Injury, Int. J.

Care Injured 41 (2010) 1120–1126

Contents lists available at ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

Management of distal radius fractures: Treatment protocol and functional results

P. Cherubino *, A. Bini, D. Marcolli
Department of Orthopaedics and Traumatology, University of Insubria, Ospedale di Circolo - Fondazione Macchi, V.le Borri 57, 2110 Varese, Italy

A R T I C L E I N F O A B S T R A C T

Keywords: Distal radius fractures are the most frequent lesions encountered during clinical practice. The treatment
Distal radial fracture is controversial and still debated in the literature. For a correct management of these lesions many
Closed reduction authors recently emphasised the importance of anatomical reduction, a stable fixation and early joint
Plaster cast immobilisation percutaneous mobilisation.
pinning
We report our experience in the daily management of these lesions. The fractures are evaluated
External fixation
Internal plates fixation
considering fracture type, fracture reduction criteria, adequacy of reduction criteria and overall fracture
Locking volar plating stability. The best treatment option must be decided in accordance to the type of fracture, the extent of
metaphyseal comminution, the quality of the bone and the medical condition of the patient.
ß 2010 Elsevier Ltd. All rights reserved.

Introduction The best option to avoid secondary loss of reduction seems to

Distal radius fractures are the most frequent lesions encoun-
tered during clinical practice.34,43 Therefore, the treatment is
controversial and still debated in the literature.
Despite the improvements made in both the diagnosis and the
management of these injuries, long term pain, stiffness and
impairment of strength of the affected joint are not uncommon.32
These sequelae may be present not only after complex fractures
but also after simple ones with up to 24% of the patients being
reported having permanent disabilities8 with substantial con-
sequences to the health care system and the tax payers.22,23,29,86
Several studies have emphasised the importance of anatomical
reduction, stable fixation and early range of motion.16,40,66,72 A
direct correlation between the quality of the reduction and
functional outcome has been reported.2,26,48,50,78,84 However, an
anatomical reduction does not necessarily lead to a satisfactory
outcome, and vice versa, an good functional outcome has been
reported in patients without anatomical reduction.4,7,9
In intra-articular fractures, the development of post-traumatic
osteoarthritis is related to a residual step off greater than 2 mm.46
Other studies however, underline that residual pain, reduction in
the range of motion and loss of strength are present with articular
step off greater than 1 mm.26,84 Extra-articular fractures have also
been shown to be associated with a poor outcome in the presence
of radial shortening20,45,57,84,87 and volar tilt.9,21
* Corresponding author. Tel.: +39 0332 278824; fax: +39 0332 278825.
E-mail address: paolo.cherubino@uninsubria.com (P. Cherubino).
be internal fixation.16,63,51,56 However, anatomical reduction is
frequently difficult to achieve in complex distal radius fractures
because of the number of fragments, osteochondral and
ligamentous associated lesions.25 There is always the possibility
to have a residual step off even when open reduction and internal
fixation is performed.15,33,84 The most recent literature reviews
regarding the management of distal radius fractures conclude
that there is not a treatment option that can be preferred to
achieve higher results.19,37 Different studies reported in the
literature compare external fixation with internal fixation,
without finding a surgical option that can be considered as
the gold standard.81,47 Margaliot et al.55 in a meta-analysis work
confirm these results.
Several factors have been shown to be important for the
management of distal radius fractures including amongst other
the type of fracture, the quality of the bone, patient co-
morbidities and the surgeons’ personal experience. The aim of
this work is to report our experience in the daily management of
these lesions.
Fracture evaluation: diagnosis criteria and fracture type
Diagnosis criteria
Different evaluation and treatment algorithms for distal radius
fractures have been described in the literature.70 We consider 5
parameters that can be used for the decision making process: (i)
fracture type, (ii) fracture reducibility, (iii) reduction acceptability
criteria, (iv) fracture instability parameters and (v) associated joint
lesions.

