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Unstable Distal Radial Fractures Treated with External Fixation, a

Radial Column Plate, or a Volar Plate. A Prospective Randomized
Trial
David H. Wei, Noah M. Raizman, Clement J. Bottino, Charles M. Jobin, Robert J. Strauch and Melvin P.
Rosenwasser
J Bone Joint Surg Am. 2009;91:1568-1577. doi:10.2106/JBJS.H.00722

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 1568
C OPYRIGHT Ó 2009 BY T HE J OURNAL OF B ONE AND J OINT S URGERY, I NCORPORATED

Unstable Distal Radial Fractures Treated with

External Fixation, a Radial Column Plate,
or a Volar Plate
A Prospective Randomized Trial
By David H. Wei, MD, Noah M. Raizman, MD, Clement J. Bottino, MD, Charles M. Jobin, MD,
Robert J. Strauch, MD, and Melvin P. Rosenwasser, MD

Investigation performed at Columbia University Medical Center, New York Presbyterian Hospital, New York, NY

Background: Optimal surgical management of unstable distal radial fractures is controversial, and evidence from rig-
orous comparative trials is rare. We compared the functional outcomes of treatment of unstable distal radial fractures with
external fixation, a volar plate, or a radial column plate.
Methods: Forty-six patients with an injury to a single limb were randomized to be treated with augmented external
fixation (twenty-two patients), a locked volar plate (twelve), or a locked radial column plate (twelve). The fracture
classifications included Orthopaedic Trauma Association (OTA) types A3, C1, C2, and C3. The patients completed the
Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire at the time of follow-up. Grip and lateral pinch strength,
the ranges of motion of the wrist and forearm, and radiographic parameters were also evaluated.
Results: At six weeks, the mean DASH score for the patients with a volar plate was significantly better than that for the
patients treated with external fixation (p = 0.037) but similar to that for the patients with a radial column plate (p =
0.33). At three months, the patients with a volar plate demonstrated a DASH score that was significantly better than
that for both the patients treated with external fixation (p = 0.028) and those with a radial column plate (p = 0.027). By
six months and one year, all three groups had DASH scores comparable with those for the normal population. At one
year, grip strength was similar among the three groups. The lateral pinch strength of the patients with a volar plate was
significantly better than that of the patients with a radial column plate at three months (p = 0.042) and one year (p =
0.036), but no other significant differences in lateral pinch strength were found among the three groups at the other
follow-up periods. The range of motion of the wrist did not differ significantly among the groups at any time beginning
twelve weeks after the surgery. At one year, the patients with a radial column plate had maintained radial inclination
and radial length that were significantly better than these measurements in both the patients treated with external
fixation and those with a volar plate (all p < 0.05).
Conclusions: Use of a locked volar plate predictably leads to better patient-reported outcomes (DASH scores) in the first
three months after fixation. However, at six months and one year, the outcomes of all three techniques evaluated in this study
were found to be excellent, with minimal differences among them in terms of strength, motion, and radiographic alignment.
Level of Evidence: Therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence.

Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants
in excess of $10,000 from the Doris Duke Clinical Research Fellowship. In addition, one or more of the authors or a member of his or her immediate family
received, in any one year, payments or other benefits in excess of $10,000 or a commitment or agreement to provide such benefits from a commercial
entity (Biomet EBI). No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical
practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

A commentary is available with the electronic versions of this article, on our web site (www.jbjs.org) and on our quarterly CD-ROM/DVD (call our
subscription department, at 781-449-9780, to order the CD-ROM or DVD).

