Volume 21, Issue 3, Pages 279-506 (August 2005)

Distal Radius Fractures

Edited by David J. Slutsky and Andrew P. Gutow

articles 1 - 27
1 TOC
Pages v-x

2 Forthcoming Issues
Page xi

3 Distal Radius Fractures

Pages xiii-xiv
David J. Slutsky and Andrew P. Gutow

4 Distal Radius Fractures

Page xv
David J. Slutsky and Andrew P. Gutow

5 Essential Radiographic Evaluation for Distal Radius Fractures

Pages 279-288
Robert J. Medoff

6 Predicting the Outcome of Distal Radius Fractures

Pages 289-294
David J. Slutsky

7 Avoidance and Treatment of Complications of Distal Radius Fractures

Pages 295-305
Andrew P. Gutow

8 Closed Manipulation and Casting of Distal Radius Fractures

Pages 307-316
Diego L. Fernandez

9 Treatment of Distal Radius Fractures with Intrafocal (Kapandji) Pinning and

Supplemental Skeletal Stabilization
Pages 317-328
Wayne M. Weil and Thomas E. Trumble
10 Biomechanics and Biology of Plate Fixation of Distal Radius Fractures
Pages 329-339
Alan E. Freeland and Kurre T. Luber

11 Dorsal Plating for Distal Radius Fractures

Pages 341-346
Jason D. Tavakolian and Jesse B. Jupiter

12 Volar Plate Fixation of Distal Radius Fractures

Pages 347-354
Jorge Orbay

13 Fragment-Specific Internal Fixation of Distal Radius Fractures

Pages 355-362
Donald S. Bae and Mark J. Koris

14 Biomechanics and Biology of External Fixation of Distal Radius Fractures

Pages 363-373
Randy R. Bindra

15 Non-spanning External Fixation of the Distal Radius

Pages 375-380
Margaret M. McQueen

16 Nonbridging External Fixation of Intra-Articular Distal Radius Fractures

Pages 381-394
David J. Slutsky

17 Combined Internal and External Fixation of Distal Radius Fractures

Pages 395-406
John A. McAuliffe

18 Intra-articular Distal Radius Fractures: The Role of Arthroscopy?

Pages 407-416
William B. Geissler

19 Treatment of Injuries to the Ulnar Side of the Wrist Occuring with Distal Radial
Fractures
 Pages 417-425
Tommy Lindau

20 Combined Fractures of the Scaphoid and Distal Radius: A Revised Treatment

Rationale Using Percutaneous and Arthroscopic Techniques
Pages 427-441
Joseph F. Slade III, Sudeep Taksali and John Safanda

21 Nonunion of the Distal Radius

Pages 443-447
David Ring

22 Use of Bone Graft Substitutes and Bioactive Materials in Treatment of Distal

Radius Fractures
Pages 449-454
Brian J. Hartigan and Mark S. Cohen

23 Rehabilitation of Distal Radius Fractures: A Biomechanical Guide

Pages 455-468
David J. Slutsky and Mojca Herman

24 Extra-articular Distal Radial Fracture Malunion

Pages 469-487
Frances Sharpe and Milan Stevanovic

25 Salvage of Post-Traumatic Arthritis Following Distal Radius Fracture

Pages 489-498
Ladislav Nagy

26 Erratum
Page 499

27 Index
Pages 501-505
 DISTAL RADIUS FRACTURES

CONTENTS

Preface xiii
David J. Slutsky and Andrew P. Gutow

Dedication xv
David J. Slutsky and Andrew P. Gutow

Essential Radiographic Evaluation for Distal Radius Fractures 279

Robert J. Medoff
Because radiographic interpretation of distal radius fractures has such a profound im-
pact on the type of treatment and clinical outcome, accurate assessment of standard
radiographs is essential for appropriate management. Subtle abnormalities of radio-
graphic landmarks can provide critical information for recognition of the pattern and ex-
tent of injury but often may be unrecognized simply because the physician is not trained
to recognize these features. The 10° lateral projection and assessment of parameters such
as the teardrop angle, anteroposterior distance, and other landmarks and parameters are
essential for the evaluation and treatment of these injuries. The purpose of this paper is
to provide specific guidelines for improved interpretation of X-rays in patients with
distal radius fractures.