0020–1383/$ – see front matter ß 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.injury.2010.09.016
 P. Cherubino et al. / Injury, Int. J. Care Injured 41 (2010) 1120–1126
Fracture type: AO classification
We define the fracture type in accordance to the AO
classification.60 This gives us the possibility to define the essential
elements that must be considered in the fracture: joint involve-
ment and comminution of the fracture represent important factors
to define the prognosis and treatment of the injury.
Criteria for fracture reduction
Simple and user friendly is the flow chart proposed by Gupta
et al.36 named as the ‘‘11s Rule’’: re-establishment of the radius
height of 11 mm, ulnar variance of 1 mm, radial inclination of 228
and volar tilt of 118. When these radiographic parameters are
achieved the fracture reduction is accomplished. We consider as
extra-articular parameters the criteria described by Van der Linden
and Ericson and Castaing,17,84 and as intra-articular parameters the
step off scale proposed by Knirk and Jupiter46 and articular gap
evaluation proposed by Gliatis et al.33
Reduction acceptability criteria
If the fracture is not anatomically reduced, but the criteria
proposed by Fernandez25 are achieved, it is not always necessary to
proceed to a second fracture reduction manipulation. These
criteria are:
- dorsal tilt less than 108;
- radial shortening less than 2 mm;
- radial inclination greater than 158;
- distal radio-ulnar joint congruence;
- articular step off less than 2 mm.
We have observed that if these parameters are respected even if
the anatomical reduction is not achieved it is possible to obtain a
good outcome.12
Fracture instability parameters
After the evaluation of the quality of the reduction, our decision
to proceed to a surgical or non-surgical procedure is based on the
fracture instability parameters described in the literature by
Lafontaine et al.49:
- radial dorsal angle more than 208;
- dorsal fracture comminution;
- intra-articular fracture line;
- presence of ulna fracture;
- patient’s age more than 60 years.
Furthermore we consider a radial shortening more than 4 mm
as indicated by Altissimi et al.5 In accordance with these authors
we believe that the presence of three or more of these
parameters are related to a highly probable loss of fracture
reduction.
Evaluation of associated joint lesions
Finally associated joint lesions must be considered. We evaluate
the injuries of the distal radio-ulnar joint in accordance with the
classification of Fernandez and Jupiter.27 Associated capsular and
ligamentous lesions and fractures are included in this classifica-
tion. The more frequent wrist injures found are the scapholunate
dissociation, perilunate dislocations, lunotriquetral ligament
injury and scaphoid fractures.59,89,90 Elbow injuries must also be
considered, in particular radial head fractures.
Such associated injuries can be identified by standard wrist and
elbow X rays. An injury of the scapholunate ligament must be
suspected if there is an important radial styloid or lunate facet
dislocation. A lesion of the lunotriquetral ligament must be
considered if there is a severe radius shortening and an impact of
1121
the ulna head on the carpus. These radiographic parameters are
part of the static evaluation of the wrist. Furthermore, during
surgery dynamic wrist evaluation must be performed under
fluoroscopy. Dynamic and static wrist evaluation as described by
Henry,37 allow obtaining a correct assessment of associated
injuries in distal radius fractures.
During follow up we always evaluate the range of motion of the
affected wrist and we compare it to the healthy wrist. The strength
parameter is assessed with a Jamar dynamometer whereas pain is
quantified using a Visual Analogue Scale (VAS). Radiographic
evaluation includes the development of post-traumatic wrist
osteoarthritis assessed according to the Knirk and Jupiter
criteria.46 Functional assessment is performed using the Gartland
and Werley scale30 and the DASH (Disability Arm Shoulder Hand)
scale.39
Treatment options: our techniques and review of the literature
Closed reduction and plaster cast immobilisation
There is no agreement in the literature whether the immobi-
lisation must be performed in a long or short arm cast, in
supination, pronation or neutral position.4,52,54,69,74,85,88 Even the
time of immobilisation is still under debate.30,69,79,85
The cast immobilisation must be kept for at least 6 weeks.
Cast removal before 6 weeks, could be responsible for a loss of
fracture reduction. Loss of reduction can be as high as 60% of the
cases and for this reason it is important to perform X rays during
the first 3 weeks after the injury.30,68 If loss of reduction is
present then revision surgery by closed means is desir-
able.23,41,79 It is of note that Abbaszadegan et al.1 reported that
secondary loss of reduction can occur even after 6 weeks from
the injury.
In 100 extra-articular fractures of distal radius treated in our
department between 2004 and 2007, we observed a secondary loss
of reduction during plaster cast immobilisation in 35% of cases. All
of these patients underwent revision surgery. After an accurate
analysis of these fractures, we observed that the secondary loss of
reduction was in reality 5% as the remaining fractures that lost
reduction were wrongly classified as stable fractures and, therefore
were incorrectly treated in plaster cast.12
Closed reduction, percutaneous pin fixation and plaster cast
immobilisation
In 1929 Bòhler14 was the first to propose percutaneous fixation
with metallic pins and immobilisation with plaster cast of distal
radius fractures. Several authors since then reported good
anatomical and functional results with pin fixation and plaster
cast immobilisation but they also described a high rate of
complications.3,67,75,18,42 Munson and Gainor61 achieved and
maintained the correct radial angle in 87% and the radial length
in 92% of the cases treated. We achieved a successful outcome in 29
of 30 fractures treated between 2004 and 2007 with pin fixation
and plaster cast immobilisation. Loss of the ideal radiographic
parameters was negligible.48 During follow up in 12 cases we
observed an average radial shortening of 1, 5 mm and an average
volar tilt loss of 38.
External fixation
Anderson and O’Neil described external fixation in 1944.6 In the
presence of metaphyseal and diaphyseal comminution, external
fixation is considered the safer fixation method to avoid radial
shortening.31,58 Complications of the external fixation have been
reported in up to 53% of patients.38,67,68,69 Excessive fracture
1122 P. Cherubino et al. / Injury, Int. J. Care Injured 41 (2010) 1120–1126

