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An Essay Submitted For Partial Fulfillment Of The
Requirement For M.Sc. Of Orthopedic Surgery

Supervisors
Prof. Dr. Mohamed Morsy Ibrahim Wahba
Professor of Orthopedic Surgery
Faculty of Medicine, Mansoura University

Dr. Mohamed Fathy Mohamed Mostafa
Assistant Professor of Orthopedic Surgery

Dr. Ahmed El-Sayed Magdy El-Hawary
Lecturer of Orthopedic Surgery

2014
Mansoura University
Faculty of Medicine
Orthopedic Surgery Department
THE USE OF LOCKED PLATES IN
DISTAL RADIUS FRACTURES
f
I

BY
Mohamed El-Sayed El-Mekawy
M. B. B. Ch (Mansoura)
Resident of Orthopedic Surgery

-

4102

Acknowledgment

I

Acknowledgment

First and foremost, I feel indebted to ALLAH, The most graceful,
who gave the strength to complete this work.
I would like to express my deepest gratitude and appreciation to
my principal supervisor Prof. Dr. Mohamed Morsy I brahim Wahba,
professor of orthopedic surgery, Faculty of Medicine, Mansoura
University for his generous support, encouragement, helpful suggestions
and continuous supervision throughout the research, and for his precious
time and effort that made this essay possible.
I am particularly grateful to Prof. Dr. Mohamed Fathy Mohamed
Mostafa, Assistant professor of orthopedic surgery, Faculty of Medicine,
Mansoura University for his valuable foresight and meticulous
supervision of this work. His generous advice was illuminative
throughout the work.
My extreme appreciation to Dr. Ahmed El-Sayed Magdy El-
Hawary, Lecturer of Orthopaedic Surgery, Faculty of Medicine,
Mansoura University for his willing help and critical review. His endless
support always pushed me to do better.
Words do fail to express my gratitude to my professors in
Department of Orthopedic surgery, Faculty of Medicine, Mansoura
University for their continuous encouragement, advise & supervision.
Special thanks to my parents, my wife, my brother & my friends.

Mohamed El-Sayed El-Mekawy

2014
List of Contents

II

List of Contents

Acknowledgement
I
List of Contents II

List of Abbreviations
III
List of Figures
IV
Introduction & Aim of the work
1
Review of Literature

Anatomy
3
Biomechanics
10
Mechanism of injury & Classification
23
Treatment
36
Complications
53
Representative Cases
64
Summary & Conclusion
77
References
79
Arabic summary
1


III


TFCC Triangular Fibro-Cartilagenous Complex

DRUJ Distal Radio-Ulnar Joint

ECA Extensor Compartment Artery

FCR Flexor Carpi Radialis

FPL Flexor Pollicis Longus

SRN Superficial Radial Nerve

DVP Distal Volar Plate

CRPS Complex Regional Pain Syndrome

RND Reflex Neurovascular Dystrophy

List of Figures

IV

List of Figures
Fig. 1 Trabecular pattern of distal radius.

Fig. 2 Normal x-ray anatomy of the distal radius. PA view.

Fig. 3 Normal x-ray anatomy of the distal radius. Lateral view.

Fig. 4 Blood supply of distal radius.

Fig. 5 Wrist Kinematics.

Fig. 6 Standard screws Vs Locking screws inclinations.

Fig. 7 1st & 2nd generation DVR plates.

Fig. 8 Illustration of combiholes.

Fig. 9 Small fragment locking T-plate used as an internal fixator.

Fig. 10 Failure of non-locked volar plating.

Fig. 11 fixed-angle implant transferring load stress from the fixed distal
fragment to the proximal radial shaft.

Fig. 12 The three column concept of Rickli & Regazzoni.

Fig. 13 Colles' fracture.

Fig. 14 Smith's fracture.

Fig. 15 Barton's fracture.

Fig. 16 Frykman classification.

Fig. 17 Melon classification.

Fig. 18 Universal classification.

List of Figures

V

Fig. 19 Modified Mayos classification.

Fig. 20 AO Classification.

Fig. 21 Short arm cast applied for a stable distal radius fracture.

Fig. 22 Percutaneous pin fixation of a distal radius fracture.

Fig. 23 External Fixation of a distal radius fracture.

Fig. 24 Fragment specific fixation of a distal radius fracture.

Fig. 25 Bridging by locking plate produces a load-free area.

Fig. 26 Case 1 preoperative PA and lateral x-rays.

Fig. 27 Case 1 Immediate post-operative PA and lateral x-rays.

Fig. 28 Case 1 follow up after 2 months.

Fig. 29 Case 1 functional outcome.


Fig. 31 Case 2 preoperative CT scan showing articular depression.

Fig. 32 Case 2 immediate post-operative PA and lateral x-rays.

Fig. 33 Case 2 follow up after 3 months showing union.



Fig. 36 Case 3 immediate post-operative PA and lateral x-rays.

Fig. 37 Case 3 follow up after 3 months showing union.



1

I ntroduction

Distal radius fractures are the most frequent lesions encountered during
clinical practice. The treatment is controversial and still debated in the literature.
For a correct management of these lesions many authors recently emphasized the
importance of anatomical reduction, a stable fixation and early joint
mobilization.
[1]
In most cases, reduction is easy to achieve but difficult to maintain by closed
means. Tscherne and Jahne
[2]
showed that between 20% and 30% heal with an
unsatisfactory anatomical and functional result, and others have reported a high
incidence of malunion, radial shortening, and articular incongruity with a poor
functional outcome. Surgical methods, which include arthroscopy, plate
osteosynthesis with bone graft, and external fixation, are technically demanding,
may require long periods of postoperative immobilisation and also have high
complication rates.
[3]
Operative treatment for unstable distal radius fractures had gained popularity
recently.
[4]
It enables the maintenance of reduction while allowing early
mobilization and return to function.
[5]
Dorsal comminution, often seen in this group
of fractures, impedes stability and renders their surgical management
challenging.
[6]
Previous biomechanical studies had shown that the greatest degree
of stability in dorsally comminuted distal radial fracture is achieved with internal
fixation by means of dorsally placed plates.
[7]
However, these implants are not
devoid of complications, mainly with regard to extensor tendon irritation.
[8]
While
the use of a volar approach to the distal radius can avoid these complications,
conventional, non-locking volar implants do not provide adequate stability
required for dorsally comminuted fractures.
[7]


2

Locked plating of distal radial fractures is used extensively and there has
been a proliferation of locking plates available for this region. There are
improvements in construct rigidity when locking plates are used compared to
conventional plates and they have been used successfully for this region.
[9]
There
has also been a move towards the use of volar locking plates in dorsally unstable
fractures although complications are starting to be reported and the biomechanical
advantage may lie with dorsal plates.
[10]
Currently, the benefit of a locked volar
plate over a dorsal plate or external fixator remains to be shown.
[11]
Recently introduced volar locking plates had shown promising clinical
results in unstable distal radial fractures.
[5]
Experimental biomechanical evidence
supporting their use with dorsally comminuted unstable distal radius fractures was
recently published.

However supporting clinical evidence for these findings is still
lacking in the literature.
[12]

Aim of the work

The aim of this work is to give a detailed review about the use of locked
plate in management of distal radius fractures. Some selected patients with distal
radial fractures treated with locked plate will be followed up for short term.
Collection of literature from references, papers, articles and internet.

Anatomy

3

Anatomy of the distal radius
The distal end of the radius forms the anatomic foundation of
the wrist joint.
[13]
The articular surface of the distal radius is
biconcave and triangular with the apex of the triangle directed
towards the styloid process, the base represents the sigmoid notch for
articulation with the ulnar head. The surface is divided into two
facets by a well-defined ridge. One facet, the fossa lunata articulates
with the lunate bone; the second, the fossa scaphoidea articulates
with the scaphoid bone.
[14]

The volar surface of the distal radius is relatively flat. It is
covered proximally by the pronator quadratus muscle. The flexor
tendons and the median nerve lay more superficially. The dorsal
surface is convex. Between the second and the third extensor
compartment there is a bony ridge, Listers tubercle. The extensor
tendons are only separated from the bony surface by the floor of the
extensor retinaculum and the periostium. These anatomic relations
between the six extensor compartments, the retinaculum extensorum
and the dorsal radial cortex are of extreme importance for the dorsal
surgical approaches to the distal radius.
[14]

The direct articulation between the distal ulna and the carpus
is less important. It is covered by a complex cartilaginous structure,
the triangular fibro cartilaginous complex (TFCC). It is the
development of this TFCC combined with the lack of a true ulno-
Anatomy

4

carpal joint that differentiates the hand of the human of that of lower
primates and gives the human wrist its extreme freedom of
movement. On the other hand, the TFCC is a structure that is very
sensible to trauma and degeneration and can be a source of ulnar
wrist pain that is difficult to treat.
[14]
The distal radio-ulnar joint (DRUJ) is of equal importance as
the radio-carpal joint. It is composed of the fixed ulnar head and the
sigmoid notch. This sigmoid notch not only rotates around the ulnar
head, but it makes at the same time a translational movement. In
pronation, the ulnar head moves dorsally in the sigmoid notch. In
supination, it is displaced anteriorly. The most important stabilizer of
the DRUJ is the TFCC, additional stabilizers are the interosseous
membrane of the forearm, pronator quadratus muscle and the
tendons and sheets of the extensor and flexor carpi ulnaris muscles.
As the interaction of all of these structures is of great importance for
stability and motion, deformity after injury or fracture has an
important influence on the function of the entire wrist.
[14]

