SCIENTIFIC ARTICLE

Load Distribution in Dorsally-Angulated

Distal Radius Deformity Using Finite
Element Analysis
Hirotaka Yan, MD,* Kotaro Sato, MD,* Gaku Takahashi, MD,† Yoshikuni Mimata, MD,*
Kenya Murakami, MD,* Minoru Doita, MD*

Purpose The load axis of the carpals is located on the volar side of the normal distal radius.
A volar lunate facet fracture (VLFF) is exposed to volar-shearing stress, which can
cause volar displacement of the carpus. A previous biomechanical study reported that the load
at the scaphoid fossa was located more dorsally and the pressure at the lunate fossa decreased
in a dorsally-angulated model. However, the distal radius load distribution for various volar
tilts remains unclear. We speculate that if the volar tilt decreases, the load distribution moves
dorsally and decreases the stress on the VLFF. Therefore, we analyzed a dorsally-angulated
distal radius model to evaluate changes in the load distribution using finite element analysis.
Methods A 3-dimensional finite element wrist model was developed using computed to-
mography images. The ligaments were modeled as tension-only spring elements. We
considered the intact wrist model for a volar tilt of 15 and created 5 additional models for
volar tilts of 10 , 5 , 0 , 5 , and 10 .
Results As the dorsal angulation increased, the stress distribution moved from volar to dorsal
and from the lunate fossa toward the scaphoid fossa. The maximum stress on the volar lunate
facet was reduced as volar tilt decreased. The maximum stress was higher on the lunate fossa
for volar tilts from 15 to 5 . In contrast, the maximum stress was higher on the scaphoid
fossa for volar tilts of 0 .
Conclusions Load transmission moved from volar to dorsal and from the lunate fossa to the
scaphoid fossa when the volar tilt decreased. Therefore, a decrease in the volar tilt would
reduce the load on the VLFF.
Clinical relevance This study provides surgeons accurate knowledge regarding load distribution
of the distal radius for various volar tilts that could be helpful in treating patients with VLFFs.
(J Hand Surg Am. 2023;48(10):1062.e1-e6. Copyright Ó 2023 by the American Society for
Surgery of the Hand. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).)
Key words Distal radius, finite element analysis, load distribution, volar lunate facet, volar rim.

From the *Department of Orthopaedic Surgery, Iwate Medical University, Iwate, Japan; and Corresponding author: Kotaro Sato, MD, Department of Orthopaedic Surgery, Iwate
the †Department of Critical Care Medicine, Iwate Medical University, Iwate, Japan. Medical University, 2-1-1 Idaidori, Yahaba-cho, Shiwa-Gun, Iwate, Japan, 028-3695; e-mail:
kodsad3333@yahoo.co.jp.
Received for publication October 12, 2021; accepted in revised form February 28, 2022.
0363-5023/23/4810-0018
No benefits in any form have been received or will be received related directly or indirectly https://doi.org/10.1016/j.jhsa.2022.02.022
to the subject of this article.

Copyright Ó 2023 by the American Society for Surgery of the Hand

1062.e1 r This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
 LOAD DISTRIBUTION IN ANGULATED DISTAL RADIUS 1062.e2