distraction can lead to an increased incidence of delayed union and
non-union.67 Hybrid external fixation of neglected distal radial
fractures results in good outcomes if care is taken to prevent over
distraction of bone fragments.35
In a recent retrospective study of 90 patients treated for
fractures type A, B, C in accordance with the AO classification we
achieved an overall good outcome in 76% of cases.13
Internal fixation—volar plates
Different studies demonstrated that anatomical reduction of
distal radius fractures with early joint mobilisation leads to good
functional outcomes.62,42,40,73
Plates and osteosynthesis techniques have undergone an
important evolution during the last years resulting in new
implant designs with greater versatility. Locking volar plates
introduced recently work biomechanically as if they were
external fixators placed directly on the fracture.24 The results
described in the literature with the use of locking volar plates are
very encouraging.64,65,73
It is of note that locking volar plates have been used
successfully for the treatment of fractures with dorsal displace-
ment, elderly patients with osteoporosis and complex type C
fractures according to the AO classification.10,28,37,44,71,80,83 In a
recent retrospective study of 63 patients treated for A, B and C
fractures in accordance to the AO classification, we achieved
good results in 77.8% of the patients based on the Gartland and
Werely scoring system.11 We noted an increase from 64.5% to
93.7% of good results with the use of locking volar plates. These
findings have been attributed to the absence of supplementary
external fixation and to an early joint mobilisation. According to
[(Fig._1)TD$IG]
our protocol we initiate joint mobilisation 4 weeks after surgery.
In a clinical trial Lozano-Calderòn et al.53 compared two
groups of patients, one started physiotherapy after 2 weeks
and the second after 6 weeks form surgery. The authors reported
that both groups of patients achieved similar functional
outcomes.
Our treatment indications
Stable extra-articular fractures
In our experience this type of fractures are well managed with
non-operative treatment.
We perform closed reduction and plaster cast immobilisation
(long arm) in neutral position with the wrist kept in 208 of flexion
and 208 of ulnar deviation. Radiographic evaluation is performed at
7 and 15 days from injury to eventually identify secondary fracture
displacement.
The long arm cast is kept for 4 weeks, followed by a short arm
cast for 2 weeks followed by removal of plaster and referral to
physiotherapy.
Extra-articular fractures without important metaphyseal
comminution
These fractures are normally treated with closed reduction,
percutaneous fixation with Kirschner wires and immobilisation in
short arm cast.81,90
We perform closed reduction and stabilisation of the fracture
using two Kirschner wires positioned through the radial styloid
and one wire through the dorsal aspect of the radius. Under

Fig. 1. (A) ME, 68 y.o. Extra-articular fracture with important metaphyseal comminution in patient affected by osteoporosis and older than 60 years old, without the correct
restoration of the radial inclination, radial height and the radio-ulnar distal index; an ulnar fracture head is, also, present. (B) Closed reduction with restoration of the extra-
articular parameters, stabilisation with Kirschner wires of the fracture and of the radio-ulnar distal joint. Positioning of bridging external fixator; mini-open access and
grafting with autologous bone. The percutaneous pinning to stabilise the radio-ulnar distal joint is removed after 4 weeks, the Kirschner wires and external fixator are
removed after 6 weeks. (C) AM, 42 y.o. Type A3 extra-articular fracture, unstable, with scaphoid mid 1/3 fracture-type B2 of Herbert classification. (D) Open reduction and
internal fixation with L.C.P. plate and scaphoid Twin-Fix screw. The limb is immobilised for 4 weeks by a short arm plaster cast with the thumb included.
[(Fig._2)TD$IG] P. Cherubino et al. / Injury, Int. J. Care Injured 41 (2010) 1120–1126 1123