The bony architecture of the distal radius can be viewed in
terms of columns. Rikli and Regazzoni
[3]
divided the distal forearm
in three columns: the medial column consisting of the ulna, the
TFCC and the DRUJ; the intermediate column made up of the fossa
lunata and the sigmoid notch and the lateral column including the
fossa scaphoida and the styloid process. Fracture lines often run
between these columns. The intermediate column can also be split in
a sagittal plane, creating the dorsal and the volar intermediate
Anatomy

5

fragment. The surgical reconstruction of the distal radius should be
based on the knowledge of these columns. Almost 80% of the
transmitted forces go over the distal radius by longitudinal loading of
the wrist, if radius and ulna are equally long (ulna neutral).
Lengthening of the ulna shifts force transmission in the direction of
the ulna, whereas ulnar shortening shifts forces towards the radius.
[15]

Trabecular pattern of the distal radius
analysing the radiographic trabecular pattern of an area of the
distal radius revealed that the pattern runs along the direction of the
bone, as shown in figure 1 but is not nearly as organised as that
observed in the femoral head since the loading of the radius is not as
consistent.
[16]

(Fig. 1) Trabecular pattern of distal radius.
[16]
Anatomy

6

Radiological anatomy of the distal radius
The normal distal radius articular surface inclines radially
between 22 and 23 degrees in the frontal plane.
[17]
(Fig 2)

Radial length refers to the distance between the tip of the
radial styloid process and the distal articular surface of the ulnar
head.
[18]
The average radial length is 11 to 12 mm. Ulnar variance is
the relative length between the head of the ulna and the articular
surface of the distal radius. This measurement must be taken from a
neutral rotation posteroanterior (PA) radiograph because forearm
rotation affects the relative length from the distal radius to the
ulna.
[19]
The average ulna and radius end within 1 mm of one
another.
[20]
These anatomic parameters have become well accepted in
the radiographic evaluation of distal radius fractures (Fig. 3).
[21]

(Fig. 2) Normal x-ray anatomy. PA view. Measurement of radial height and inclination
and ulnar variance.
[13]
Anatomy

7

The joint surface slopes palmward between 4 and 22 degrees, with an
average palmar inclination of 10 to 12 degrees. This is best appreciated on a
true lateral radiograph.
[17]

(Fig. 3) Normal x-ray anatomy, lateral view. Measurement of palmar inclination.
[13]

Blood Supply of the Distal Radius
Blood supply to the distal radius includes the radial, ulnar, anterior
interosseous, and posterior interosseous arteries. Anastomoses between the
anterior branch of the anterior interosseous artery and the palmar carpal arch
and also between the anterior and posterior interosseous arteries and the
dorsal carpal arch are always present. Small vessels coming from the
anterior interosseous artery and the insertion of pronator quadratus over the
sigmoid notch of the radius were also present. The intraosseous areas of
vascularization came from these adjacent small branches.
[22]
The distal radius is supplied by three main vascular systems:
epiphyseal, metaphyseal, and diaphyseal. The palmar epiphyseal vessels
Anatomy

8

branched from the radial artery, palmar carpal arch, and anterior branch of
the anterior interosseous artery. They entered the bone through three points:
the radial styloid process, Lister's tubercle, and the sigmoid notch.
[22]

The intraosseous point of entry to the dorsal epiphyseal vessels is
from the fourth and fifth extensor compartment arteries (ECA). The fourth
ECA is located on the radial aspect of the fourth extensor compartment
floor. It originates from the posterior division of the anterior interosseous
artery or its fifth extensor compartment branch and anastomoses with the
dorsal intercarpal arch and the radiocarpal arch. The fifth ECA is supplied
by the posterior division of the anterior interosseous artery and anastomoses
distally with the dorsal intercarpal arch. It also may make distal connections
to the fourth ECA and the dorsal radiocarpal arch. The fifth ECA provides
direct nutrient branches to the radius.
[22]

More proximally, in the metaphyseal area, numerous periosteal and
cortical branches originated from the anterior interosseous artery as it
courses through the pronator quadratus. These branches provided the main
supply to the distal radius. The vessels perforated the bone-forming and
anastomotic network. The metaphyseal arteries are multiple and enter all the
periosteal surfaces of the proximal and distal metaphyses. They provide the
entire supply of the metaphyses, and their terminal branches anastomose
with the terminal branches of the medullary arterioles at each end of the
medullary cavity.
[22]

The nutrient artery provides intraosseous vascularity only to the
diaphyseal part of the distal radius. The principal nutrient artery approaches
the diaphysis under the protection of a fascial attachment. It traverses the full
thickness of the cortex to enter the bone where it divides into the ascending
Anatomy

9

and descending branches of the medullary artery. These branches subdivide
into arterioles, which enter the endosteal surface of all portions of the
diaphysis.
[22]

(Fig. 4) A. Dorsal and B. palmar views of blood supply of distal radius.
[23]

Biomechanics

10

Biomechanics of the Wrist J oint

The wrist complex is biaxial joint, with motions of flexion/extension
(volar flexion/dorsiflexion) around a coronal axis, and radial deviation/
ulnar deviation (abduction/adduction) around an anteroposterior axis.
[24]
In the normal wrist, the total arc of motion from full flexion to full
extension is approximately 150.
[24]
This motion is made up approximately
equally by motion at the midcarpal and radiocarpal joints. However, the
midcarpal joint contributes more to flexion (62%) than does the radiocarpal
joint as the wrist moves from neutral to full flexion. Conversely, as the wrist
moves from neutral to full extension, the radiocarpal joint contributes more
(62%) than the midcarpal joint.
[25]
Further, wrist radial-ulnar deviation is
contributed to by motion at the midcarpal and radiocarpal joints, with the
majority (55%) of this motion occurring at the midcarpal joint.
[26]
As the wrist moves from radial to ulnar deviation, the proximal row
extends as well as deviates ulnarly. As the wrist moves from ulnar to radial
deviation, the proximal row flexes and deviates radially. The distal row also
translates dorsally in ulnar deviation and volarly in radial deviation. This
translation may be the cause of proximal row extension and flexion.
[27]

Biomechanics

11

(Fig. 5) A, In radial deviation, the proximal carpal row deviates toward the radius, translates toward the
ulna, and flexes as seen by visualizing the lunate on the lateral radiograph. B, With the wrist in neutral, the
capitate, lunate, and radius are nearly colinear. C, In ulnar deviation, the proximal row deviates toward the
ulna, translates toward the radius, and extends as visualized by the lunate on the lateral radiograph.
[28]
Biomechanics

12

Biomechanics of Fracture Reduction

Traction, ligamentotaxis, periosteotaxis, and manipulation are the
mainstays of fracture reduction. The brachioradialis is the only muscle
attached to the distal radial fracture fragment. Sarmiento and colleagues
[29]

recognized the resistance and deforming force of the brachioradialis on the
distal radial metaphyseal or styloid fragment during the wrist flexion and
forearm pronation maneuvers of classically applied closed reduction
techniques. The brachioradialis also may remain a deforming force after
closed fracture reduction. They also reported and advocated fracture
reduction, positioning, and cast bracing with the forearm in a supinated
position to relax brachioradialis tension during and after fracture
reduction.
[29]
The rule of the majority, also known as the vassal rule, may be
helpful in assembling the fracture fragments. This rule states that the major
fragments should be realigned, and that the smaller or vassal fragments
follow the major fragments into position. Replacement of each of the
articular fragment components before definitive plate fixation may avoid
some of the difficulties that may be encountered in reducing ulnar die-
punch fragments after radial styloid fixation. Fluoroscopy or arthroscopy or
both may be useful in achieving fracture and articular alignment. Kirschner
wires may be used for provisional fixation before plate insertion.
[4]
Biomechanics of plate of the distal radius
Plate strength is proportionate to the cube of its thickness and
inversely proportionate to the cube of its length.
[30]
Screws enhance plate
strength and holding power at the plate-bone interface. Wider spacing of
screws in the stem increases the bending strength of plate-screw-bone
Biomechanics

13

fixation. The torsional strength of plate stem fixation is independent of
screw spacing and is proportionate to the number of screws holding the
stem.
[31]
Fixed-Angle Principle:

The working portion of a buttress plate is the bar - the distal
segment of the plate supporting the metaphyseal fracture fragment or
fragments. Support of the metaphyseal fragment and overall plate-bone
construct strength may be improved by blades affixed to the plates or screws
or pegs locked into the screw or peg holes of the bar by matching threads.
Each fixed-angle blade or locking screw or peg provides an additional point
of fixation within the plate and increases plate stability.
[30]
Fixed-angle
blades or locking screws or pegs in the bar of the plate provide additional
support for the articular surface of the distal radius against axial loads
compared with conventional screws.
[32]
Several plates have a fixed-angle
screw or peg option for the bar of the plate (Fig. 6). The increased stability
of fixed-angle blades or locking screws or pegs may be especially
advantageous in osteopenic bone.
[33]
The distal volar plate (DVP) (Hand Innovations, Miami, FL) and
similarly designed plates combine fixed-angle locking screws or pegs in the
stem of the plate with robust design so that they may be applied to the
palmar side of the distal radius for almost all fracture configurations
regardless of the direction of instability (Fig. 7).
[33]
The goal of this plate
design is consistently to avoid dorsal plate application and its consequences.
Fixed-angle pegs follow the articular contour, are directed to support the
articular surface, and help to ensure fixation of commonly found articular
fragments. The radial most pegs are directed into the styloid, and the ulnar
Biomechanics