D
ISTAL RADIUS FRACTURE ASSOCIATED with a
volar lunate facet fragment (VLFF) can
cause volar displacement of the carpus.1e4
Harness et al 1 reported that carpal displacement
occurred in patients with a volar-shearing fracture
who failed VLFF fixation. The volar lunate facet
(VLF) has a narrow flat surface and projects anteri-
orly; therefore, achieving secure fixation is chal-
lenging.2,5 Recent reports show that using
specifically designed plates or surgical methods can
support the volar rim fragment.3,4 However, to our
knowledge a widely accepted approach to stabilizing
this fracture type has not been established. Further- FIGURE 1: Three-dimensional finite element model of the wrist
more, salvage surgery for failed VLFF, such as repeat developed using computed tomography images.
reduction, arthrodesis, and intra-articular osteotomy,
also is challenging.1,6
The articular surface of the distal radius is inclined
volarly, and the load axis is located on the volar
side.7e9 Therefore, once a VLFF occurs, the fragment
is exposed to volar-shearing stress. In this regard,
Orbay et al10 reported a salvage procedure for failed
VLFF fixation based on a volar opening wedge
osteotomy to decrease volar tilt. Short et al11 reported
a biomechanical study of the distal radius articular
surface using pressure-sensitive film. For 20 dorsal
angulation from the original position, the load on the
scaphoid fossa and ulnocarpal joint moved more
dorsally, and the pressure at the lunate fossa
decreased.11 However, load distribution in the distal
radius for various volar tilts remains unclear. We
speculate that if the volar tilt decreases, then the load
distribution moves toward the dorsal side. In this FIGURE 2: Ligaments were modeled as linear mechanical links
where the position of the insertion points was estimated based on
case, stress in the VLFF would decrease, and volar
previous studies.
displacement of the carpus could be avoidable.
We hypothesized that reducing volar tilt can
decrease the load on the volar rim. We analyzed a Version Q-2020.6; Synopsys, Inc) was used, and the
dorsally-angulated distal radius model using finite model was divided into 4-node tetrahedral elements.
element analysis. All meshed parts of the model were imported from
the initial software to the secondary software, (Patran
2020; MSC Software, Inc), as preepost processors.
MATERIALS AND METHODS The model used isotropic and linear elastic material
Finite element model of the distal radius and carpal properties. Thus, Young’s moduli of 18,000 MPa and
This study was approved by our institutional review 100 MPa were assigned to the cortical and cancellous
board (Iwate Medical University; No. MH2021-063). bones, respectively.13 The Poisson ratio was set to 0.2
A 3-dimensional finite element method wrist model for cortical bone and 0.25 for cancellous bone.13 The
was developed using computed tomography images ligaments were modeled as linear mechanical links,
(Fig. 1). The distal end of the radius and ulna to the where the position of the insertion points was esti-
proximal one-third of the metacarpals from a skele- mated based on previous studies (Fig. 2).14e16 The
tally mature man was scanned with the wrist in a stiffness of the ligaments was defined as 10e350 N/
neutral position. The wrist had a type 1 lunate mm, as in previous studies (Table 1).15,16 Multiple
without a medial (hamate) facet.12 The scanned parallel links were used to better model the distribu-
model was differentiated into cortical and cancellous tion of ligaments.13,17 The wrist model had a total of
bone. Image analysis software (Simpleware Scan IP 59,470 nodal points and 276,100 elements.

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1062.e3 LOAD DISTRIBUTION IN ANGULATED DISTAL RADIUS

TABLE 1. Ligaments Included in the Model and

Stiffness Parameters
Ligament Stiffness (N/mm)

Dorsal radiocarpal 27
Dorsal intercarpal 128
Long radiolunate 75
Short radiolunate 75
Volar radioscapholunate (scaphoid) 50
Volar radioscapholunate (lunate) 75
Radioscaphocapitate 50
Volar radioulnar 50
Dorsal radioulnar 50
FIGURE 3: Magnitude of the reaction force acting on the
Radial collateral carpal 10 scaphoid fossa and lunate fossa in the intact wrist and dorsally-
Ulnar collateral 100 angulated models. The maximum stress was higher on the
Ulnolunate 40 lunate fossa for a volar tilt of 15 e5 . In contrast, the maximum
Ulnotriquetral 40 stress was higher on the scaphoid fossa for a volar tilt of 0 .
Volar lunotriquetral 350 VT, volar tilt.