J Bone Joint Surg Am. 2009;91:1568-77 d doi:10.2106/JBJS.H.00722

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T
he ideal method of surgical management of unstable
distal radial fractures is controversial1. Excellent clinical
results have been achieved with either external fixation
or internal fixation2. Recently, fixation with a locked volar plate
has gained widespread popularity. Although some evidence
supporting its use instead of external fixation is available3, data
from randomized clinical trials in which the investigators
employed validated patient-reported outcome measures are
only beginning to emerge and have yet to demonstrate clear
superiority4.
In addition, application of a plate to the radial column as
a separate means of fixation, independent of its role as part of a
more complex system of fragment-specific fixation5, has yet to
be explored in the comparative literature, to our knowledge.
Use of a radial column plate offers some theoretical advantages
over other plate techniques. Dorsal and volar metaphyseal
fragments can be indirectly stabilized with minimal disruption
of their vascular supply. Furthermore, the adhesion and rup-
ture of the extensor tendons that can be associated with dorsal
fixation may be avoided6,7. A biomechanical study conducted at
our institution showed the radial column plate to be five times
as stiff as the volar plate during wrist flexion and extension, as
it is 90° orthogonal to the flexion-extension axis8. In addition,
the clinical safety and efficacy of fixation with a radial column
plate were demonstrated in our retrospective cohort study,
Fig. 1
Randomization flow chart.
U N S TA B L E D I S TA L R A D I A L F R A C T U R E S T R E AT E D W I T H E X T E R N A L
F I X AT I O N , A R A D I A L C O LU M N P L AT E , O R A V O L A R P L AT E
which showed minimal surgical morbidity as well as satisfac-
tory reduction and stability until union9.
The present prospective randomized study was performed
to investigate whether use of a volar plate would accelerate re-
covery of function as assessed with validated patient-reported
outcome measures and also to determine how three surgical
modalities—augmented external fixation, use of a locked volar
plate, and use of a locked radial column plate—would compare
in terms of functional and radiographic outcomes in patients
with an unstable distal radial fracture.
Materials and Methods
Study Design
W e conducted a single-center, prospective, randomized
clinical trial that was approved by our institutional review
board and was in accordance with the Declaration of Helsinki
ethical principles for medical research involving human sub-
jects. We report our findings according to the guidelines set
forth by the CONSORT group for randomized clinical trials10.
Patient Selection
All patients who were at least eighteen years of age and had an
unstable distal radial fracture were invited to participate in the
study. Fractures were deemed unstable if they had displaced
after initial treatment with closed reduction and splinting, or
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Fig. 2
Posteroanterior and lateral radiographs were made at each follow-up visit. Examples of the three surgical
techniques are shown.

if three of the following criteria, as described by Lafontaine tiLock, Parsippany, New Jersey). The patients who were to
et al.11, were met: (1) dorsal angulation of >20°, (2) dorsal receive a locked volar plate underwent open reduction of the
comminution, (3) an intra-articular fracture, (4) an associated fracture through a modified Henry approach12.
ulnar styloid fracture, or (5) an age of more than sixty years. Plate fixation of the radial column was carried out
The unstable fracture types included Orthopaedic Trauma through an incision made on the radial aspect of the forearm
Association (OTA) class A3 (extra-articular with comminu- over the first dorsal compartment, based from the tip of the
tion), C1 (simple intra-articular), C2 (simple intra-articular volar aspect of the radial styloid and extending proximally by
with a multifragmentary metaphysis), and C3 (multifragmen- approximately 8 cm. The radial sensory nerve and its branches
tary with involvement of the intra-articular cortex). Patients were identified and were gently retracted with vessel loops. The
with an OTA class-B fracture (partial articular), considerable retinaculum of the first dorsal compartment was incised, and
preexisting arthritis of the hand or wrist that limited grasp, an its tendons were retracted dorsally. The brachioradialis tendon
open or bilateral fracture, a concomitant ulnar shaft fracture, was reflected approximately 10 cm proximal to its distal in-
or prior trauma to either hand were excluded. We engaged all
patients participating in this study in a thorough discussion of
the risks, benefits, and alternatives prior to and following en- TABLE I Demographic Characteristics
rollment. Each patient signed and retained a detailed informed
consent form. Internal Fixation
External Radial Volar
Randomization Fixation Column Plate Plate
Patients were randomized to three study arms in two phases (N = 22) (N = 12) (N = 12)
(Fig. 1). First, the patients were randomly assigned to be
treated with either augmented external fixation or internal Sex*
fixation. During a second randomization, the patients who had Women 16 8 9
been assigned to receive internal fixation were further ran- Men 6 4 3
domized to be treated with either a volar or a radial column Age (yr)† 55 ± 16 60 ± 17 61 ± 18
plate. This randomization scheme was designed to balance Side injured*
internal and external fixation arms and allow one surgeon to Dominant 12 3 6
perform only augmented external fixation while the other Nondominant 10 9 6
surgeon performed only internal fixation. All randomization Handedness*
was done by computer-generated allocation with use of sealed, Right 19 10 12
opaque, numbered envelopes containing the treatment as- Left 3 2 0
signments. The research investigator assessing eligibility cri-
Fracture class*
teria had no foreknowledge of the assigned treatment until
Extra-articular 10 2 3
after the patient was enrolled and the envelope was opened. (class A)
The patients were not made aware of the selected treatment
Intra-articular 12 10 9
option until after the surgery was performed. (class C)