14

most pegs are directed into the dorsal ulnar edge of the radius to incorporate
styloid and dorsal die-punch fragments. Failure to incorporate the dorsal
die-punch fragment may lead to loss of reduction and arthrosis. The distal
palmar edge of the plate supports palmar die-punch fractures, which also
may be incorporated with pegs.
[34]

(Fig. 6) A, Threaded standard screw. B, Partially threaded standard screw. C, Threaded locking screw. D,
Locking peg. Arrows pointing to C and D indicate a space between the locking plate and the bone.
Standard holes and flexible bushings in locking holes allow 15 degrees of screw angulation from the
perpendicular position. (Universal Distal Radius System; courtesy of Striker Leibinger Micro Implants,
Portage, MI.)
[4]

Biomechanics

15

(Fig. 7) A, First-generation DVP plate. B, Undersurface first generation DVP plate with a row of locking
pegs (arrow in B) designed to parallel and support the subchondral portion of the articular surface of the
distal radius. C, Second-generation DVP plate. D, A proximal row of screws (arrow 1) or pegs (arrow 2)
may be inserted to incorporate or support the dorsal lip or fragments of the distal radius. (Courtesy of Hand
Innovations, Miami, FL.)
[4]

Biomechanics

16

Locking Plate Stems and Combination Plate Holes
(Combiholes)

The fixed-angle principle also may be applied to the plate stem.
Elliptical plate holes (combiholes) have been added to the stems of the
AO/ASIF distal radius locking plate set (Fig. 8) (Synthes, Paoli, PA).
Combiholes allow the option of inserting either a fixed-angle locking
screw or a conventional screw. Standard screws compress the plate onto the
bone and stabilize the fracture owing to friction between the plate and the
bone. Locking screws inserted into the stem of the plate provide an
additional point of fracture fixation, prevent screw toggle, and increase plate
resistance to axial loads compared with conventional screws, owing to
locking screw head thread engagement in corresponding threads within the
locking plate hole. Distal radius locking plates are precontoured and do not
have to be shaped to or rest flush on all parts of the bone and, in essence,
may act as an internal fixator (i.e., an implanted external fixator) (Fig. 9).
This feature makes locking plates more biocompatible with the bone. A
locking plate might be envisioned as the ultimate external fixator with the
plate (connecting bar) placed extremely close to the mechanical axis of the
bone, maximizing its stability. Locking plate stems may be especially
advantageous in osteopenic bone.
[30]
The pullout strength of a unicortical screw from bone is about 60%
compared with a bicortical screw. The surgeon must decide whether to
engage one or both cortices. Unicortical drilling may minimize damage to
the endosteal circulation of the distal radius and eliminates the need to
measure screw length.
[30]

Biomechanics

17

(Fig. 8) A to C, Combihole (A) allows engagement of a conventional screw (B) or a locking screw (C).
Arrow 1, The smooth portion of the combihole accommodates a standard screw head. Arrow 2, The
threaded portion of the combiholeaccommodates a locking screw head. Arrow 3, Space between the
fixed-angle locking plate and the bone surface. Standard screw holes or bushings incorporated in locking
plate holes may allow a few degrees of angulation from the vertical position. (Courtesy of Synthes, Paoli,
PA.)
[4]

(Fig. 9) Small fragment locking T-plate used as an internal fixator with a small space between parts of
the plate and the bone (arrows). (Courtesy of Synthes, Paoli, PA.)
[4]
Biomechanics

18

Rationale and Basic Biomechanics:

Although the concept of volar plating could be initially attributed to
Lanz and Kron
[35]
back in 1976 for plate fixation after osteotomy of
malunited distal radius fractures, the volar approach remained restricted to
fixation of volar rim fractures in the acute setting only.
[36]
Volar plating was
first recommended for fixation of both typical and atypical distal radius
fractures by Georguoulis and associates in 1992.
[37]
This was published in a
little-known journal and was not widely accepted for dorsally displaced
fractures until the landmark paper by Orbay and Fernandez in 2002.
[38]
Volar
plating offers many advantages when used in dorsally displaced fractures.
The key to its success is to ensure that this was a locking plate, hence
creating a fixed-angle device that would maintain the reduction and
eliminate screw toggle (Fig. 10). Volar plating also provides the opportunity
to release the pronator quadratus muscle, which is often trapped in the
fracture and can be a cause of pronation contracture.
[39]
A nonlocking plate when used in buttress mode can resist only
moderate axial and bending forces. Thus, a simple nonlocking volar plate
used in a dorsally displaced fracture without any bony contact in the
opposite cortex is subject to much higher axial and bending loads, leading to
failure. Therefore, a stable and strong volar fixation of a dorsally displaced
fracture is only possible with a fixed-angle locking plate that can resist such
high forces. Fixed-angle implants transfer load stress from the fixed distal
fragment to the intact radial shaft, thus enhancing peg/plate/bone construct
stability (Fig. 11), unlike rigid internal fixation devices that rely mainly on
the frictional force between plate and bone to achieve fixation.
[39]

Biomechanics

19

(Fig. 10) Schematic diagram showing volar fixation maintaining the anatomy of the radius but screw toggle
leads to plate motion relative to the shaft, which can lead to late failure.
[40]

(Fig. 11) Schematic diagram showing fixed-angle implant transferring load stress from the fixed distal
fragment to the proximal radial shaft.
[40]

Biomechanics

20

The ideal volar implant should have a design compatible with the
volar articular surface of the radius and should provide concomitant angular
and axial stability while stabilizing the dorsal surface.
[41]
The distal volar
plate (DVR Hand Innovations, Depuy Orthopedics, Warsaw, Indiana) has
two parallel rows, and the orientation planes of their respective pegs
specifically match the complex three-dimensional shape of the radial
articular surface.
[40]
The primary row pegs are directed obliquely from proximal to
distal to support the dorsal aspect of the articular surface. They are angled
accurately to provide support for the radial styloid and the dorsal ulnar
fragment. These pegs are most effective in supporting the dorsal aspect of
the subchondral plate and hence avoid the re-displacement of the dorsally
displaced fractures. Concurrently, their action induces a volar force that
tends to displace the fragments in a volar direction, an effect that must be
opposed by a properly configured volar buttressing surface.
[40]
To enhance fracture fixation in cases of severe comminution,
volar instability, or osteoporosis, an additional row of pegs originating from
a more distal position on the plate and having an opposite inclination to the
proximal row was conceived. The distal row is directed in a relatively
proximal direction and crosses the proximal row at its midline and is
intended to support the more volar and central part of the subchondral bone.
It prevents the dorsal rotation of a volar marginal fragment and volar
rotation of severely osteoporotic or unstable distal fragments with central
articular comminution, thus neutralizing volar displacing forces of the pegs
in the proximal row.
[40]
Biomechanics

21

Newer generation of volar plates have now introduced the concept of
variable-angle locking screws and/or pegs. This provides the distinct
advantage of being able to vary the plate placement with the locking screws
adjusting to the necessary angle to be placed in the strongest subchondral
bone.
[40]

Volar Versus Dorsal Plating:

The approach is generally dictated by the location of major fracture
fragments and the direction of displacement. However, orthopaedic and
upper extremity surgeons continue to move away from dorsal plating where
complications can include extensor tendon rupture and hardware irritation.
Volar plating is generally welltolerated. Fixation of dorsally angulated and
comminuted fractures is also possible with newer fixed angle devices.
[42]

Although overall satisfactory outcomes have been reported with
dorsal plating systems, disadvantages of dorsal plates include the need for
mobilization of extensor tendons to achieve proper plate placement, possible
tendon irritation or rupture, and the possibility of additional surgery to
remove the symptomatic dorsal plate, some reporting up to 30%.
[43]
Tendon
rupture has been reported as early as 8 weeks and as late as 7 months after
surgery. To prevent tendon injury, some recommend that a portion of the
extensor retinaculum be interposed between the plate and the tendon sheaths,
or that dorsal plates be removal routinely.
[44]

Biomechanics

22

The advantages of a volar exposure and plating include the following:
1. Dorsally displaced fractures are simpler to reduce because the volar
cortex is usually disrupted by a simple transverse line.
2. Anatomic reduction of the volar cortex facilitates restoration of radial
length, radial inclination and volar tilt.
3. The avoidance of dissection dorsally helps to preserve the vascular
supply to the dorsal fragments.
4. Because the implant is separated from the flexor tendons by the
pronator quadratus, the incidence of flexor tendon complications is
lessened
5. When stabilized with a fixed angle internal fixation device, shortening
and secondary displacement of articular fragments is improved, and the
need for bone grafting is reduced.
[43]

Several studies have compared outcomes of dorsal versus volar
plating of distal radius fractures. Ruch and Papadonikolakis
[45]
performed a
retrospective review of 34 patients, 20 of whom had undergone dorsal
plating and 14 of whom had volar plating. The authors found that both
groups of patients had similar DASH scores, but the functional outcome in
terms of Gartland and Werley scores was better in the volar plating group. In
addition, there was a higher rate of volar collapse and late complications in
the dorsal plating group compared with the volar plating group.
[45]


23

Mechanism of injury

Most commonly, injuries occur after a simple fall from standing
height. Rarely do clinicians take any more detailed history. Yet much
information can be gained from asking patients to describe their fall.
[46]
It is natural to pronate the forearm as you fall forwards, and supinate it
as you fall backwards. Impact on the pronated forearm is likely to be on the
radial side of the wrist, whilst that on the supinated forearm is likely to be on
the ulnar side of the wrist. This information stimulates thought as to which
other associated structures could be injured during the fall. A fall forwards
will focus the examination on the radial structures in the wrist; a fall
backwards will draw attention to the ulnar structures.
[46]