Fig. 2. (A) RR, 37 y.o. Type B1 partially articular fracture in association with the ulnar styloid fracture and instability of the radio-ulnar distal joint, without dynamic or static
lesions of the scapholunate ligament. (B) Closed reduction, stabilisation of the radial styloid with two Kirschner wires and of the radio-ulnar distal joint with one transversal
radio ulnar Kirscher wire. Immobilisation in short arm plaster cast for 6 weeks. Removal of the transversal pin after 4 weeks and of the styloid pins after 6 weeks.

fluoroscopy we evaluate the stability of the radio-ulnar distal joint,
and if necessary we stabilise it using a Kirschner wire inserted
through ulna to the radius. Then we immobilise the limb with a
short arm plaster cast for a period of 6 weeks. Kirschner wires are
[(Fig._3)TD$IG]
usually removed after 4 weeks.
Unstable extra-articular fractures with important metaphyseal
comminution
Our preferred method of fixation is closed reduction, stabilisa-
tion with percutaneous pinning and neutralisation of the fixation

Fig. 3. (A) RN, 83 y.o. Fracture type B3, Barton’s volar fracture. (B) Open reduction and internal fixation with locking volar plate. Immobilisation in short arm plaster cast for 15
days, then joint mobilization for range of motion recovery is begun.
[(Fig._4)TD$IG]
1124 P. Cherubino et al. / Injury, Int. J. Care Injured 41 (2010) 1120–1126

Fig. 4. (A) TG 47 y.o. Complex metaphyseal fracture with articular extension type C2. (B) Open reduction and internal fixation achieved with Acu-Loc plate. Immobilisation in
short arm plaster cast for 4 weeks.

with an external bridging fixator, type Penning. We perform when
indicated a trabecular bone grafting with a mini-open access in
order to gain fracture stability and to accelerate the consolidation
period76 (Fig. 1A and B).
More recently we are considering open reduction and internal
fixation of these fractures with locking volar plates.77,82 This
procedure is performed in young patients with high functional
demands, in polytrauma patients and in elderly patients with
underlying osteoporosis (Fig. 1C and D).
Articular B1, B2, B3 fractures according to the AO classification
Partial articular fractures type B1 (radial styloid)
We perform closed reduction and use a Kirschner wire as a
joystick. The fracture is stabilised by percutaneous pinning. The
wrist is then immobilised with short arm plaster of Paris (Fig. 2A
and B).
If closed reduction is not successful, we perform open
reduction and osteosynthesis with a cannulated screw. We
carefully search for any associated scapholunate ligament injury
performing under fluoroscopy dynamic stress views. We
stabilise these unstable lesions with two 1 mm diameter
Kirschner wires (inserted through scaphoid and lunate and
scaphoid respectively). Static lesions of the scapholunate
ligament are treated with mini Mitek anchors and 1 Kirschner
wire to secure stability or direct suture of the ligament with non-
absorbable suture.
B2 partial articular fracture, ‘‘Dorsal Barton’s fracture’’
In these cases we proceed with closed reduction and fixation
with percutaneous pinning and further stabilisation with a
bridging external fixator. To obtain the reduction of the dorsal
fractures comminution we perform, if necessary, a dorsal mini
open approach.
Internal fixation is performed if loss of reduction is evident after
2 weeks from conservative treatment. If the dorsal fracture
fragment appears uncontrollable with the percutaneous pinning,
open reduction and internal fixation is performed using locking
volar plates. Dorsal plates are used only in special situations
because they have a high rate of complications on the extensor
compartment. For this reason we prefer the removal of the dorsal
plate after 6 months from surgery.
B3 partial articular fractures, ‘‘Barton’s fracture’’
Our favourite procedure is the open reduction and
internal fixation currently with locking volar plates. For
these fractures we do not consider any other options (Fig. 3A and B).
Type C1, C2, C3 fractures according to the AO classification
Distal radius meta epiphyseal fractures type C1
If we achieve a good reduction according to Fernandez criteria
we proceed to an external fixation with an eventual mini open
access to correct any intra-articular step offs. Bone grafting is used
as indicated.