Predicting the Outcome of Distal Radius Fractures 289

David J. Slutsky
There are myriad factors affecting the clinical result following a distal radius fracture.
It is useful to identify those variables that have some predictive value with regard to
fracture instability, patient satisfaction, and hand function. Possessing a knowledge of
the predictive factors that adversely affect the functional outcome allows the surgeon
to manage complications proactively to maximize the potential for an acceptable end
result.

Avoidance and Treatment of Complications of Distal Radius Fractures 295

Andrew P. Gutow
Complications of treating distal radial fractures include post-traumatic arthritis, stiffness,
complex regional pain syndrome, artery injury, nerve injury and irritation, tendon irrita-
tion and rupture, infection, compartment syndrome, carpal instability, distal radial ulnar
joint instability, and malunion. Knowledge of these and methods for avoiding them max-
imize treatment outcomes. As techniques have moved from closed reduction, percutane-
ous pinning, and external fixation toward internal fixation, complications have changed

VOLUME 21 Æ NUMBER 3 Æ AUGUST 2005 v

 from those of inadequate fixation to those of internal fixation: nerve and tendon injury
and infection. Surgeons must balance treatment outcome with the risk of treatment
method to give the fastest, safest return to wrist usage, and counsel patients that even
with the best treatment, full return to preinjury status may not be possible.

Closed Manipulation and Casting of Distal Radius Fractures 307

Diego L. Fernandez
Despite increasing sophistication of operative treatment of distal radius fractures, there
are still formal and relative indications for closed treatment. These include the displaced,
’reducible but stable’ fracture patterns that do not fall into the radiographic criteria of
instability. Although many aspects of cast treatment are still controversial, the author
presents the indications and techniques that, in his hands, have proven to be efficient
and have rendered predictable results.

Treatment of Distal Radius Fractures with Intrafocal (Kapandji) Pinning

and Supplemental Skeletal Stabilization 317
Wayne M. Weil and Thomas E. Trumble
Intrafocal pinning using the percutaneous technique described by Kapandji provides
control of distal fragment rotation and length. Distal radius fractures with significant
comminution also may require supplemental skeletal stabilization to preserve the length
of the radius. Supplemental skeletal stabilization includes external fixation and internal
spanning bridge plate techniques. This technique can be performed quickly with mini-
mal soft tissue damage. It is indicated for treatment of unstable extra-articular or mini-
mally displaced intra-articular fractures of the distal radius. The use of this technique
achieves the goal of surgical treatment of distal radius fractures, which is restoration
of hand and wrist function through the restoration of alignment and articular surface
congruity.

Biomechanics and Biology of Plate Fixation of Distal Radius Fractures 329

Alan E. Freeland and Kurre T. Luber
The fracture management principles of anatomic or near anatomic reduction, fracture
stabilization, minimal operative trauma, and early joint motion are paramount in man-
aging unstable distal radial fractures. The operative approach and plate selection should
correlate with the fracture configuration. Plates have the advantages of providing secure
fixation throughout the entire healing process without protruding wires or pins and
allowing early and intensive forearm, wrist, and digital exercises. Disadvantages include
additional operative trauma, including fragment devascularization; some additional risk
of wrist stiffness; occasional tendon rupture; and at times, the need for plate removal.
New developments in plate and screw design and operative strategies, fragment specific
fixation, and plate strength have improved results with plate fixation. Fixed angle blades
and locking screws and pegs enhance overall plate stability, support the articular surface
of the distal radius, and are effective in fractures occurring in osteopenic bone.