Treatment *The values are given as the number of patients. †The values are
Open reduction and internal fixation was performed with a given as the mean and standard deviation.
precontoured, locked radial column or volar plate (EBI Op-
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TABLE II Scores on the DASH Questionnaire*

Internal Fixation†
External Fixation† Radial Column Plate Volar Plate P Value Favoring

Baseline 76 ± 16 80 ± 14 73 ± 22
6 weeks 56 ± 19a 48 ± 19 41 ± 23a a: 0.037 Volar plate
3 months 29 ± 18a 28 ± 17b 7 ± 5ab a: 0.028, b: 0.027 Volar plate for both
6 months 11 ± 10 18 ± 16 6±4
12 months 18 ± 14c 18 ± 12a 4 ± 5ca a: 0.025, c: 0.056 Volar plate for both

*The DASH questionnaire is scored on a 100-point scale, with lower scores being better. †The values are given as the mean and standard
deviation. Values that share a letter in each row were significantly (a and b) or nearly significantly (c) different from one another.

sertion into the radial metaphysis to be utilized for soft-tissue
coverage over the plate and to reduce the deforming forces of
the brachioradialis on the distal fracture fragment. The frac-
ture was opened through its radial aspect and was reduced by
direct manipulation under visual and fluoroscopic guidance.
The plate was provisionally fixed both proximally and distally
with Kirschner wires before drill-holes were made. To control
facet displacement, the distal holes were diverged in the sagittal
plane to capture the volar and dorsal lunate facet fragments.
Cancellous screws were inserted into the distal holes, the
Kirschner wires were removed, and the plate was used as a
reduction tool to ensure proper restoration of radial length and
tilt. Finally, the proximal holes were filled with cortical screws.
Adjunctive use of cancellous bone allograft or the use of a
secondary means of fixation, such as a dorsal plate or external
fixation, was carried out after assessment of the stability of the
primary fixation.
The patients received standardized follow-up care, in-
cluding a volar splint for comfort, instructions to immediately
begin finger motion, and hand therapy including wrist motion
and strengthening exercises starting at ten to fourteen days.
The patients in the augmented external fixation group
underwent fracture reduction with use of intrafocal fracture
pinning under fluoroscopy, followed by stabilization of frac-
ture fragments with placement of percutaneous Kirschner
wires, usually subchondral or transradial styloid. Two 3.0-mm
pins were then placed in the base of the index metacarpal and
two were placed in the distal part of the radial shaft before
a bridging external fixator (Hoffmann II Compact; Stryker,
Mahwah, New Jersey) was applied. Additional augmentation
strategies included filling of a metaphyseal void with cancellous
bone allograft and/or the use of additional small buttress plates
as deemed appropriate by the orthopaedic surgeon. The pa-
tients were instructed regarding appropriate pin care, and all

TABLE III Grip and Lateral Pinch Strength

Internal Fixation
External Fixation Radial Column Plate Volar Plate
%* kg %* kg %* kg P Value Favoring

Grip
6 weeks 21 ± 21 2.9 27 ± 12 8.8 33 ± 12 6.3
3 months 49 ± 10 11.2 44 ± 12 12.5 60 ± 16 16.3
6 months 75 ± 21a 19.3 53 ± 9a 14.5 59 ± 13 15.3 a: 0.042 External fixation
12 months 69 ± 34 18.0 57 ± 4 20.8 75 ± 25 16.9
Lateral pinch
6 weeks 40 ± 27 3.4 47 ± 22 4.7 52 ± 25 3.6
3 months 68 ± 16 4.6 66 ± 14a 5.8 86 ± 13a 5.9 a: 0.042 Volar plate
6 months 86 ± 24 5.8 81 ± 15 6.5 88 ± 12 4.4
12 months 94 ± 12 5.4 73 ± 8a 5.9 94 ± 5a 4.7 a: 0.036 Volar plate

*The values represent the percentage of the value on the uninjured side and are given as the mean and standard deviation. Values that share a
letter in each row were significantly different from one another.
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TABLE IV Range of Motion

Internal Fixation
External Fixation Radial Column Plate Volar Plate
%* Degrees %* Degrees %* Degrees P Value Favoring