[(Fig._5)TD$IG]

Fig. 5. (A) GR, 33 y.o. Metaphyseal complex articular fracture type C3 in politraumatized patient. (B) Open reduction through dorsal access after 44 days from injury,
autologous bone grafting, stabilisation with Kirschner wires and positioning of bridging external fixator.
[(Fig._6)TD$IG] P. Cherubino et al. / Injury, Int. J. Care Injured 41 (2010) 1120–1126
Fig. 6. (A) PC, 54 y.o. Meta-epiphyseal complex fracture type C3 with associated a transcapho-transcapitate perilunate dislocation. (B) Open reduction and internal fixation
with Acu-Loc plate and additional Kirschner wires; scaphoid and capitate synthesis through dorsal access and fixation with Acutrak screw, reconstruction of the scapho
lunate ligament with MiniMitek Anchor and stabilisation of the scapho lunate and lunate triquetrum bones with Kirschner wires; bridging external fixator.
We perform an external fixation in patients with associated
lesions and local conditions affected by soft tissue trauma.
If it is not possible to achieve a good reduction it will be
necessary to perform open reduction and internal fixation using
locking volar plates.
Meta epiphyseal fracture type C2
To treat this type of injury we prefer the use of an external
fixator. If a long period of immobilisation with the external fixator
is required we prefer the use of open reduction and internal
fixation. Locking volar plates are used without the need for bone
grafting (Fig. 4A and B).
Meta epiphyseal complex fracture type C3
These lesions frequently require an integrated treatment with
percutaneous pinning, internal fixation and bridging external
fixator. The use of locking volar plates may avoid the need of a
supplementary external fixation (Fig. 5A and B). Often it is
necessary to treat even associated injuries such as fractures and
ligament lesions (Fig. 6A and B).
Conclusions
Great versatility of treatment options for distal radius fractures
is required in order to be able to manage all the considered fracture
types. It is not reasonable to assume that there is a gold standard of
treatment for all distal radius fractures. The best treatment option
must be decided in accordance to the type of fracture evaluated
from the radiographs after temporarily reduction. Many factors
must be taken into consideration including the quality of the bone,
the extent of comminution, the risk of loss of reduction, and the
overall medical condition of the patient.
When treatment is being evaluated, it is also necessary to
consider the cost-benefit ratio for both the patient and the
society. We consider appropriate the treatment option that is
simpler, less invasive and able to control the fracture variables.
The more complex treatment options should be reserved only in
those fractures that are particularly difficult to reduce and to
stabilise.
Conflict of interest statement
All authors disclose any financial and personal relationships
with other people or organization that could inappropriately
influence the work, within 3 years from submission of the work.
There are no conflicts of interest.
1125
References
1. Abbaszadegan H, von Sivers K, Jonsson U. Late displacement of Colles’ fractures.
Int Orthop 1988;12:197–9.
2. Adani R, Tarallo L, Amorico MG, et al. The treatment of distal radius articular
fractures through L.C.P. system. Hand Surg 2008;13(2):61–72.
3. Agee JM. External fixation: technical advances based upon multiplanar liga-
mentotaxis. Orthop Clin North Am 1993;24:265–74.
4. Altissimi M, Antenucci R, Fiacca C, Mancini GB. Long term results of conserva-
tive treatment of fractures of the distal radius. Clin Orthop 1986;206:202–10.
5. Altissimi M, Mancini GB, Azzara A, Ciaffoloni E. Early and late displacement of
fractures of the distal radius: the prediction of instability. Int Orthop
1994;18:61–5.
6. Anderson R, O’Neil G. Comminuted fractures of the distal end of the radius. Surg
Gynecol Obstet 1944;78:434–40.
7. Arora R, Gabl M, Gschwentner M, et al. A comparative study of clinical and
radiologic outcomes of unstable colles type distal radius fractures in patients
older than 70 years: nonoperative treatment versus volar locking plating. J
Orthop Trauma 2009;23(April (4)):237–42.