Dorsal Plating for Distal Radius Fractures 341

Jason D. Tavakolian and Jesse B. Jupiter
Dorsal plating of distal radius fractures is the preferred technique for certain fracture
patterns. Historically, dorsal plating has reliably supported the radiocarpal joint, leading
to low rates of arthrosis at the expense of wrist stiffness and problems with extensor
tendons. New, smaller implants may prove capable of buttressing the joint with a lower
incidence of extensor irritation. The authors outline the history of dorsal plating, describ-
ing early experiences, advances in implant design and application, and the current state
of the art.

vi CONTENTS
Volar Plate Fixation of Distal Radius Fractures 347
Jorge Orbay
Volar fixed angle fixation may be considered as the beginning of a new era in restoring
wrist function to patients with dorsally displaced distal radius fractures even in the face
of comminuted or osteopenic bone. A thorough understanding of the anatomy of the
wrist is a prerequisite when volarly approaching dorsally displaced distal radius frac-
tures. The demonstration of the device theoretical and practical advantages requires an
appreciation of the basics of working length, principles of plate stability, and the effect of
cantilever bending. Volar fixed angle fixation successfully improves wrist function and
significantly prevents the complications of the dorsal approach previously intractable
to treatment. The current advantages, indications, clinical results, and complications of
this new technology are being reviewed.

Fragment-Specific Internal Fixation of Distal Radius Fractures 355

Donald S. Bae and Mark J. Koris
Restoration of articular congruity and maintenance of a stable, anatomic reduction are
critical in the treatment of distal radius fractures. Internal fixation of these injuries can
be challenging, owing to the limited soft-tissue coverage, proximity of adjacent tendons
and nerves, and presence of small, often osteoporotic fracture fragments. Fragment-
specific fixation refers to the use of limited surgical incisions and low-profile, anatomi-
cally contoured implants to provide rigid fixation of each individual fracture fragment.
This article reviews the principles of fragment-specific internal fixation, discusses the
biomechanical and clinical data supporting its use, and provides a description of surgical
technique.

Biomechanics and Biology of External Fixation of Distal Radius Fractures 363

Randy R. Bindra
Although there are various designs of external fixators available commercially, all follow
the same basic concept of a frame anchored to the radius with pins. This article outlines
the mechanical principles of external fixation and its application to distal radius frac-
tures. The biomechanics of distraction and its limitations and adverse effects on tissue
are discussed. The biology of the pin–bone interface and current concepts of preventing
pin track problems are detailed.

Non-spanning External Fixation of the Distal Radius 375

Margaret M. McQueen
Non-spanning external fixation of the distal radius employs pins in the distal fragment
and pins in the radius proximal to the fracture. It is indicated in the treatment of minimal
articular or extra-articular fractures of the distal radius with metaphyseal instability, and
in distal radial osteotomy for malunion. This article describes the technique, with
emphasis on correct pin placement in the distal radius. Results show that anatomy is
well-restored and maintained, and that function is improved using non-spanning exter-
nal fixation in preference to spanning external fixation.

Nonbridging External Fixation of Intra-Articular Distal Radius Fractures 381

David J. Slutsky
Non-bridging external fixation achieves superior results to bridging fixation of extra-
articular distal radius fractures. This also can be applied to intra-articular fractures in
select circumstances. The biomechanical considerations and a case report in this article
highlight the underlying foundations of this technique.

CONTENTS vii
Combined Internal and External Fixation of Distal Radius Fractures 395
John A. McAuliffe
Combined internal and external fixation of distal radius fractures is most commonly uti-
lized to treat injuries with joint surface or metaphyseal comminution. External fixation
aids reduction intraoperatively, and facilitates arthroscopic, percutaneous, or open
manipulation of the fracture. Internal fixation maintains precise reduction of critical
anatomy, principally the contour and orientation of the articular surface. Postoperatively,
the fixator functions as a neutralization device, preventing fracture collapse, and de-
creasing the biomechanical demands on the internal fixation hardware. The combined
technique exploits the benefits of both forms of fixation, allowing each to be used to full
advantage in the treatment of complex distal radius fractures.

Intra-articular Distal Radius Fractures: The Role of Arthroscopy? 407

William B. Geissler
Arthroscopy has revolutionized the practice of orthopedics by providing the technical
capability to examine and treat intra-articular abnormalities. The development of wrist
arthroscopy was a natural evolutionary progression from the successful application of
arthroscopy to other larger joints such as the knee and shoulder. Wrist arthroscopy
has seen considerable growth since Whipple et al, reported their original description
of the techniques that they developed for viewing the anatomy of the wrist. Wrist
arthroscopy allows direct visualization of the articular surface, interosseous ligaments,
and components of the triangular fibrocartilage complex under bright light and magni-
fication. In addition, it is well known that the management of acute interosseous liga-
ment tears have a better prognosis when compared to chronic lesions.