Almost all distal radius fractures (apart from dorsal rim avulsion
fractures) can be produced by hyperextension of the wrist.
[47]
Bending forces
tend to occur in low-energy falls and typically produce dorsal displacement.
Shearing forces disrupt the ligamentous connections of the wrist and
produce unstable fracture-dislocations, whilst axial loading, high-energy
injuries compress the articular surface and cause fragments of joint surface
to be impacted.
[46]
Important work, published by Rikli and Regazzoni
[15]
, on load transfer
across the wrist described the existence of three separate structural
columns within the wrist. This 3 column concept highlights not only how
the intact wrist functions, but also provides clear mechanical guidance on
how best to reconstruct fractures in this area. The radius has both a radial
and intermediate column, and the ulna represents the third column (Fig.
12).
[15]
The understanding of this concept allows the surgeon to think about

24

rebuilding the fragmented wrist in a logical and natural manner and also
emphasizes the importance of distal ulnar injuries. Indeed, this concept has
also been pivotal in the design of anatomic implants for both the distal radius
and ulna.
[48]
The intermediate column is the major load-bearing column of the
wrist, confirmed by the dense subchondral bone seen in X-rays of the intact
radius. This also explains its involvement in dye-punch articular
depression injuries. In addition to being a central structural column, the
intermediate column also provides the radial component of the distal
radioulnar joint (DRUJ) with the sigmoid notch. The bone quality in this
distal ulnar corner of the radius is universally good (as a result of its
function) and, by virtue of its involvement in both flexion/extension and
forearm rotation movements, forms the key area when planning surgical
fracture reconstruction. Consequently, surgical reconstruction of the
fractured distal radius will concentrate on restoring the integrity and shape of
the intermediate column (together with the orientation of the two associated
joint surfaces) before restoring the buttressing function of the radial column,
and the pivotal function of the distal ulna.
[46]


25

(Fig. 12)The three column concept of Rickli & Regazzoni.
[15]

Classification
Various classification systems have been proposed to describe the
injury and help formulate a treatment plan. Broadly they tend to be
anatomical classifications that group fracture patterns, biomechanical that
describe the mechanism of injury and fracture stability or a combination of
both.
[46]
The eponymous descriptions associated with distal radius fractures
have traditionally been good indicators of the type of injury and treatment.
Colles fracture: It is an extra-articular distal radius fracture with dorsal
comminution, dorsal angulation, dorsal displacement, and radial
shortening.
[49]


26

(Fig. 13): Colles' fracture, Diagrammatic representation of displacement, Top, Characteristic dorsal
angulation and impaction with shortening (lateral view). Below, loss of radial angulation, Radial shortening
with impaction and radial displacement (postero-anterior view)
[50]

Smiths fracture: It is a fracture of the distal radius with volar
displacement.
[51]

(Fig. 14): Smith's fracture. Modified Thomas classification. Palmar angulated fracture. Type 1, extra-
articular transverse, Type 2,extra-articular oblique with palmar carpal displacement and Type 3,intra-
articular palmar displacement of the carpus entering the radiocarpal joint. Type 3, is equivalent to a palmar
Barton fracture-dislocation
[50]


27

Bartons fracture: It is is a displaced, unstablearticular fracture-subluxation
of the distal radius with displacementof the carpus along with the articular
fracture fragment.These may be either dorsal or volar.
[52]

(Fig. 15): Palmar Barton's fracture, palmar displacement of the carpus with intra-articular component
(identical to Smith type 3). Dorsal Barton's fracture, dorsal displacement of the carpus, presenting as
complex fracture of the distal radius or as fracture-disloaction of the wrist.
[50]

Chauffeurs fracture: It is a fracture of the radial styloid. It may be
associated with displacement of the carpus and may be the only bony
component of perilunate injury.
[53]

Die-punch fracture: It is an intra-articular fracture with depression of the
dorsal aspect of the lunate fossa.
[54]

FRYKMAN'S CLASSIFICATION:

In 1967, Frykman published a classification system that was important
in being the first to recognize the involvement (and relevance) of injuries to
the distal ulna.
[55]

28

Type I: Is an extra-articular radial fracture.
Type II: Is an extra-articular radial fracture with an ulnar styloid
fracture.
Type III: Is an intra-arlicular fracture of the radiocarpal joint.
Type IV: Is an intra-articular fracture of the radiocarpal joint with an
ulnar styloid fracture.
Type V: Is an intra-articular fracture of the radioulnar joint.
Type VI: Is an intra-articular fracture of the radioulnar joint with
fracture of the ulnar styloid.
Type VII: Is an intra-articular fracture involving both radio-carpal and
radioulnar joints.
Type VIII: Is an intra-articular fracture involving both radiocarpal and
radioulnar joints with an ulnar styloid fracture.

(Fig. 16): Frykman classification. Six types of intra-articular fractures: 3/4, radiocarpal joint alone+/- ulnar
styloid; 5/6, radioulnar joint alone +/- ulnar styloid; and 7/8, both radiocarpal and radioulnar joints.
[50]

29

MELONE'S CLASSIFICATION OF INTRA-ARTICULAR
FRACTURES:

The Melone system (1993) identified the importance of fragmentation
patterns and articular involvement. This classification was developed from
the observation that components of articular fractures consistently fall into
four basic parts despite frequent comminution; they are:
[56]

1. The radial shaft.
2. The radial styloid.
3. The dorsal medial fragment.
4. The palmar medial fragment.

Type I: Undisplaced or displaced but stable after closed reduction
Type II: The medial complex is displaced as a unite with
comminution and instability which may affect dorsal
fragment (Die-punch fragment) or less often the palmar
fragment (volar Barton's fracture)
Type III: It equals to type II with displacement of a spike fragment
which may injure the median nerve or flexor tendons
Type IV: Fractures demonstrate wide separation or rotation of the
dorsal or palmar medial fragments with profound disruption
of the distal radial articulations, usually associated with
severe damage to adjacent soft tissues.


30

(Fig. 17): Melon classification. A, classification of articular fractures on the basis of consistent patterns
results from the characteristic die punch mechanism of injury. Four articular fractures: 1, Radial shaft; 2,
Radial styloid; 3, Lunate fossa, dorsal medial ; and 4, Lunate fossa , palmar medial.
[50]

UNIVERSAL CLASSIFICATION:

A fracture may be defined as either extra-articular or intra-articular.
[57]
Type I: Extra-articular non displaced
Type II: Extra-articular displaced
Type III: Intra-articular non-displaced
Type IV: Intra-articular displaced
Further, displaced articular or nonarticular fractures may be:
a) Reducible, Stable.
b) Reducible, Unstable.
c) Complex, Irreducible.
Indicators of instability are:
i. Shortening of greater than 5 mm.
ii. Dorsal angulation greater than 20.
iii. Marked dorsal comminution.
iv. Displacement in a plaster of Paris cast.

31

(Fig. 18): Universal classification. Type I, Nonarticular (extra-articular), undisplaced, and stable. Type II,
Nonarticular (extra-articular), displaced, and unstable. Type III, Intra-articular, undisplaced, and
stable.Type IV, Intra-articular and displaced.A, Reducible and stable after the reduction.B, Reducible but
unstable.C, Irreducible and unstable. D, Complex (comminuted, unstable, and irreducible) (not shown)
[50]

MODIFIED "MAYO CLINIC" CLASSIFICATION:

For more clear distinguishing of different articular fractures that
individually can be involved with DRFs, this classification has been
proposed as a second sub-classification in which the scaphoid, lunate, and
sigmoid notch of the distal radius are considered as separate articulations.
[58]

This classification has four types:-
Type I: Fractures are intra-articular but un-displaced.
Type II: Fractures are displaced and involve the radio-scaphoid joint.
Type III: Fractures are displaced and involve the radio-lunate joint.
Type IV: Fractures are displaced and involve both the radio-scapho-lunate
joints and the sigmoid fossa of the distal radius.