8. Bacorn RW, Kurtzke JF. Colles’ fracture: a study two thousand cases from the
New York State Workmen’s compensation Board. J Bone Joint Surg
1953;35A:643–58.
9. Batra S, Gupta A. The effect of fracture-related factors on the functional outcome
at 1 year in distal radius fractures. Injury 2002;33(July (6)):499–502.
10. Berglund LM, Messer TM. Complications of volar plate fixation for managing
distal radius fractures. J Am Acad Orthop Surg 2009;17(June (6)):369–77.
11. Bini A, Surace MF, Baldo F, et al. Ruolo della placca volare nella sintesi delle
fratture dell’estremo distale di radio. Riv Chir Mano Sett 2009;46(2):121–2.
12. Bini A, Surace MF, Pilato G. Complex articular fractures of the distal radius: the
role of closed reduction and external fixation. J Hand Surg Eur 2008;33(3):305–
10.
13. Bini A, Valli F, Pala F, Pilato G. Indicazioni e limiti della fissazione esterna nelle
fratture di polso. Riv Chir Mano Sett 2008;45(2):303–4.
14. Bòhler L. The treatment of fractures. Vienna, Austria: W Maudrich; 1929.
15. Bradway JK, Amadio P, Cooney W. Open reduction and internal fixation of
displaced comminuted intra articular fractures of the distal end of the radius. J
Bone Joint Surg 1989;71:839–47.
16. Campbell DA. Open reduction and internal fixation of intra articular and
unstable fractures of the distal radius using the AO distal radius plate. J Hand
Surg 2000;25B:528–34.
17. Castaing J. Les fractures recente de l’extremité inferieure du radius chez
l’adulte. Chir Orthop 1964;5:581–696.
18. Chapman DR, Bennet JB, Bryan WJ, Tullos HS. Complications of distal radial
fractures: Pins and plaster treatment. J Hand Surg 1982;7A:509–12.
19. Chen NC, Jupiter JB. Management of distal radius fractures. J Bone Joint Surg Am
2007;89(September (9)):2051–62.
20. Clancey GJ. Percutaneous Kirschner fixation of Colles fractures. A prospective
study of thirty-five cases. J Bone Joint Surg 1984;66A:1008–14.
21. Cooney III WP. Distal radius fractures: external fixation proves best. Hand Surg
Am 1998;23(November (6)):1119–21.
22. Cooney III WP, Dobyns JH, Linscheid RL. Complications of Colles’ Fractures. J
Bone Joint Surg 1980;62A:613–9.
23. Cooney III WP, Linscheid RL, Dobyns JH. External pin fixation for a unstable
Colles’ fractures. J Bone Joint Surg 1979;61A:840–5.
24. Dacatra U, Lauri G, Merello A. Recenti orientamenti nell’osteosintesi con placca
delle fratture del radio distale. In: Landi A, Catalano F, Luchetti R, editors.
Trattato di chirurgia della mano, vol. 1. Roma: Verduci; 2007. p. 241–6.
25. Fernandez DL. Should anatomic reduction be pursued in distal radius fractures?
J Hand Surg Br 2000;25(6):523–7.
26. Fernandez DL, Geissler WB. Treatment of displaced articular fractures of the
radius. J Hand Surg 1991;16A:375–84.
1126 P. Cherubino et al. / Injury, Int. J. Care Injured 41 (2010) 1120–1126
27. Fernandez DL, Jupiter JB. Fractures of the distal radius. New York: Springer-
Verlag; 1996.
28. Frattini M, Soncini G, Corradi M, et al. Complex fractures of the distal radius
treated with angular stability plates. Chir Organi Mov 2009;93(3):155–62.
29. Frykman G. Fracture of distal radius including sequelae: shoulder–hand–finger
syndrome, disturbance in the distal radio-ulnar joint and impairment of nerve
function: a clinical and experimental study. Acta Orthop Scand 1967;108
(Suppl.):153–5.
30. Gartland JJ, Werley CW. Evaluation of healed Colles’ fractures. J Bone Joint Surg
1951;33 A:895–907.
31. Geissler WB, Fernandez DL. Percutaneous and limited open reduction of the
articular surface of the distal radius. J Orthop Trauma 1991;5:255–64.
32. Gellmann H. Fratture del radio distale. CIC Edizioni Internazionali; 2002. p. 1–
40; Italian edition of the American of Orthopaedic Surgeons Rosemont, Illinois
1998.
33. Gliatis JD, Plessas SJ, Davis TR. Outcome of distal radial fractures in young
adults. J Hand Surg 2000;25B:527–35.
34. Graff S, Jupiter JB. Fracture of the distal radius: classification of treatment and
indications for external fixation. Injury 1994;25(Suppl. 4):S-D14–25.
35. Grala P, Zielinski W. Hybrid external fixation for neglected fractures of the distal
radius: results after one year. J Orthop Traumatol 2008;9(4):195–200.
36. Gupta A. Why and how I fix distal radius fractures—a personal prospective. In:
10th FESSH Meeting; 2005.
37. Henry MH. Distal radius fractures: current concepts. J Hand Surg Am
2008;33(7):1215–27.
38. Howard PW, Steward HD, Hind RE, Burke FD. External fixation or plaster for
severely displaced comminuted Colles’ fractures? A prospective study of ana-
tomical and functional end results. J Bone Joint Surg 1989;71B:68–73.
39. Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity
outcome measure: the DASH (disabilities of the arm, shoulder and hand)
[corrected]. The Upper Extremity Collaborative Group (UECG). Am J Ind Med
1996;29(6):602–8.
40. Jakob M, Rikli DA, Regazzoni P. Fractures of the distal radius treated by internal
fixation and early function. A prospective study of 73 consecutive patients. J
Bone Joint Surg Br 2000;82:340–4.
41. Jenkins NH, Mintowt-Czyz WJ. Mal-union and dysfunction in Colles’ fracture. J
Hand Surg 1988;13B:291–3.
42. Jupiter JB. Current concepts review. Fracture of the distal hand of the radius. J
Bone Joint Surg 1991;73A:461–9.
43. Jupiter JB. Fractures of the distal end of the radius. J Bone Joint Surg (Am)
1991;73:461–9.
44. Jupiter JB, Marent-Huber M, et al. Operative management of distal radius
fractures with 2.4 millimeter locking plates. A multicenter prospective case
series. J Bone Joint Surg Am 2009;91(January (1)):55–65.
45. Keating JF, Court-Brown CM, McQueen MM. Internal fixation of volar displaced
distal radial fractures. J Bone Joint Surg 1994;76B:401–5.
46. Knirk J, Jupiter JB. Intra-articular fractures of the distal end of the radius in
young adults. J Bone Joint Surg 1986;68A:647–59.
47. Kreder HJ, Hanel DP, Agel J, et al. Indirect reduction and percutaneous fixation
versus open reduction and internal fixation for displaced intra-articular frac-
tures of the distal radius: a randomised, controlled trial. J Bone Joint Surg Br
2005;87(June (6)):829–36.
48. Kurup HV, Mandalia VM, Shaju KA, et al. Late collapse of distal radius fractures
after K-wire removal: is it significant? J Orthop Traumatol 2008;9(2):69–72.
49. Lafontaine M, Hardy D, Delice P. Stability assessment of distal radius fractures.
Injury 1989;20:208–10.
50. Lauri G, Ceruso M. Insuccessi della fissazione esterna nelle fratture del radio
distale. Riv Chir Mano 2001;38:121–6.
51. Leung F, Tu YK, Chew WY, Chow SP. Comparison of external and percutaneous
pin fixation with plate fixation for intra-articular distal radius fractures. A
randomized study. J Bone Joint Surg Am 2008;90:16–22.
52. Liporace FA, Adams MR, Capo JT, Koval KJ. State of art: distal radius fractures. J
Orthop Trauma 2009;23:739–48.
53. Lozano-Calderòn SA, Souer S, Mudgal C, et al. Wrist mobilisation following volar
plate fixation of fractures of the distal part of the radius. J Bone Joint Surg Am
2008;90(June (6)):1297–304.
54. Lucas GL, Sachtjen KM. An analysis of hand function in patients with Colles’
fractures treated by Rush rod fixation. Clin Orhtop 1981;155:172–9.
55. Margaliot Z, Haase SC, Kotsis SV, et al. A meta-analysis of outcomes of external
fixation versus plate osteosynthesis for unstable distal radius fractures. J Hand
Surg Am 2005;30(6):1185–99.
56. Matthews SJ, Nikolaou VS, Giannoudis PV. Innovations in osteosynthesis and
fracture care. Injury 2008;39(August (8)):827–38.
57. McQueen MM, Hajducka C, Court-Brown CM. Redisplaced unstable fractures of
the distal radius: a prospective randomised comparison of four methods of
treatment. J Bone Joint Surg Br 1996;78(May (3)):404–9.
58. Modi CS, Ho K, Smith CD, et al. Dynamic and static external fixation for distal
radius fractures—a systematic review. Injury 2010;41(July (7)):950–5.
59. Modi CS, Nancoo T, Powers D, et al. Operative versus nonoperative treatment of
acute undisplaced and minimally displaced scaphoid waist fractures—a sys-
tematic review. Injury 2009;40(March (3)):268–73.
60. Muller ME, Nazarian S, Koch P, Schatzker J. The comprehensive classification of
fractures of long bones. Berlin: Springer-Verlag; 1990. p. 106–15.
61. Munson GO, Gainor BJ. Percutaneous pinning of distal radius fractures. J Trauma
1981;21:1032–5.
62. Musgrave DS, Idler RS. Volar fixation of dorsally displaced distal radius fractures
using the 2.4-mm locking compression plates. J Hand Surg Am 2005;30(July