Treatment of Injuries to the Ulnar Side of the Wrist Occuring with Distal
Radial Fractures 417
Tommy Lindau
Injuries to the ulnar side of the wrist comprise both the obvious radiographic fracture
and serious associated injuries to the triangular fibrocartilage complex (TFCC). The frac-
ture causes a ‘‘double incongruency’’ in both the radio-carpal and distal radio-ulnar joint
(DRUJ) that leads to associated injuries to the TFCC, which have been found to cause
later instability of the DRUJ. These tears can then be reinserted to the fovea of the ulnar
head. In modern management of distal radial fractures, it is not only important to select
the right treatment for the patients’ radius fracture, but also to be aware of the severity of
the entire injury to the wrist.

Combined Fractures of the Scaphoid and Distal Radius: A Revised Treatment

Rationale Using Percutaneous and Arthroscopic Techniques 427
Joseph F. Slade III, Sudeep Taksali, and John Safanda
The revised treatment protocol for the treatment of combined scaphoid and distal radius
fractures involves a three-step process: (1) percutaneous reduction of the scaphoid frac-
ture and provisional stabilization with a guidewire placed along its central axis, (2) per-
cutaneous/arthroscopic reduction and rigid fixation of the distal radius fracture to
permit early motion, and (3) fixation of the scaphoid fracture. This final step is accom-
plished by dorsal percutaneous implantation of a cannulated headless compression
screw along the central scaphoid axis. Dorsal percutaneous fixation of scaphoid fractures
with headless compression screws and rigid fixation of unstable distal radius fractures
with a volar locking plate system offer the most secure fixation.

viii CONTENTS
Nonunion of the Distal Radius 443
David Ring
Nonunion of the distal radius—long considered to be extremely rare—has been noted
more frequently in recent years. While some have speculated that the advent of external
fixation and other techniques for maintaining the length of the radius has created bony
defects that can lead to nonunion, nonunion is also seen after internal fixation or non-
operative treatment. While the cause and incidence of nonunion of the distal radius
are uncertain, the need for operative treatment is clear. The majority of nonunions are
synovial. The wrist is usually deformed, unstable, and painful. Operative treatment
can improve upper limb function in patients with nonunion of the distal radius by either
fusing the wrist or healing the fracture. Improved implants and operative techniques
have improved the ability to gain healing of the fracture, thereby preserving some wrist
motion.

Use of Bone Graft Substitutes and Bioactive Materials in Treatment of Distal

Radius Fractures 449
Brian J. Hartigan and Mark S. Cohen
Although autogenous bone graft has been shown to be useful in the treatment of distal
radius fractures, the role of bone graft substitutes and the optimal replacement material
remains unclear. Several products are commercially available, each with differing osteo-
conductive, osteoinductive, and structural properties. Indications and choice of graft
substitute should be based on the needs of the individual case with regard to need for
structural support, gap filling, or bone healing stimulation. Further comparative research
will help clarify the indications and most appropriate material for a given fracture and
clinical situation.

Rehabilitation of Distal Radius Fractures: A Biomechanical Guide 455

David J. Slutsky and Mojca Herman
A methodologic approach to rehabilitation following a distal radius fracture is pre-
sented, based on a knowledge of the biology of fracture healing and biomechanics of fix-
ation. Procedure-specific protocols are outlined.

Extra-articular Distal Radial Fracture Malunion 469

Frances Sharpe and Milan Stevanovic
With the increase in surgical options for the treatment of distal radius fractures, the
authors anticipate that distal radial fracture malunions will be a less frequently seen
problem. Nevertheless, they will still occur. Although patient selection has been
weighted toward the younger patient, the authors believe that surgery should be based
on patient activity level, functional needs, and disability related to the malunion. With
advances in biotechnology and improved anesthetics, surgical intervention even in the
older and osteopenic population is now more promising. Surgical intervention still
requires appropriate patient selection, careful preoperative planning, and meticulous
surgical technique. The appropriate surgical procedure should be tailored to the patient’s
symptoms, age, needs, and radiographic findings.