32

(Fig. 19): Modified Mayos classification of DRFs. Intra-articular fractures involve one or more
articular fossae of the distal radius. Type I, Intra-articular but undisplaced involving the radio-lunate
joint. Type II, Radioscaphoid (RS) fossa fracture, displaced. Type III, Radiolunate fossa fracture with
die punch fracture (thin arrows) components. Direction of fracture displacement (thick arrows). Type
IV, Radio-scapho-lunate fossa involvement with extension into the distal radioulnar joint. The fracture
surface involvement extends into all three joints with articular step-off and displacement. D, dorsal; L,
lunate; S, scaphoid; V, volar.
[50]


33

A.O. CLASSIFICATION:

This classification is proposed by Mller et al., (1988). They
differentiated between simple and multi-fragmentary fractures and between
extra and intra-articular fractures with further recognition of different
degrees of articular surface involvement.
[59]

Group A: Extra-articular fractures:-
Al: Extra-articular fracture, of ulna, radius intact.
1. Styloid process
2. Metaphyseal simple
3. Metaphyseal multi-fragmentary
A2 Extra-articular fracture, of radius, simple and impacted
1. Without any tilt
2. With dorsal tilt (Pouteau-Colles')
3. With volar tilt (Goyrand-Smith)
A3 Extra-articular fracture, of radius, multi-fragmentary
1. Impacted with axial shortening
2. With a wedge
3. Complex


34

Group B: Partial articular fractures:-
B1: Partial articular fracture of radius, sagittal
1. Lateral simple
2. Lateral multi-fragmentary
3. Medial
B2 Partial articular fracture of radius, dorsal rim
1. Simple
2. With lateral sagittal fracture
3. With dorsal dislocation of the carpus
B3 Partial articular fracture of radius, volar rim
1. Simple, with a small fragment
2. Simple, with a large fragment
3. Multi-fragmentary

Group C: Complete articular fractures:-
C1: Complete articular fracture, of radius, articular simple metaphyseal
simple
1. Posteromedial articular fragment
2. Sagittal articular fracture line
3. Frontal articular fracture line


35

C2: Complete articular fracture, of radius, articular simple, metaphyseal
multi-fragmentary
1. Sagittal articular fracture line
2. Frontal articular fracture line
3. Extending into diaphysis
C3: Complete articular fracture, of radius, multi-fragmentary
1. Metaphyseal simple
2. Metaphyseal multi-fragmentary
3. Extending into diaphysis

(Fig. 20) AO Classification of DRFs.
[60]

Treatment

36

Treatment has long been defined by the lack of correlation between
anatomic reduction and function. This idea is only true in extremely elderly,
dependent patients, with low functional needs. Thus, today anatomic
reduction is the goal because it makes it possible to limit loss of function.
The problem is not the type of fixation or the immobilization technique, but
the quality and stability of reduction. A fracture with malunion is going to
affect the radiocarpal joint (problems with underlying carpal alignment, loss
of flexion-extension, loss of wrist strength) and the radioulnar joint (loss of
pronosupination, ulnocarpal impingement syndrome).
[61]
When the dorsal angle is greater than 20, radial inclination is below
10, and radial shortening is more than 6 mm, there are definite functional
consequences. Thus the more a fracture is displaced and/or associated with
an ulnar head fracture, the older the patient is (after the age of 60) and the
more fragile the bone is (osteoporosis), the less immobilization (normally
associated with reduction) will result in permanent reduction. A displaced
fracture should therefore be reduced and stabilized.
[61]
Although fragile bone can make fixation insufficient to maintain the
patients level of activity and autonomy, this aspect of treatment should
never be neglected. Over time, the limits of reduction and immobilization by
cast including the elbow became evident (too much secondary
displacement). Intra- and extrafocal pinning techniques, which were made
popular by Kapandji in France, made it possible to improve functional
outcome. However little by little as the life expectancy and the frequency of
osteoporosis has increased in the population, the development of plate
fixation is solving the problem of secondary displacement (which occurs in
30% of the cases of pin fixation) while making it unnecessary to wear a cast
Treatment

37

(allowing patients to use their new wrist at their own speed). External
fixation is still indicated for high-energy fractures with metaphyseal-
epiphyseal injury.
[61]
Despite the frequency of this type of fracture and because of the wide
variety of lesions, the level of evidence to define the best fixation is low.
Finally for the same fracture, the type of complications they cause
differentiates different types of internal fixation techniques. An effort must
be made in methodology to better identify the costs of each technique and
the functional advantages for the patient.
[61]

CAST IMMOBILIZATION
Cast immobilization is an appropriate treatment for all nondisplaced
fractures and stable displaced fractures that have been reduced. It may also
be appropriate for low demand patients who would not be able to tolerate
surgery for medical reasons. Closed reduction of displaced fractures consists
of longitudinal traction, palmar translation of the hand, pronation of the hand
relative to the forearm, and finally ulnar tilt. This reduction maneuver does
not require wrist flexion.
[42]
Determining which fractures will heal uneventfully with cast
immobilization may be difficult. An unstable distal radius fracture can be
defined by several criteria, which include: comminution greater than 50%
from dorsal to volar, angulation greater than 20 degrees of dorsal tilt,
shortening greater than 10 mm, a shearing fracture pattern, and significant
displacement with 100% loss of opposition.
[62]
All unstable fracture patterns
require surgical intervention.
[42]
Treatment

38

Cast treatment typically consists of immobilization in a sugar-tong
splint for three weeks immediately following closed reduction, which is then
converted to a short arm cast for an additional three weeks. Patients are
usually given a removable splint for a final three weeks and instructed to
perform active range of motion exercises to regain flexibility. Early in the
treatment course, radiographs should be obtained weekly to ensure fracture
stability. The palmar crease should be free to allow full motion about the
metacarpophalangeal joints (Fig. 21).
[42]

(Fig. 21) A well molded short arm cast applied for a stable distal radius fracture.
[42]

Treatment

39

PERCUTANEOUS PIN FIXATION
Because unstable distal radius fractures have a tendency to redisplace
in plaster, percutaneous pinning is a relatively simple and effective method
of fixation that is recommended for reducible extra-articular fractures,
simple intra-articular fractures that are nondisplaced, and in patients with
good bone quality.
[42]
Multiple different techniques have been described for pinning distal
radius fractures. These include pins placed through the radial styloid, two or
three crossed pins across the fracture site, or intrafocal pinning within the
fracture site. Some techniques also incorporate transfixation wires across the
distal radioulnar joint for added stability. The actual technique used is
probably not significant as long as the wires confer sufficient fixation to the
fractured radius.
[42]
Kapandji
[63]
popularized the technique of double intrafocal pinning to
both reduce and maintain distal radius fractures. This procedure is probably
best reserved for noncomminuted extraarticular injuries. Kapandjis
technique first requires a Kirschner wire introduced into the fracture site in a
radialtoulnar direction. When the wire reaches the ulnar cortex, the wire is
used to elevate the radial fragment and recreate the radial inclination. This
wire is then driven through the ulnar cortex for stability. A second wire is
introduced 90 degrees to the first in a similar manner to restore volar tilt.
Generous skin incisions must be made about the pin sites to prevent skin
tethering. Care must also be taken to avoid injury to the cutaneous nerves
(Fig. 22).
[63]
Treatment

40

(a) (b)

(c) (d)

(Fig. 22) Percutaneous pin fixation of an unstable distal radius fracture: a. The xrays of the initial fracture.
b. Two percutaneous pins through the radial styloid. c. Fracture healing in an anatomic position.
d. Functional result.
[42]

Treatment

41

EXTERNAL FIXATION
External fixators are typically used as an adjunct to other forms of
fixation, particularly for the treatment of highly unstable or comminuted
injuries. External fixators provide ligamentotaxis that can help to maintain
fracture reduction, thereby preventing collapse. In addition, they function by
neutralizing compressive, torsional, and bending forces across the fracture
site. Occasionally, external fixators will be used for definitive reduction of
fractures, but more often it will be used in conjunction with other forms of
fixation.
[42]
Several biomechanical studies support the use of augmented external
fixation with supplemental Kirschner wires. Wolfe, et al.
[64]
performed a
cadaveric study comparing osteotomized distal radii stabilized with an
external fixator alone or with various supplemental Kirschner wire
configurations. Fracture transfixation wires placed into the distal fragment
and secured to the external fixator were superior to exfixation alone in
reducing fracture motion. A single wire was enough to gain appreciable
stability, and additional wires did not improve stability further.
[64]
Despite its usefulness, the rate of complications with external fixation
is high. Complications include stiffness, pin tract infections, pin loosening,
radial sensory nerve injury, and reflex sympathetic dystrophy. These
complications may be avoided to some degree by avoiding carpal
overdistraction, excessive wrist flexion, and prolonged fixator treatment.
[42]

(Fig. 23)
Treatment

42

(Fig. 23) External fixator with K-wires in management of DRF
[42]
Treatment

43

ARTHROSCOPICALLY ASSISTED FIXATION
Wrist arthroscopy is a technique that provides a minimally invasive
way of monitoring closed reduction of distal radius fractures with
percutaneous pin fixation. Obviously, it allows assessment of the articular
joint surface as well as the diagnosis of interosseous carpal ligament injury
or TFCC injury. Finally, it facilitates the excision of osteochondral flaps and
loose bodies as needed.
[42]
To perform wrist arthroscopy, a small joint (2.7 mm) arthroscope may
be introduced through the 34 portal. Instrumentation can be introduced
through the 45 or 6R portals. Wrist arthroscopy with fixation is generally
best achieved about four to seven days from the time of injury. Surgery
performed too soon after injury may face difficulties with fracture hematoma
impeding articular visualization. Likewise, fractures treated after one week
from the time of injury may be difficult to manipulate with percutaneous
wires. Fracture fragments are typically elevated using Kirschner wires as
joysticks. Fractures can then be pinned transversely beneath subchondral
bone.
[42]

FRAGMENT SPECIFIC FIXATION
The concept of fragment specific fixation has been touted as a surgical
alternative to volar plating alone. Some basic tenets of fracture fixation for
fragment specific systems include: (1) application of small contoured plates
on the specific components of the fracture; (2) fixation of distal fragments is
based on the strong bone proximally; (3) hardware should allow for gliding
motion of tendons; (4) the exposure should cause minimal soft tissue
Treatment

44

disruption; and (5) the fracture should be stable to allow early range of
motion. The type of implant used should match the specific fracture
fragment being reduced via the use of limited volar and dorsal incisions.
[42]
Rikli and Regazzoni
[15]
reviewed a series of 20 patients with distal
radius fractures fixed with two 2.0 mm titanium plates placed at 50 - 70
degrees to one another. No cases of extensor tendon problems were noted,
most likely because they were able to place a flap of retinaculum over the
small dorsal plates. Clearly, fragment specific fixation may provide some
advantages over the traditional methods of dorsal or volar plating for
fractures at the distal end of the radius.
[15]
( Fig. 24)