6 weeks
Flexion 39 ± 21 27 50 ± 9 32 49 ± 9 33
Extension 29 ± 11ab 10 46 ± 20a 32 51 ± 16b 38 a: 0.023, Radial column
b: 0.032 and volar plates
Pronation 66 ± 31 58 74 ± 17 66 89 ± 19 77
Supination 47 ± 29ab 34 68 ± 21a 57 62 ± 29b 55 a: 0.041, Radial column
b: 0.049 and volar plates
Radial deviation 44 ± 33 7 58 ± 32 9 61 ± 30 9
Ulnar deviation 44 ± 17 15 73 ± 22 25 56 ± 20 23
3 months
Flexion 73 ± 20 51 69 ± 20 44 63 ± 27 40
Extension 69 ± 23 45 62 ± 22 36 78 ± 18 48
Pronation 96 ± 7 84 93 ± 4 84 91 ± 12 75
Supination 79 ± 16 71 83 ± 19 72 89 ± 14 79
Radial deviation 76 ± 24 15 59 ± 40 11 62 ± 24 19
Ulnar deviation 81 ± 18 31 78 ± 25 26 76 ± 7 31
6 months
Flexion 73 ± 21 52 66 ± 24 45 91 ± 27 53
Extension 79 ± 21 53 76 ± 19 54 79 ± 30 48
Pronation 94 ± 12 84 96 ± 8 85 97 ± 4 85
Supination 91 ± 18 81 92 ± 18 80 100 ± 4 88
Radial deviation 75 ± 33 11 90 ± 22 18 75 ± 12 18
Ulnar deviation 85 ± 12 34 88 ± 21 29 76 ± 7 25
12 months
Flexion 91 ± 8 66 83 ± 28 53 89 ± 13 53
Extension 81 ± 15 63 82 ± 15 54 92 ± 23 63
Pronation 100 ± 6 68 97 ± 6 85 100 ± 3 89
Supination 96 ± 6 68 92 ± 11 83 92 ± 10 81
Radial deviation 100 ± 35 14 95 ± 8 20 95 ± 10 13
Ulnar deviation 91 ± 12 33 95 ± 8 40 100 ± 33 28

*The values represent the percentage of the value on the uninjured side and are given as the mean and standard deviation. Values that share a
letter in each row were significantly different from one another.

external fixators were removed between five and six weeks after
the surgery. Hand therapy, including wrist range-of-motion
and strength-training exercises, was started at that time.
Clinical Outcomes
The patients were evaluated at ten to fourteen days; six weeks;
and three, six, and twelve months after the surgery. Our pri-
mary outcome measure was the Disabilities of the Arm,
Shoulder and Hand (DASH) questionnaire13-16. The DASH
questionnaire is a validated self-reported thirty-item metric
of upper-extremity function based on a 100-point scale, with
0 points indicating no disability and 100 points indicating
maximum disability. The patients were asked to complete a
DASH questionnaire at each follow-up visit, and the score
obtained at their first visit served as the postinjury baseline
level of function.
Secondary outcomes were measured beginning six weeks
after surgery, and they included measurements of wrist and
forearm motion as well as grip and lateral pinch strength. Wrist
flexion-extension and radioulnar deviation were assessed with
a goniometer. Forearm supination and pronation were assessed
with the elbow flexed 90° at the patient’s side. Grip strength
was measured with use of a calibrated Jamar dynamometer
(Sammons Preston Rolyan, Bolingbrook, Illinois) set at level 2,
and lateral pinch strength was measured with a hydraulic pinch
gauge (Sammons Preston Rolyan). The average of three trials
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volar tilt, radial inclination, radial length, ulnar variance, and

TABLE V Pain Scores on Visual Analog Scale* steps and gaps for intra-articular fractures19. Negative values
Internal Fixation for volar tilt represent dorsal tilt, and negative values for ulnar
variance represent an ulna that is shorter than the radius. Two
External Radial Column Volar trained clinical investigators independently performed all
Fixation Plate Plate
radiographic measurements on digital radiographs with a
Baseline 3.9 ± 2.1 2.8 ± 2.0 3.6 ± 2.1 digital goniometer and ruler. An interobserver discrepancy
6 weeks 2.3 ± 1.4 1.9 ± 1.1 1.9 ± 0.9
of >15% triggered another review of the radiographs and
reconciliation of the measurements, sometimes with use of
3 months 1.9 ± 0.9 1.6 ± 0.8 1.7 ± 1.0
other radiographs made during the same visit that offered
6 months 2.2 ± 1.3 1.6 ± 0.9 1.8 ± 1.0
superior exposures.
12 months 1.8 ± 1.3 2.3 ± 1.8 1.8 ± 1.8
Study Blinding
*Pain was assessed with use of a 10-point visual analog scale. Because of the obvious nature of the intervention and residual
The values are given as the mean and standard deviation.
scars, the study was only partially blinded. An independent
investigator who collected and analyzed the functional, ra-
diographic, and range-of-motion outcomes data was blinded
for both hands was recorded for all strength measurements. to the type of treatment. The surgeons were not involved in the
The range of motion and the grip and lateral pinch strengths collection of the study data.
were also calculated as percentages of the values on the con-
tralateral uninjured side as these ratios have been shown to be Sample Size
more sensitive for detecting clinical changes17. We controlled The DASH questionnaire, our primary outcome measure, was
for hand dominance by adjusting values to reflect 10% greater used to perform an a priori power analysis. A meaningful
strength of the dominant hand if, and only if, the patient was difference in the DASH score was estimated to be 10 points15,20.
right-handed18. Pain was recorded on a 10-point visual analog Recent studies of external fixation and volar plate fixation of
scale at each follow-up visit. the distal part of the radius showing the standard deviation of
DASH scores to range from 5 to 10 points allowed for a more
Radiographic Measurements accurate power analysis21-23. We estimated that at least ten pa-
Standard neutral rotation posteroanterior and lateral radio- tients per arm of the study were necessary to detect, with an
graphs were made at each visit (Fig. 2) for measurement of 80% power, a 10-point difference in DASH scores at one year.

