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Purpose To quantify 2 patterns of carpal malalignment, midcarpal malalignment (type 1) and radiocarpal malalignment (type 2), and to evaluate the effect of distal radius osteotomy on these malalignment patterns. Methods In a retrospective review, we studied 31 wrists treated with corrective osteotomy for distal radius malunion after Colles' fracture, in 31 patients (mean age, 44 y). The patients were divided on the basis of effective radiolunate flexion (ERLF) into 2 patterns of carpal malalignment as measured on preoperative radiographs. There were 20 patients with midcarpal malalignment (ERLF ≤ 25°) and 11 with radiocarpal malalignment (ERLF > 25°). Measurements of alignment were repeated after distal radius osteotomy and compared with preoperative values. Results Both groups had correction of radial tilt and ulnar variance with distal radius osteotomy. In the midcarpal malalignment group, carpal alignment improved to normal parameters. In the radiocarpal malalignment group, we observed a notable effect on the ERLF. Neither age of the subject nor delay between fracture and osteotomy correlated with improvement in carpal alignment. Conclusions Distal radial osteotomy is a reliable technique for correction of the deformity at the distal end of the radius and both radiocarpal and midcarpal malalignment. Type of study/level of evidence Therapeutic IV.