(a)
Treatment

45

(b)
(Fig. 24) A complex articular fracture treated with fragment specific fixation with small Synthes
plates: a. The preoperative CT scan; b. Two plate dorsal fixation.
[42]

OPEN REDUCTION AND INTERNAL FIXATION
Open reduction internal fixation has obvious advantages over the
other methods discussed so far. It allows direct restoration of anatomy,
stable internal fixation, a decreased period of immobilization, and an earlier
return of wrist function. There are a number of different indications for open
reduction internal fixation, and these include: unstable articular fractures
(such as a volar Bartons injury), impacted articular fractures, radiocarpal
fracturedislocations, complex fractures requiring direct visualization of the
fracture fragments, and failed closed reductions.
[42]
Historically, distal radius fractures were treated nonoperatively until
1929, when techniques utilizing pins and plaster were introduced. External
skeletal fixation evolved in 1944 and remained popular even after the AO
group designed plates specifically for the treatment of distal radius fractures
in the 1970s. In 1994, Agee introduced the Wrist Jack (Hand Biomechanics
Treatment

46

Lab Inc, Sacramento, CA), which utilized adjustable gears for multiplanar
ligamentotaxis, but by this time open reduction internal fixation was
becoming more popular, particularly when it was noted that precise
reductions of the articular surface led to better outcomes.
[65]

LOCKED PLATE DISTAL RADIUS
Locking plates have revolutionised treatment for distal radius
fractures. However, proper reduction and technique remain as important as
ever.
[66]
The advent of fixed-angle locking plates has improved fracture
healing and addressed the inadequacies of nonlocked plates. Formerly, a
rigid fixation construct with a nonlocked plate was achieved only if there
was minimal motion at the joint or if the bone density was sufficient to
withstand applied physiologic load. In other words, the stability of the
screws in the bone and at the screwplate interface was possible if the load
was kept to a minimum. These are limiting factors that require prolonged
cast immobilization even after surgical fixation. In osteoporotic bone,
minimal axial stress may permit toggling of the screws and become loose.
The locking plate introduced threads at the screw plate interface creating a
single beam construct, which has been reported to be four times stronger
than constructs that allow motion between the screws and plate.
[39]

Locked plates are ideal for osteoporotic fractures because they
decrease the potential for toggling of the screws in the cortex. Furthermore,
a fixed-angle device transfers the load from the intact subchondral bone
across the compromised metaphysis to the intact diaphysis, which would
Treatment

47

theoretically permit early range of motion postoperatively, as the construct
can withstand physiologic loading.
[67]
Since its introduction in 2000, volar fixed-angle fixation technique has
provided an effective alternative for the management of dorsal and volar
fractures. This approach is used because fixed-angle plates eliminate the
need to place the implant on the unstable side of the fracture; therefore, the
more physiologic volar approach can be used to treat the majority of
fractures.
[68]
This approach is less disruptive to the tendons because there is
more space available on the volar aspect of the radius. Flexor tendons are
located away from the volar surface of the radius, while extensor tendons
run directly on the dorsal surface. The volar approach allows the use of a
thicker, stronger implant to better resist the loads applied during functional
rehabilitation. Refinements of volar fixed-angle fixation were based on
insights into the anatomy of the radius, biomechanics, and blood supply.
[69]

(Fig. 25) Bridging produces a load-free area to give added stability to the fracture zone.
[70]
Treatment

48

The most attractive anatomic feature of the volar aspect of the distal
radius is the absence of flexor tendon-bone intimacy. Implant fixation on the
volar aspect of the distal radius is also advantageous because its surface,
except at the very distal margin, is relatively flat in the transverse plane. This
feature facilitates the accurate restoration of rotational alignment. The volar
radius also presents a concave profile in the sagittal plane (the pronator
fossa). This feature is limited distally by a ridge called the watershed line
[71]

and allows the application of implants of substantial profile. The gliding
surface of the flexor tendons should not come in contact with the plate as
long as the implant is nested in the pronator fossa, does not cross its distal
boundary, or project above it.
[71]
A properly applied plate should be just proximal to the watershed line
and not project above or beyond it in order to avoid contact with the flexor
tendons. In addition, the plate should be in line with bone and the pegs of
adequate length.
[66]
The watershed line is used as a surgical landmark because it is easily
palpable as a bony prominence through the fibrous tissue that covers it,
especially over the most ulnar aspect (volar rim of lunate fossa) where it is
very close (2 mm) to the joint line. The radial aspect of the watershed line is
proximal (1015 mm) to the joint line as it courses along the base of the
styloid process. The volar wrist capsule and ligaments insert distal to the
watershed line, and the most distal edge of the pronator quadratus muscle is
located several millimeters proximal. The intermediate fibrous zone is
located here between capsule and muscle.
[72]

Fracture fixation frequently requires a thorough exposure of the volar
surface of the radius, including the volar rim of the lunate fossa where rare
Treatment

49

volar marginal fragments originate. This exposure is best obtained by
elevating all soft tissue proximal to the watershed line including the
intermediate fibrous zone and pronator quadratus muscle. Dorsally displaced
fractures frequently present with a rupture of the pronator quadratus muscle
located through its most distal fibers proximal to the intermediate fibrous
zone.
[72]
The need for fixed-angle plates arose from the failure of conventional
buttress plates to achieve stable fixation. Conventional screws toggle as
purchase on the weak bone of the distal fragment is usually poor. Fixed-
angle implants do not depend on screw purchase, they depend on direct bone
support through an interference effect.
[72]
Volar and dorsal fracture fixation constructs require different implant
architecture. Dorsal fracture fixation is usually performed with at least two
orthogonal implants. Volar plating, by virtue of precise peg distribution,
allows a single fixed-angle plate to provide the same dorsal stability as with
multiple dorsal implants.
[72]

Most distal radius fractures are dorsally displaced. Support of the
dorsal aspect of the articular surface is of primary importance, hence the
distal tilt of the pegs. Fixed-angle volar fixation of dorsally unstable distal
radius fractures results from the capture of distal fragment(s) between
distally inclined pegs and the surface of the plate. The distal inclination of
the pegs in the lateral plane will neutralize dorsal displacing forces while
inducing a volar force, which must be opposed by a properly configured
volar buttressing surface. Also, divergence of the pegs in space to closely
follow the complex three-dimensional shape of the articular surface
Treatment

50

improves fixation. Pegs support load in a cantilever manner, therefore the
greatest resist physiologic loads.
[72]

Pegs can be smooth or threaded. Smooth pegs are easier to insert and
provide the necessary subchondral support. Threaded pegs are useful for
stabilizing a coronal fracture plane and preventing diastases of the articular
fragment. Fixed-angle volar plates transfer loads directly from the articular
surface to the proximal radial shaft, circumventing any metaphyseal
comminution.
[72]
The implant acts as an internal fixator in which stability across the
fracture becomes a function of the properties of the plate. A volar fixed-
angle plate supporting a fracture unstable in dorsal and volar directions can
bear loads better than a dorsal fixed-angle plate. It is able to do this because
of shape of the distal radius. Its articular surface is offset with respect to the
diaphysis by a few millimeters in a volar direction, placing the joint reaction
force closer to the volar plate and decreasing its bending moment.
[72]
Providing stable fixation in the presence of substantial osteopenia has
been challenging because the holding power of a conventional screw is
directly proportional to the density of the bone. About 100,000 distal radius
fractures in osteoporotic bone have been reported annually in the United
States, most from low energy falls.
[73]
Fixed-angle support has successfully
overcome the limitations of the more traditional forms of internal fixation.
[74]

The subchondral plate is usually the strongest bone on the distal fragment,
and fixed-angle pegs provide reliable fixation if applied immediately
underneath it.
[72]
Distal radius fractures in the elderly or infirmed populations are
common and continue to occur more frequently. These patients have specific
Treatment

51

needs: stable fixation for poor quality bone, simple anesthesia because of
poor general health, and the need for quick rehabilitation. Volar fixed-angle
fixation offers an adequate treatment method for this patient population, as
the technique relies on the only substantial bone remaining in advanced
osteoporosis - the subchondral plate. The volar approach is well tolerated
and can be performed under regional anesthesia.
[33]
The question of whether using pegs or screws results in important
biomechanical differences has been addressed in a cadaveric study.
Although there were no statistically significant differences in torsional or
axial stiffness at the beginning of loading, after 1,000 cycles, pegs failed by
loosening, most often at the pegplate interface. Screw fixation provided a
more stable construct.
[75]
A number of studies were carried out to evaluate the effectiveness of
this method of treatment which contained series of unstable dorsally
displaced distal radius fractures and which treated them with volar plates
with locking screws. Constantine et al.
[76]
used a volar plate (-plate
[Synthes, Paoli, PA]) in 20 fractures with 12 months follow-up. Eighty
percent of these dorsally displaced fractures were intra-articular, and this
same percentage of patients initiated early preoperative joint motion. The
authors reported a mean range of flexion-extension of 123, a mean range of
pronosupination of 156, without any significant loss of reduction, and a low
incidence of complications.
Orbay
[68]
who employed the DVR plate, conducted a prospective
study of 29 patients with 31 unstable dorsally displaced distal radius
fractures and a mean follow-up of 13 months. With a mean final range of
flexion-extension of 112 and mean pronosupination of 158, he obtained
Treatment