TABLE VI Radiographic Measurements

Internal Fixation*
External Fixation* Radial Column Plate Volar Plate P Value Favoring

Preoperative
Radial inclination (deg) 15.0 ± 10.4 16.5 ± 9.1 11.6 ± 9.3
Volar tilt (deg) 26.7 ± 19.5 213.9 ± 15.3 215.2 ± 12.4
Ulnar variance (mm) 0.2 ± 4.4 2.7 ± 3.0 4.5 ± 3.6
Radial length (mm) 8.0 ± 5.2 8.1 ± 3.8 5.0 ± 2.7
6 weeks
Radial inclination (deg) 22.4 ± 4.3 25.0 ± 6.9a 21.1 ± 7.0a a: 0.003 Radial column plate
Volar tilt (deg) 0.3 ± 9.4 1.2 ± 9.7 4.1 ± 3.1
Ulnar variance (mm) 21.1 ± 2.5 20.7 ± 2.1 22.2 ± 3.4
Radial length (mm) 11.4 ± 2.1a 13.0 ± 3.5a 12.5 ± 3.8 a: 0.038 Radial column plate
12 months
Radial inclination (deg) 20.9 ± 3.4a 29.5 ± 5.2ab 17.6 ± 2.1b a: 0.007, b: 0.003 Radial column plate
Volar tilt (deg) 21.9 ± 8.4 28.3 ± 16.1 4.0 ± 2.0
Ulnar variance (mm) 0.0 ± 4.3 0.2 ± 2.3 21.3 ± 3.7
Radial length (mm) 10.8 ± 2.1a 16.5 ± 3.5ab 9.5 ± 2.7b a: 0.002, b: 0.027 Radial column plate

*The values are given as the mean and standard deviation. Values that share a letter in each row were significantly different from one another.

