Approaches to malunion of the distal radius may be viewed as a hierarchy of surgical options with increasing complexity and potential surgical morbidity. Choice of an appropriate surgical approach requires consideration of the patient's activity level, as well as the anatomic distortion that is present. In the posttraumatic situation, there is lack of agreement as to management of the distal ulna. Relative increased ulnar length and triangular fibrocartilage insufficiency make use of partial resection techniques more difficult. Osteotomy of the distal radius with or without a concomitant distal ulna procedure most nearly re-creates the preinjury situation anatomically and is seeing increasingly widespread application. It continues to be a challenging procedure from a technical standpoint. The need for procedures discussed in this review could be drastically reduced by a more aggressive approach to the initial fracture.