the axis, rotation and length; Intra-articular steps are smoothed.

• Distal radius: corrective osteotomy (often wedge-shaped) with an angle-stable plate; If necessary, construction with bone graft and accompanying procedures on the ulna (e.g. ulna shortening osteotomy) to balance the DRUJ
• Ulna: Ulnar shortening osteotomy or wafer resection for positive ulnar variance-related complaints
• Scaphoid: corrective osteotomy with spongiosa or vascularized chip; The goal is to restore shape to prevent SNAC wrist
• Metacarpal/finger: Derotation and angle correction osteotomies, fixed with miniplates or screws
• Intra-articular misalignments: joint reconstruction with step smoothing; In the case of advanced wear, joint-preserving alternatives or salvage (e.g. partial arthrodesis, selective denervation)
• Planning: For complex deformities, 3D planning and patient-specific cutting templates are possible

Risks and limitations are openly discussed: wound healing disorders, infection, nerve irritation (e.g. superficial branch of the radial nerve), stiffness, delayed bone healing/non-union and CRPS are possible complications. A realistic goal definition is central.

Follow-up treatment and rehabilitation

The follow-up treatment is just as important as the procedure itself. It depends on the bone, fixation method and accompanying injuries.

• Short-term immobilization (splint/orthosis), early functional mobilization under hand therapy guidance
• Pain and edema control, scar care, tendon gliding exercises
• Gradual increase in load according to radiological signs of healing
• Stopping smoking and optimizing bone metabolism parameters (e.g. vitamin D) support healing

Indicative time periods: bony consolidation often in 6–12 weeks, functional development over 3–6 months. Return to manual work and sport is planned individually.

Course and prognosis

The prognosis depends on the location, extent of the deformity, cartilage status and adherence to therapy. The aim of the treatment is a resilient, low-pain hand with everyday function. Residual discomfort or limited mobility are possible, especially if there is already existing cartilage damage. Regular follow-up checks help to fine-tune therapy and training.

Prevention: Avoid misalignments

• Careful initial treatment of fractures including early and repeated X-ray checks
• Adapted immobilization and timely stabilization for unstable fractures
• Osteoporosis diagnosis and therapy, vitamin D and calcium management
• Stop smoking, adequate protein intake, avoid chronic inflammation
• Fall prevention and strength/coordination training

When should you seek medical attention?

• Increasing pain or new deformity after a fracture
• Persistent limitation of rotational movements or loss of grip strength
• Crossing fingers when making a fist (rotation error)
• Numbness, tingling, feeling cold, or changes in color of the fingers
• Crunching, snapping or locking in the wrist

An early clarification creates clarity about the need for action and options – conservative or operational.

Your treatment in Hamburg

In our practice at Dorotheenstrasse 48, 22301 Hamburg, you will receive a careful clinical examination, modern imaging and understandable advice on your options. Wherever possible, we start with conservative measures and discuss surgical corrections transparently - including a follow-up treatment plan. Second opinions are welcome.

Related diseases and differential diagnoses

• Distal radius fracture: A common cause of later misalignment of the wrist
• Distal ulnar fracture: influence on the DRUJ and ulnar variance
• Scaphoid fracture and scaphoid nonunion: risk of malunion and carpus imbalance
• Metacarpal and finger fractures: rotation and axial errors with great functional relevance
• Osteomyelitis: Infection-related healing disorder and deformity