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TABLE VII Postoperative Step and Gap Deformity of
Intra-Articular Fractures
Internal Fixation*
Radial
External Column Volar
Fixation* Plate Plate
(N = 12) (N = 10) (N = 9)
Step deformity
Any step 4 1 2 0.428
Step >2.0 mm 1 0 0 0.441
Gap deformity
Any gap 8 2 4 0.091
Gap >2.0 mm 1 0 1 0.582
*The values are given as the number of patients.
Statistical Methods
Single-factor analysis of variance was used to compare con-
tinuous outcomes, including the DASH scores, mobility,
strength, and radiographic outcomes, among the study groups.
If a difference was detected, an independent two-sided Student
t test with use of the Bonferroni correction was employed
to compare the study groups. Significance was set at p < 0.05.
All analyses were performed with use of the intention-to-
treat principle. Thus, patients who received adjunctive fixation
in addition to their primarily assigned treatment were kept
in their originally assigned treatment arm. This intention-to-
treat method of analysis is specifically designed to mitigate
bias that would result if such patients were removed from
the analysis. By keeping them in their treatment group, we
measured the effect of allocating an intervention in actual
practice.
Source of Funding
Funding for this work was provided in part by the Doris Duke
Clinical Research Fellowship.
Results
Patient Cohort
F ifty-seven patients with a distal radial fracture were
screened over eighteen months, and eleven patients were
excluded: six because of a concomitant ulnar shaft fracture,
four because of an OTA class-B fracture, and one because of a
bilateral injury. Thus, forty-six patients with a closed, unilat-
eral, unstable distal radial fracture were randomized to three
treatment groups: twenty-two were randomized to be treated
with external fixation; twelve, to treatment with a radial col-
umn plate; and twelve, to treatment with a volar plate. Of the
patients treated with external fixation, all had placement of
supplemental Kirschner wires, four had bone-grafting of the
fracture, and two received additional plate fixation (with a
volar plate in one and a dorsal plate in the other). Within the
internal fixation arm, three patients deviated from the ran-
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domly assigned treatment: two who had been originally as-
signed to be treated with a volar plate received additional
fixation with a dorsal plate, and one who had been assigned to
fixation with a radial column plate received supplemental
buttressing of the fracture with a volar plate. Eight wrists in the
radial column plate group and four wrists in the volar plate
group received supplemental bone-grafting.
P Value The characteristics of the three study groups with respect
to sex, age, side injured, handedness, and fracture type are
shown in Table I. Thirty-three women (72%) and thirteen men
(28%) were enrolled, and their mean age (and standard de-
viation) was 58 ± 17 years. Fifteen class-A3, four class-C1,
fourteen class-C2, and thirteen class-C3 fractures were treated.
All of the forty-six randomly assigned patients returned within
two weeks after surgery for the first follow-up visit; forty-two
(91%) returned for the six-week visit; forty (87%), for the
three-month visit; thirty-six (78%), for the six-month visit;
and thirty-six (78%), for the one-year visit. The patients who
were lost to follow-up did not differ significantly, in terms of
treatment assignment, fracture class, or any other baseline
characteristic, from the patients who were not.
Subjective Outcomes
During the first follow-up visit, all patients demonstrated
marked impairment of function, with a mean postoperative
baseline DASH score of 76 ± 17 points (Table II). There was no
significant difference among the groups at this time. By six
weeks, the mean DASH score in the volar plate group was
significantly better than that in the external fixation group (p =
0.037) but not significantly different from that in the radial
column plate group. At three months, the mean DASH score in
the volar plate group was significantly better than that in both
the external fixation group (p = 0.028) and the radial column
plate group (p = 0.027). However, by six months, the DASH
score in the volar plate group was not significantly different
from that in either the external fixation group (p = 0.26) or the
radial column plate group (p = 0.38). At one year, the mean
DASH score in the volar plate group (4 ± 5 points) was sig-
nificantly better than the mean score in the radial column plate
group (18 ± 12 points) (p = 0.025) but was not significantly
different from the mean score in the external fixation group
(18 ± 14 points) (p = 0.056). At the time of final follow-up,
all treatment groups showed significant improvement in the
DASH scores compared with their original postinjury scores
(p  0.05). The final mean DASH score for all patients was
13 ± 12 points (Table II).
Objective Outcomes
The percentage of the contralateral grip strength that had been
recovered at six months by the patients treated with external
fixation was significantly higher than that recovered by those
treated with the radial column plate (p = 0.042). No other
significant differences in grip strength were found among the
groups at any other follow-up period, and all groups demon-
strated significant improvement from six weeks to one year
postoperatively (p  0.05). Overall, the average grip strength
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as a percentage of that of the uninjured hand increased from
25% ± 16% (6 ± 3 kg) at six weeks to 69% ± 24% (19 ± 9 kg) at
one year (Table III).
The lateral pinch strength of the patients with a volar plate
was significantly better than that of the patients with a radial
column plate at three months (p = 0.042) and at one year (p =
0.036). No other significant differences were found among the
groups with regard to lateral pinch strength at any of the follow-
up periods, and all groups showed a significant improvement
from six weeks to one year postoperatively (p  0.05). Overall,