Dorsal lunotriquetral 350

Dorsal scapholunate interosseous 230
Palmar carpometacarpal 100
Pisohamate 100
Angulated distal radius modeling
The intact wrist model for a volar tilt of 15 was
developed. The volar tilt was measured at the point of
bisecting scaphoid fossa as described by Daniele
et al.7 In their report, the normal anatomic volar tilt at
this point was 13 (5.1). Moreover, the volar
cortical angle was reported as the angle formed by a
straight line drawn along the volar surface of the
distal radius and a line drawn parallel to the volar
cortex.18 The normal volar cortical angle of a man
was reported from 30.4 to 34.1 .18 In the model, the
volar cortical angle was 31 . Five additional models
were developed, based on the intact wrist model, to
simulate the dorsally-angulated distal radius. The
dorsal angulation was modified in increments of 5
with volar tilt angles of 10 , 5 , 0 , 5 , and 10 . In
these models, the volar cortical angles were 26 , 21 ,
16 , 11 , and 6 . These models all were developed in
a 3-dimensional finite element method model, and
each ligament was attached similarly to the intact
model. Thus, 6 different volar tilt models were
created for the analysis.
Boundary conditions and analysis
The loading on the finite element model was applied
to each metacarpal along its longitudinal axis with a
resultant force of 647.6 N. The load was determined
based on a previous biomechanical study.17 The
magnitudes of forces for the thumb, index, middle,
ring, and little fingers were 255.6, 120.3, 106.4, 88.0,
and 77.3 N, respectively.17 The loading condition
simulates half of the maximum gripping force for a
healthy individual.17 The proximal parts of the radius
and ulna were fixed. In addition, articular contact was
established between the scaphoid and the scaphoid
fossa of the radius and between the lunate and the
lunate fossa of the radius. The contact was friction-
less, and a friction coefficient of 0.02 was assigned.13
For other articulations, the distal carpal bones were
tightly bound to each other, and the motion between
them was considered negligible.19 Similarly, these
settings were applied to all developed models. Under
these conditions, we evaluated the stress distribution
with von Mises stress using the stress contour map in
Marc 2020 (MSC Software, Inc) as a solver. The
results were compared for all 6 models to evaluate the
effect of dorsal angulation on the loading at the
radiocarpal joint and the VLF.
RESULTS
In the intact wrist model, the maximum stress on the
volar aspect of the lunate fossa and scaphoid fossa
was 90 and 88 MPa, respectively (Fig. 3). As dorsal
angulation increased, the stress distribution moved
from volar to dorsal and from the lunate fossa toward
the scaphoid fossa (Fig. 4). The maximum stress on
the VLF gradually reduced with an increase in dorsal
angulation (Figs. 5, 6). The maximum stress was
higher on the lunate fossa for a volar tilt of 15 to 5 .