52

100% of excellent or good results. Only 2 patients lost part of the radial
length obtained in the immediate post-op period. The only complication in
the series was a case of dorsal tendinous irritation caused by a screw of
incorrect length.
Drobetz and Kutscha-Lissberg
[77]
reviewed 50 dorsally displaced
distal radius fractures (two-thirds of these fractures were intra-articular),
with 26 months follow-up, treated with a fixed-angle volar plate (Mathys
Plate, Synthes, Solothurn, Switzerland). Loss of initial reduction achieved
occurred in 21 patients and implant failure in 2 cases. Final range of motion
was not reported. They had 12 complications, 6 of which were tears of the
flexor pollicis longus attributable to the design of the plate.
Chung et al
[78]
treated 87 distal radius fractures with a DVR plate and
their patients were able to start mobilizing the operated wrist at the first
week post-op, without any apparent losses of the initial reduction achieved.
Similarly, Osada et al
[9]
in a series of 49 patients with this type of fracture,
used the DRV Locking Plate (Mizuho Ikakogyo Co, Ltd, Tokyo, Japan) and,
without recourse to splinting in the first few weeks post-op, observed that,
physiologically, wrist joint motion during everyday activities transmitted an
axial load of 100 N through the joint, while the load rose to 250 N on active
finger flexion. This seems to confirm that an antebrachiopalmar splint does
not neutralize the axial load generated by finger movements in the operated
wrist.
[9]

In view of these results, authors do not recommend routine use of the
splint, except in patients where there is doubt as to the stability afforded by
the fixation system used.
[79]

Complications

53

The reported complication rates of distal radius fractures in the
literature vary from 6% to 80%.
[80]
Complications may occur from the
fracture or its treatment.
[81]
McKay and colleagues
[80]
reviewed the overall incidence of
complications after distal radius fractures in the literature (Table 1) and
subsequently in their series of 250 consecutive patients treated for distal
radius factures. They found a physician reported complication rate of 27%
and a patient reported complication rate of 21%. They also found that
patients and physicians report distal radius fractures differently;
unsurprisingly, patients focused more on symptoms, whereas physicians
were more apt to classify complications into diagnoses.
Complications caused by distal radius fractures and their treatment are
divided chronologically into immediate, early (<6 weeks), and late (>6
weeks).
[81]
Abbreviations: ROM, range of motion; RSD, reflex sympathetic dystrophy.
After McKay, et al (2001)
[80]

Complications

54

IMMEDIATE COMPLICATIONS
Nerve I njury:
Distal radius fractures complicated by nerve injury are relatively
common, with a reported incidence varying from 0% to 17%. The median
nerve is most frequently involved, followed by the radial and ulnar
nerves.
[80]
Acute carpal tunnel syndrome is more common in patients who
have more severe and comminuted fractures and also in those undergoing
multiple closed reduction attempts.
[82]
Patients should be carefully examined to rule out neurologic injury.
Splinting or casting in extreme wrist flexion should be avoided because this
significantly increases carpal tunnel pressures, compromising median nerve
function.
[83]
Gelberman and colleagues
[83]
found that mean carpal tunnel
pressures were 18 mmHg in a neutral wrist position, 27 mm Hg in 20 of
flexion, and 47 mm Hg in 40 of flexion. In a series of patients who had
carpal tunnel syndrome, the pressure was 23 mm Hg in neutral and 38 mm
Hg in flexion, but was 8 mm Hg in neutral and 14 mm Hg in flexion for
normal control subjects.
[84]
Mild carpal tunnel symptoms are common and usually related to
swelling and contusion around the median nerve. In patients who have
significant hand and wrist swelling, splints or bivalve casts should be used
rather than circumferential casts. Patients should be encouraged to keep the
hand elevated and actively flex and extend their fingers. The symptoms
usually diminish as the swelling subsides. A carpal tunnel release should be
considered if the symptoms are more severe or progressive, or if surgical
intervention is planned that may increase swelling. Patients who undergo
Complications

55

early release have a better long term outcome, because delayed treatment
can result in an incomplete or prolonged recovery period.
[82]
Open I njury:
Open fractures of the distal radius are infrequent. However, open
fractures of the distal ulna in association with a distal radius fracture are
more common. Gustilo and Anderson type I injuries are the most common
and may be easily missed, especially on the volar side of the wrist. The skin
around the distal forearm and wrist must be carefully examined before and
after manipulation. Intravenous antibiotics should be administered and
tetanus status assessed in the emergency department. These injuries require
prompt irrigation, debridement, and fracture stabilization.
[81]
Patients who have an open fracture should be advised that they have
an increased likelihood of a poor outcome. The largest reported series of
open fractures included 18 consecutive patients and was collected over 8-
years. Type I Gustilo and Anderson injuries were the most common with an
incidence of 50%, followed by type II and III injuries with incidences of
17% and 33%, respectively. Most injuries were the result of high-energy
trauma. Four patients in this series also had nerve injuries, four patients had
tendon injuries, and two had vascular injuries. Patients who had higher
Gustilo and Anderson types required a greater number of secondary surgical
procedures, because type I injuries required a mean of 0.3 additional
procedures, whereas type III fractures required a mean of 4.7 procedures.
Eight of the 18 patients developed postoperative infections (five soft tissue
and three osteomyelitis) and five patients developed a nonunion.
[85]

Complications

56

Skin I njury During Manipulation:
Distal radial fractures are more common in the elderly population.
[86]

The overlying skin may be thin and can be traumatized during fracture
manipulation, converting a closed fracture into a potential open injury.
[81]
Compartment syndrome:
Compartment syndrome associated with distal radius fractures is rare,
with an incidence of 1%, and can occur up to 54 hours after the initial injury.
It occurs more frequently in younger patients who are more likely to sustain
higher energy injuries.
[81]
Missed Associated I njury:
Distal radial fractures in elderly patients are usually caused by a low-
energy injury; but are often caused by high-energy forces in young patients.
High-energy injuries may be associated with injuries remote to the wrist (eg,
elbow, shoulder, spine, lower limb) or local to the wrist (eg, carpal or
metacarpal injury). A careful history, thorough physical examination, and
appropriate radiographs will identify other sites of injury.
[81]

EARLY COMPLICATIONS (<6 WEEKS)
Cast I ssues:
Applying a full cast on an acute injury will not accommodate
subsequent swelling. It may be used for unstable fractures, but patients
should be warned of the potential complications of increased pain, nerve
compression, and, ultimately, compartment syndrome. A non-
Complications

57

circumferential splint provides less support to the fracture, but will
accommodate swelling.
[81]

Post trauma swelling reduces in the days and weeks after injury. The
cast may become loose and should be changed. If a non-circumferential
splint was initially applied, then it may be replaced by a complete cast at 10
to 14 days.
[81]
The cast should support the fracture and permit free movement of the
fingers and thumb. After application, the cast must be inspected to ensure
that it does not compromise finger motion. The patient should be encouraged
to exercise the fingers to prevent stiffness and reduce the risk for
dystrophy.
[81]
Loss of Reduction:
Charnleys
[88]
three-point fixation technique is recommended to
support the fracture within the cast. If the fracture displaces, then it should
be promptly corrected through either closed manipulation or surgery. Many
factors have been associated with an increased risk for displacement,
including increasing age, dorsal comminution, and degree of dorsal
angulation at presentation.
[89]
Mackenney and colleagues
[90]
reported that
early instability was (1) ten times more common in patients older than 80
years compared with patients younger than 30 years, (2) six times more
common in fractures with any form of dorsal comminution, and (3) five
times more common in fractures maintaining 5 to 10 of dorsal angulation
compared with fractures achieving any degree of volar angulation.
Complications

58

A risk for displacement also exists with operative treatment. With
percutaneous K-wires, the risk for displacement is greatest in older
individuals and fractures with greater than 50% dorsal comminution.
[91]
Operative technique is important. A randomized study comparing
treatment with two styloid wires and treatment using a single styloid wire
with the addition of two dorsal Kapandji wires found that the two-styloid-
wire technique was less reliable.
[92]
A randomized study of external fixators
found than an additional pin in the distal radial fragment provided better
stability and decreased the pintrack infection rate.
[93]

I nfection:

Compound fractures and fractures treated operatively are at risk for
infection. The largest reported series of compound fractures reported a 44%
infection rate, with 62% of the infections involving the soft tissues and 38%
as osteomyelitis.
[85]

The infection rate with K-wire fixation has been reported to be as high as
33%. Infection may occur within the soft tissues and can be treated with oral
antibiotics, or may involve the bone causing an osteomyelitis that requires
surgical intervention. Burying the wires beneath the skin reduces the risk for
infection.
[94]
An infection rate of 21% has been reported for external fixation.
[95]

Infection with internal fixation is less common. If infection occurs, then
internal fixation should be removed and the fracture treated with cast support
or external fixation and antibiotics.
[81]

Complications

59

Neurologic Complications:

A review of more than 200 patients with displaced Colles fractures
found that 17% had carpal tunnel symptoms at 3 months and 12% had
symptoms at 6 months. The patients who had carpal tunnel symptoms were
significantly older and their fractures showed significantly greater residual
dorsal angulation.
[96]
Mackay and colleagues reported 22% median, 11% radial nerve, and 6%
ulnar nerve symptoms complicating distal radius fractures.
[80]
The radial
nerve sensory branch is particularly vulnerable to injury. This nerve exits
beneath the dense fascia between the tendons of brachioradialis and extensor
carpi radialis longus. This anatomy acts as a local tether that prevents
excursion of the nerve away from a blindly placed surgical instrument. Care
should be taken when inserting K-wires, spreading the overlying tissues, and
during blunt dissection to bone before wire insertion. Neuromas in this area
are particularly troublesome because they can be irritated by rubbing against
shirt cuffs, watches, and bracelets.
[97]