(4)):743–9.
63. Orbay JL. The treatment of unstable distal radius fractures with volar fixation.
Hand Surg 2000;5:103–12.
64. Orbay JL, Fernandez DL. Palmar fixation of dorsally displaced fracture of the
distal radius: a preliminary report. J Hand Surg 2002;27A:205–15.
65. Osada D. Prospective study of distal radius fractures treated with a volar locking
plate system. J Hand Surg Am 2008;33(May–June (5)):691–700.
66. Palmer AK. Fractures of the distal radius. In: Greed DP, editor. 2nd ed., Operative
hand surgery, vol. 2, 2nd ed. New York, NY: Churchill-Livingstone; 1988 . p.
991–1026.
67. Parry BR. Colles’ fracture: efficacy of pins and plaster treatment. J Hand Surg
1982;7A:509–12. 55.
68. Pattee GA, Thompson GH. Anterior and posterior marginal fracture—disloca-
tions of the distal radius. An analysis of the results of treatment. Clin Orthop
1988;231:183–95.
69. Pool C. Colles’ fractures: a prospective study of treatment. J Bone Joint Surg
1973;55(B):540–4.
70. Putnam MD, Seitz Jr WH. Advances in fracture management in the hand and
distal radius. Hand Clin 1989;5(August (3)):455–70.
71. Rampoldi M, Marsico S. Complications of volar plating of distal radius fractures.
Acta Orthop Belg 2007;73(December (6)):714–9.
72. Ring D, Jupiter JB. Riduzione aperta e fissazione interna dlle fratture distali del
radio. CIC Edizioni Internazionali; 2002 . p. 41–58; Italian edition of the
American of Orthopaedic Surgeons 1998 Rosemont, Illinois.
73. Ring D, Prommesberger K, Jupiter JB. Combined dorsal and volar plate fixation
of complex fractures of the distal part of the radius. J Bone Joint Surg Am
2005;87(Suppl 1 (Pt. 2)):195–212.
74. Sarmiento A, Pratt GW, Berry NC, Sinclair WF. Colles’ fractures: functional
bracing in supination. J Bone Joint Surg 1975;57(A):311–7.
75. Scheck M. Long term follow up of treatment of comminuted fractures of the
distal end of the radius by transfixation with Kirschner wires and cast. J Bone
Joint Surg 1962;44A:337–51.
76. Scheer JH, Adolfsson LE. Tricalcium phosphate bone substitute in corrective
osteotomy of the distal radius. Injury 2009;40(March (3)):262–7.
77. Shyamalan G, Theokli C, Pearse Y, Tennent D. Volar locking plates versus
Kirschner wires for distal radial fractures—a cost analysis study. Injury
2009;40(September (12)):1279–81.
78. Solgaard S. Classification of distal radius fractures. Acta Orthop Scand
1985;56:249–52.
79. Soolgaard S. External fixation or a cast for Colles’ fractures. Acta Orthop Scand
1989;60:387–91.
80. Stevenson I, Carnegie CA, Christie EM, et al. Displaced distal radial fractures
treated using volar locking plates: maintenance of normal anatomy. J Trauma
2009;67(September (3)):612–6.
81. Stewart T, Cheong W, Barr V, Tang D. Strong and light plaster casts? Injury
2009;40(August (8)):890–3.
82. Tan SL, Balogh ZJ. Indications and limitations of locked plating. Injury
2009;40(July (7)):683–91.
83. Trumble TE, Schmitt SR, Vedder NB. Factors affecting functional outcome of
displaced intra-articular distal radius fractures. J Hand Surg Am 1994;19(March
(2)):325–40.
84. Van der Linden W, Ericson R. Colles’ fracture: how should its displacement be
measured and how should it be immobilised? J Bone Joint Surg
1981;63(A):1285–8.
85. Vaughan PA, Lui SM, Harrigton IJ, Maistrelli GL. Treatment of unstable fractures
of the distal radius by external fixation. J Bone Joint Surg 1985;67:
385–9.
86. Villar RN, Marsh D, Rushton N, Greatorex RA. Three years after Colles’ fracture. A
prospective review. J Bone Joint Surg Br 1987;69(August (4)):635–8.
87. Wahlstrom O. Treatment of Colles’ fracture. A prospective comparison of three
different positions of immobilisation. Acta Orthop Scand 1982;53:225.
88. Wei DH, Raizmann NM, Bottino CJ, et al. Unstable distal radial fracture treated
with external fixation, radial column plate, or a volar plate. A prospective
randomized trial. J Bone Joint Surg Am 2009;91(7):1568–77.
89. Weinberg AM, Pichler W, Grechenig S, et al. The percutaneous antegrade
scaphoid fracture fixation—a safe method? Injury 2009;40(June (6)):
642–4.
90. Wik TS, Aurstad AT, Finsen V. Colles’ fracture: dorsal splint or complete cast
during the first 10 days? Injury 2009;40(April (4)):400–4.