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 LOAD DISTRIBUTION IN ANGULATED DISTAL RADIUS
FIGURE 4: Von Mises stress plots at the distal end of the radius in
the intact wrist and dorsally-angulated models. The intact wrist for
a volar tilt of 15 . As the dorsal angulation increased, the stress
distribution moved gradually from the volar to the dorsal and from
the lunate fossa towards the scaphoid fossa. VT, volar tilt.
In contrast, the maximum stress on the scaphoid fossa
was higher for a volar tilt of 0 .
DISCUSSION
The volar margin of the distal radius projects and
forms the lunate facet.5 The VLF includes the inser-
tion of the short radiolunate ligament, with a height
and width of approximately 3 and 19 mm, respec-
tively.5,14 A previous study reported that the trans-
mission of forces to the lunate fossa, scaphoid fossa,
and triangular fibrocartilage was 29% to 47%, 43% to
55%, and 6% to 25%, respectively.8 In the lunate
fossa, the centroid of the pressure is located volarly in
the neutral position.8 Márquez-Florez et al9 estimated
the load distribution of the radiocarpal joint using a
rigid body spring model method. Our model for a
volar tilt of 15 showed a similar load distribution to
that in their report.9
This study revealed that the maximum stress on the
VLF gradually reduced when the dorsal angulation
increased. Therefore, we considered that a decrease in
volar tilt would reduce the load on the VLFF and
possibly prevent volar displacement of the carpus in
the clinical setting. Moreover, a decrease in the volar
tilt may be an option in the case of corrective
osteotomy for failed primary surgery of volar rim
fractures. Several studies have reported that loss of
the volar tilt or radial length reduction did not
correlate with functional outcomes.20e22 However,
other reports have indicated that dorsal angulation of
the radius is the primary cause of wrist disabil-
ities.23,24 Taleisnik and Watson23 reported on patients
who complained of midcarpal pain and instability in
J Hand Surg Am.
1062.e4
FIGURE 5: Von Mises stress plots at the VLF. VT, volar tilt.
FIGURE 6: Magnitude of the reaction force acting on the VLF.
The maximum stress on the VLF gradually reduced with a dorsal
angulation increase. VT, volar tilt.
the presence of a distal radius malunion with an
average dorsal angulation of 23 . They concluded
that abnormal dorsal angulation leads to midcarpal
instability. In addition, Padmore et al24 conducted a
biomechanical study on dorsally-angulated distal
radius deformities. In their report, the radiocarpal
motion arc increased, but the midcarpal motion arc
decreased when dorsal angulation increased.24 The
study also indicated that the altered contribution of
the radiocarpal and midcarpal joints might result in
pain, stiffness, and arthritis development. Saito et al25
conducted a biomechanical study of distal radioulnar
joint stability using a dorsally-angulated distal radius
fracture model for volar tilts of 10 , 0 , 10 ,
and 20 . They reported that the distal radioulnar
joint stiffness decreased at volar tilts of 10
and 20 . Their findings suggested that dorsal
angulation of the radius should be corrected to be less
than 10 of the volar tilt.
Stresses between the scaphoid fossa and lunate
fossa were well balanced in models for volar tilts of
r Vol. 48, October 2023
1062.e5 LOAD DISTRIBUTION IN ANGULATED DISTAL RADIUS
15 and 0 . Nevertheless, volar tilts of 10 and 5
showed higher maximum stress in the lunate fossa.
These results imply that a slight decrease in volar tilt
might increase the joint stress in the lunate fossa
except for VLF. Surgeons must be aware of this when
treating patients with comminuted distal radial frac-
tures with VLFF. Although the load to the VLFF
would reduce with a decrease in the volar tilt, other
parts of the fragment might be subjected to higher
forces. Based on our results, fixation in a volar tilt of
0 could be the recommended angle to treat a distal
radial comminuted fracture with VLFF.
Some possibilities could be considered regarding
the increase in the maximum stress of the lunate fossa
in the models for volar tilts of 10 and 5 . First, the
lunate fossa is different from the scaphoid fossa in
size and shape. In the sagittal plane, the concavity of
the lunate fossa is wider than that of the scaphoid
fossa.5 In the axial plane, the lunate fossa presents an
oval shape spanning the dorsovolar direction,
whereas the scaphoid fossa has a longer oval shape
spanning the radioulnar direction. The volar tilt of the
scaphoid fossa is approximately 4 greater than that
of the lunate fossa.7 These morphologic features
might have contributed to our observations. A
decreased volar tilt can generate nonphysiologic
forces that could lead to radiocarpal arthritis. In
addition, dorsally-angulated distal radius malunion
was associated with a risk of flexor tendon rupture.26
Recent commercial volar locking plates have a
mediolateral extension; therefore, the contact be-
tween the tendon and plate occurs more readily in the
dorsally-angulated distal radius than in anatomic
tilt.26,27 Although a decrease in volar tilt might
contribute to preventing a volar dislocation of the
carpus, it is uncertain how much dorsal angulation
can be tolerated before producing other harmful ef-
fects. Further studies are required to validate the
extent to which dorsal angulation is suitable for
treating distal radius fractures with VLFFs.
This study has several limitations. First, this model
had simplifications, including assumptions of the
bones as rigid bodies and ligaments as linear elastic
materials. Second, we modeled the triangular fibro-
cartilage complex through various ligaments accord-
ing to previous reports.15,16 Although we did not
replicate the fibrocartilage, the proposed intact wrist
model showed similar pressure distribution to previ-
ous reports.8,13 Third, we used a normal bone model
without a VLFF. The size and shape of these frag-
ments might affect the results. Finally, the experi-
ments focused on a single volunteer; therefore,
individual differences in distal radius morphology
J Hand Surg Am.
could affect the results. However, future work could
expand on these results by including additional par-
ticipants to address this possibility.
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