Tendon Rupture:

Tendon ruptures can occur as an early or late complication. The extensor
pollicis longus tendon is most commonly ruptured. The incidence in
undisplaced distal radius fractures is 3%, with rupture occurring at a mean of
7 weeks (range, 2 weeks to 11 months).
[98]
Extensor tendon ruptures are more common than flexor tendon ruptures
in fractures treated nonoperatively. Both flexor and extensor tendon ruptures
Complications

60

occur more commonly on the radial side of the wrist. Tendon ruptures have
also been reported from multiple passes of K-wires and from volar or dorsal
internal fixation.
[99]
LATE COMPLICATIONS (>6 WEEKS)
Nerve Complications:

A review of 60 patients reported electrodiagnostically confirmed
carpal tunnel syndrome in 20% of patients at a mean of 10 months (range,
1.5 to 27 months) between injury and the onset of symptoms. The authors
found a significant correlation between the final clinical results of treatment
and the presence of post-traumatic median nerve compression neuropathy,
but did not find a correlation with the initial fracture configuration or the
final radiographic findings.
[100]
Complex Regional Pain Syndrome:

A syndrome characterized by severe burning pain in an extremity
accompanied vasomotor and trophic changes in bone without an associated
specific nerve injury. This condition is most often precipitated by trauma to
soft tissue. The skin over the affected region is usually erythematous. It is
called Complex Regional Pain Syndrome type 1 (CRPS), Reflex
Neurovascular Dystrophy (RND), Reflex Sympathetic Dystrophy and
Sudeks atrophy.
[80]
Early recognition of CRPS and proper management, including
psychiatric intervention (alleviate heightened pain response), occupational
therapy (restore function and motion), and pain management is paramount in
obtaining a good functional outcome in those patients.
[80]
Complications

61

Arthrosis:

A review of patients at a mean of 6.7 years after an intra-articular
fracture of the distal radius found that 65% had radiographic evidence of
posttraumatic arthrosis. Fractures that healed with residual radiocarpal
incongruity had a higher rate of radiographic arthrosis (91%) versus
fractures that healed with a congruous joint (11%). The authors reported that
restoration and maintenance (extraarticular reduction) of the dorsal tilt and
radial length were not critical except when severe radial shortening occurred.
A step-off of 2 mm or more in the distal radial articular surface at healing
has been found to be a significant risk for arthrosis.
[101]

Malunion:

Malunion is defined as malalignment resulting in dysfunction. Distal
radius malunion is the most common complication following a distal radius
fracture. The incidence of distal radius malunion has been reported to be up
to 17% and is more common in those treated nonoperatively than those
treated surgically. A malunited distal radius in a low-demand elderly patient
may be of minimal functional consequence. Therefore, impairment of
function rather than radiographic malunion determines if an intervention is
necessary. Malunion should be categorized as either extra-articular or intra-
articular, because treatment may differ. The most common deformity
following an extra-articular distal radius fracture is shortening, rotation of
the distal fragment, loss of volar tilt, and loss of ulnar inclination. A
malunited distal radius affects wrist, forearm.
[102]

Complications

62

Biomechanical and clinical studies have evaluated distal radius
deformity and wrist mechanics. Radial shortening changes the radiolunate
contact area and shifts the load on the lunate facet. It also has been shown
that 10 mm of shortening reduced forearm pronation by 47% and supination
by 29 %. A shortened radius increases the strain on the TFCC, which may
result in distal radioulnar joint (DRUJ) instability. Lastly, a shortened radius
effectively lengthens the ulna and increases the load borne by the ulna,
resulting in ulnocarpal impaction. A decrease in radial inclination shifts the
load from the scaphoid to lunate fossa. A dorsally angulated fracture
effectively shifts the load on the dorsal aspect of the wrist joint at all
radiocarpal articulations. It causes incongruency at the DRUJ, resulting in
loss of forearm rotation.
[103]
Early intervention allows correction of the deformity before soft tissue
contracture develops, minimizes potential DRUJ dysfunction or arthritis, and
lessens the period of disability for the patient. Advocates of late intervention
argue that functional disability should be declared before undergoing a
potentially unnecessary surgical procedure. The concept of intentional delay
is often prudent, in which a comminuted fracture is allowed to heal in order
to create bone stock, with plans for future osteotomy. Jupiter and
coworkers
[104]
compared early versus late timing for osteotomy and found no
clinical difference. However, they felt that early intervention is technically
easier and decreases the duration of disability.

Nonunion/Delayed Union:

Fractures that show no radiographic signs of bridging trabeculae
across the fracture site at 4 months are categorized as delayed unions and as
Complications

63

nonunions after 6 months. Nonunion of the distal radius is uncommon. In
their study of 2000 distal radial fractures, Bacorn and Kurtzke reported a
nonunion rate of 0.2%.
[105]
Open fractures, severe comminution, infection, tissue interposition,
devascularization of the bone ends, and pathologic lesions predispose to
nonunion. It is also reported that nonunion of the distal radius associated
with nonunion of a distal ulna fracture. The loss of the intact distal ulna may
affect the stability of the distal radial fracture and lead to increased motion at
the fracture site, with resultant nonunion. A review of 23 nonunions found
that 9 had an associated distal ulna fracture. Treatment factors may also
predispose to nonunion, including over distraction of the fracture and
inadequate stabilization of the fracture.
[106]
Medical factors have also been
implicated, including diabetes, peripheral vascular disease, peripheral
neuropathy, alcoholism, and smoking.
[107]


46

Case 1:
62 years old male, judge, presented to Mansoura Emergency hospital with
distal radius fracture due to falling from standing height on outstretched
hand, x-rays were done and he was prepared for surgery.

(Fig. 26) Case 1 preoperative PA and lateral x-rays.


46

Immediate post-operative x-rays:

(Fig. 27) case 1 Immediate post-operative PA and lateral x-rays showing fixation by
volar locked plate and k-wires.


44

2 months follow up:

(Fig. 28) Case 1 follow up after 2 months showing union.


46

(Fig. 29) Case 1 functional outcome.


46

Case 2:
20 years old male, manual worker, presented to Mansoura
Emergency hospital with distal radius fracture due to falling from 2
meters height on outstretched hand, x-rays were done and he was
prepared for surgery.


46

(Fig. 31) Case 2 preoperative CT scan showing articular depression.

67


(Fig. 32) case 2 immediate post-operative PA and lateral x-rays showing fixation by
volar locked plate.


67

3 months follow up:



67



67

Case 3:
32 years old male, Accountant, presented to Mansoura Emergency
hospital with distal radius fracture due struggle, x-rays were done and he
was prepared for surgery.



66


(Fig. 36) case 3 immediate post-operative PA and lateral x-rays showing fixation by
volar locked plate.


66

3 months follow up:


64



77

Summary
Distal radius fractures are the most frequent lesions encountered
during clinical practice. The treatment is controversial and still debated in
the literature.
[1]
The distal end of the radius forms the anatomic foundation of the
wrist joint.
[13]
The volar surface of the distal radius is relatively flat. It is
covered proximally by the pronator quadratus muscle. The flexor tendons
and the median nerve lay more superficially. The dorsal surface is
convex.
[14]
The wrist complex is biaxial joint, with motions of
flexion/extension (volar flexion/dorsiflexion) around a coronal axis, and
radial deviation/ ulnar deviation (abduction/adduction) around an
anteroposterior axis.
[29]
Most commonly, injuries occur after a simple fall from standing
height. Almost all distal radius fractures (apart from dorsal rim avulsion
fractures) can be produced by hyperextension of the wrist.

Bending forces
tend to occur in low-energy falls and typically produce dorsal
displacement. Shearing forces disrupt the ligamentous connections of the
wrist and produce unstable fracture-dislocations, whilst axial loading,
high-energy injuries compress the articular surface and cause fragments
of joint surface to be impacted.
[51, 52]
Various classification systems have been proposed to describe the
injury and help formulate a treatment plan. Broadly they tend to be
anatomical classifications that group fracture patterns, biomechanical that
describe the mechanism of injury and fracture stability or a combination
of both.
[51]


78

Locking plates have revolutionised treatment for distal radius
fractures. However, proper reduction and technique remain as important
as ever.
[71]
The advent of fixed-angle locking plates has improved fracture
healing and addressed the inadequacies of nonlocked plates. Formerly, a
rigid fixation construct with a nonlocked plate was achieved only if there
was minimal motion at the joint or if the bone density was sufficient to
withstand applied physiologic load. In other words, the stability of the
screws in the bone and at the screwplate interface was possible if the
load was kept to a minimum. These are limiting factors that require
prolonged cast immobilization even after surgical fixation. In
osteoporotic bone, minimal axial stress may permit toggling of the screws
and become loose. The locking plate introduced tines at the screw plate
interface creating a single beam construct, which has been reported to
be four times stronger than constructs that allow motion between the
screws and plate.
[44]
Conclusion:
Locked plate is ideal for distal radius fractures.
It decreases the potential for toggling of the screws in the cortex.
It permits early range of motion postoperatively, as the construct
can withstand physiologic loading.

Allows the volar approach to be used to treat both volar and dorsal
displaced fractures.
Special value in the management of highly comminuted
metaphyseal and/or osteoporotic fractures in which screws
purchase in the distal fragments might be impossible.

References

79

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