the average percentage of the lateral pinch strength of the un-
injured hand improved from 45% ± 23% (4 ± 2 kg) at six weeks
to 89% ± 13% (5 ± 2 kg) at one year (Table III).
Range-of-motion analysis revealed significant improve-
ment from six weeks to one year in all groups (p < 0.05). Al-
though early differences in extension and supination
demonstrating less motion in the external fixation group (all
p < 0.05) were found at six weeks, no significant differences
were found at any follow-up period thereafter (Table IV).
At the final evaluation, wrist flexion-extension averaged
117° ± 20° (86% ± 17% of the value on the contralateral
side), forearm pronation-supination averaged 158° ± 25°
(94% ± 12% of the value on the contralateral side), and
wrist radioulnar deviation averaged 48° ± 9° (98% ± 21% of
the value on the contralateral side). An analysis of the pain
scores recorded on the visual analog scale did not reveal
significant differences among the groups during any follow-
up period (p > 0.05) (Table V).
Radiographic Outcomes
An analysis of radiographs at six weeks showed that the radial
column plate maintained significantly greater radial inclina-
tion than did the volar plate (p = 0.003) and significantly
greater radial length than did external fixation (p = 0.038)
(Table VI). At one year, the degree of radial inclination and the
radial length in the patients with a radial column plate were
significantly greater than those in both the patients treated
with external fixation (p = 0.007 and p = 0.002, respectively)
and the patients treated with a volar plate (p = 0.003 and p =
0.027). Final measurement showed a mean of 8° of dorsal
radial tilt in the patients with a radial column plate, 4° of volar
tilt in those with a volar plate, and 2° of dorsal tilt in those
treated with external fixation. However, there were no signif-
icant differences among the groups with regard to volar tilt or
ulnar variance at any follow-up period.
An analysis of the intra-articular fractures for step and
gap deformities (Table VII) did not reveal any significant dif-
ferences among the groups (p > 0.05), but there was a trend
toward a higher proportion of patients with a gap deformity of
any size in the external fixation group (p = 0.091).
Complications
Transient neuropathy in the distribution of the median nerve
developed in three patients in the external fixation group, three in
the radial column plate group, and two in the volar plate group.
None required carpal tunnel release, and all but one case resolved
U N S TA B L E D I S TA L R A D I A L F R A C T U R E S T R E AT E D W I T H E X T E R N A L
F I X AT I O N , A R A D I A L C O LU M N P L AT E , O R A V O L A R P L AT E
by six months after the operation. One patient who received
external fixation experienced pin site irritation and underwent
early removal of the fixator at four weeks, but there was no
subsequent loss of reduction or additional complications.
Thirty-eight (83%) of the patients had no complications.
There were no infections, tendon ruptures, loss of digital
motion, radial sensory nerve injuries, or secondary procedures
(i.e., implant removal).
Discussion
B ridging external fixation of distal radial fractures has been
part of the surgeon’s armamentarium far longer than have
locked plates. External fixation continues to be employed by
many surgeons as a familiar technique requiring minimal ex-
posure24,25. External fixation is used to maintain axial length
while reduction is attained by manipulation of fracture frag-
ments with supplemental Kirschner wires and ligamentotaxis
in intra-articular and extra-articular fracture patterns26,27.
However, external fixation alone is limited by the inability to
directly reduce intra-articular fracture fragments in complex
unstable fracture patterns.
The advantages of open reduction and internal fixation
include direct visualization and manipulation of the fracture
fragments28. Multiple studies have demonstrated good clinical
results with various plates, including dorsal, volar, and fragment-
specific devices5,29,30. Of these, locked volar plates have grown in
popularity, but there have been few evidence-based trials
comparing these techniques31.
Several randomized studies comparing external and in-
ternal fixation of distal radial fractures have been limited by the
use of first-generation implants32,33 or by the absence of well-
validated outcome measures2,33,34. Other studies supporting the
use of volar plates have largely been observational or retro-
spective35-37. To our knowledge, this is the first prospective
randomized clinical trial of the use of a radial column plate as
an independent means of fixation of complex distal radial
fractures.
We showed that, compared with both external fixation
and use of a radial column plate, fixation with a locked volar
plate led to a more rapid improvement in subjective function.
This advantage over external fixation was evident at the six-
week time point, which may not be relevant because of the
delay in initiating therapy when a spanning external fixator is
in place. By three months, the patients with a volar plate not
only had a higher level of subjective function than the patients
treated with the other two techniques, but they also had a
mean DASH score comparable with normative values15. By six
months, all three surgical groups demonstrated excellent
subjective functional scores, and at one year, the patients in the
volar plate group had significantly better subjective function
only when compared with those treated with a radial column
plate. Thus, the patients who had been treated with a volar
plate had the distinct advantage of achieving normal subjec-
tive function three months earlier than the patients who had
been managed with either external fixation or a radial column
plate.
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This study also shows that fixation with a radial column
plate is a viable option that produces excellent subjective and
objective clinical outcomes that are no different from those
obtained with external fixation. At the time of final follow-up,
the patients with a radial column plate demonstrated signifi-
cantly better maintenance of radial inclination and radial
length. The change in mean volar tilt demonstrated a slightly
increased amount of dorsal collapse at one year, but the values
were not significantly different from those in the other groups
and all patients demonstrated excellent DASH scores and
range-of-motion measurements.
We also found that a significantly better DASH score
does not correlate directly with better grip strength. Specifi-
cally, at six months, although no difference in the DASH scores
was found, the patients who had received external fixation had
a significantly higher mean percentage of contralateral grip
strength (75% ± 21%) than those with a radial column plate
(53% ± 9%) (p = 0.042). Conversely, no significant differences
in grip strength were found at one year, despite a significantly
better DASH score in the volar plate group. Our results are
similar to those of several other comparative studies of distal
radial fractures, which demonstrated better grip strength in the
external fixation group32-34. For example, Kreder et al. also
found a significantly better mean grip strength in the external
fixation group at six months, no difference at one year, and
no significant difference in patient-rated outcomes at either
time period34. Thus, these data suggest that grip strength
may not contribute substantially to the patient’s perception
of function as measured by the DASH questionnaire. Al-
though grip strength after closed treatment of distal radial
fractures has been shown to be a significant predictor of the
scores on another subjective outcome questionnaire, the
Patient-Rated Wrist Evaluation38, additional investigations
are necessary to delineate the true relationship between grip
strength and the scores on the DASH questionnaire in this
patient population.
We discovered significant differences in lateral pinch
strength that paralleled differences in the DASH scores. Both at
three months and at one year, the lateral pinch strength in the
volar plate group was significantly higher than that in the ra-
dial column plate group (p = 0.042 and p = 0.036, respec-
tively). This finding suggests that lateral pinch strength may be
an important predictor of patient perceived function, espe-
cially in the setting of internal fixation with a radial column
plate. The lower lateral pinch strength in the radial column
plate group may reflect the surgical exposure of the first
dorsal compartment tendons. However, no patients reported
pain over that area. As this is the first comparative trial of
radial column and volar plates, to our knowledge, we believe
that lateral pinch strength deserves further exploration in
future trials as it may serve as a sensitive predictor of per-
ceived function when plate fixation of the radial column is
involved.
This study had several limitations. First, we enrolled the
number of patients that we believed necessary to detect a
difference in our primary outcome measure, the DASH score.
U N S TA B L E D I S TA L R A D I A L F R A C T U R E S T R E AT E D W I T H E X T E R N A L
F I X AT I O N , A R A D I A L C O LU M N P L AT E , O R A V O L A R P L AT E
Our study was not powered to detect differences in our sec-
ondary outcomes, such as mobility or pain. Such differences
may exist, and our results should be confirmed by future
randomized trials to further identify factors contributing to
the differences that we found in functional outcome. More-
over, we randomized patients in two phases, resulting in three
treatment groups of unequal numbers of wrists. Randomiza-
tion in a single phase should be considered to distribute pa-
tients equally across treatment groups. Another limitation of
this study was our difficulty with maintaining patient follow-
up despite vigorous attempts to do so. However, our follow-up
rates were comparable with that in another randomized study
involving distal radial fractures34. Also, our primary objective
in conducting this study was to compare functional outcomes
using the DASH questionnaire. Multiple authors have noted
the durability of function after one year, irrespective of long-
term changes such as radiocarpal arthritis, strongly suggesting
that longer follow-up is unnecessary in this patient popula-
tion34,39,40. Nonetheless, a comparative trial with longer follow-
up would allow evaluation of potential long-term sequelae,
such as the development of arthritis.
We believe that the subjective short-term advantage of
the use of a locked volar plate is robust and applicable to the
treatment of unstable distal radial fractures. The selection of
implants and their application for any given fracture is based
on the surgeon’s experience, an assessment of the fracture
pattern, the characteristics of the patient, and common sense.
We also acknowledge that certain fractures may require both a
primary fixation implant and a secondary implant to stabilize a
displaced articular facet.
In conclusion, this study provides new evidence sup-
porting the trend toward fixation of distal radial fractures with
locked volar plates1,37. Although function was no different at six
months, the patients who received a locked volar plate for the
treatment of a distal radial fracture recovered more quickly
than did the patients in the other two treatment arms. This
evidence indicates that locked volar plates may be advantageous
for a patient who desires an accelerated return of function;
however, all three techniques can provide good subjective and
objective functional outcomes at one year. n
David H. Wei, MD
Clement J. Bottino, MD
Charles M. Jobin, MD
Robert J. Strauch, MD
Melvin P. Rosenwasser, MD
The Trauma Training Center, 622 West 168th Street,
PH 11, Room 1164, New York, NY 10032.
E-mail address for D.H. Wei: ttc@columbia.edu
Noah M. Raizman, MD
Department of Orthopaedic Surgery,
George Washington University School of Medicine,
2150 Pennsylvania Avenue, N.W.,
7th Floor, Washington, DC 20037
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