Salvage of Post-Traumatic Arthritis Following Distal Radius Fracture 489

Ladislav Nagy
Recent advances in the understanding of the biomechanics of the wrist joint, together
with an increasing sophistication of internal fixation techniques, allow for increasing
the potential of the specific procedure and better patient selection for the individual type

CONTENTS ix
 of fusion. The goal of this article is to make recommendations for improving the opera-
tive technique and simplify the decision between the different treatment options based
on the author’s experience and data. Among all diagnoses, painful arthritis following
fracture of the distal radius is the most difficult to treat and yields the poorest results.
Emphasis must be on better initial fracture treatment and earlier secondary reconstruc-
tive interventions. Prosthetic replacement merits serious consideration, especially when
it can be adapted to the specific post-traumatic setting.

Erratum 499

Index 501

x CONTENTS
 FORTHCOMING ISSUES

November 2005
Wrist Arthritis
Brian Adams, MD, Guest Editor

February 2006
Pediatric Fractures, Dislocations and Sequelae
Scott H. Kozin, MD, Guest Editor

May 2006
Hand Arthritis
Matthew M. Tomaino, MD, Guest Editor

RECENT ISSUES

May 2005
Flexor Tendon Injuries
Daniel P. Mass, MD, and Craig S. Phillips, MD
Guest Editors

February 2005
Brachial Plexus Injuries in Adults
Allen T. Bishop, MD, Robert J. Spinner, MD,
and Alexander Y. Shin, MD, Guest Editors

November 2004
Elbow Trauma
Graham J.W. King, MD, MSc, FRCSC
Guest Editor

THE CLINICS ARE NOW AVAILABLE ONLINE!

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www.theclinics.com
 Hand Clin 21 (2005) xiii–xiv
Preface
Distal Radius Fractures
David J. Slutsky, MD, FRCS(C) Andrew P. Gutow, MD
Guest Editors
The management of distal radius fractures is in
the midst of a renaissance. Novel locking plate
designs have resulted in a rethinking of the
contemporary approach to fracture fixation. In
this issue of the Hand Clinics, two complementary
articles, one by Jason Tavakolian and Jesse
Jupiter and one by Mark Koris, illustrate the
various techniques for fragment-specific fixation
of intra-articular fractures. Jorge Orbay spreads
his wisdom with his method of volar reduction of
dorsally displaced fractures. Alan Freeland and
Kurre Luber elegantly keep us on the straight and
narrow by giving us the scientific basis for current
plate designs. Brian Hartigan and coauthor suc-
cinctly summarize the literature supporting the
use of bone graft substitutes. Randy Bindra
provides the biomechanical foundation for exter-
nal fixation, while Margaret McQueen reprises her
pioneering work with nonbridging external fixa-
tion for extra-articular fractures. This is followed
by a like-minded article on intra-articular frac-
tures. John McAuliffe ties it all together with his
article on combined internal and external fixation.
Will Geissler shares his decade-long experience
with arthroscopic reduction and limited internal
fixation of complex fractures. Tommy Lindau
provides a comprehensive and cogent guide for
the treatment of associated ulnar-sided inju-
ries. Joe Slade once again reveals his innova-
tive thinking as he leads us down the road to
0749-0712/05/$ - see front matter Ó 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.hcl.2005.04.001
redemption for the treatment of combined distal
radius and scaphoid fractures. Lest we forget,
Thomas Trumble and coauthor remind us of the
time-honored techniques for Kapandji pinning.
The article by Diego Fernandez personifies the art
of medicine through his masterful discussion of
closed reduction and casting. In a similar vein,
Robert Medoff gives a nuanced dissertation on
the interpretation of the early trauma films. The
initial fracture displacement also has some pre-
dictive value, which may influence early decision
making. The avoidance of complications is as
important as knowing how to treat them.
If things go badly, David Ring shows us how to
extract a successful outcome from a difficult non-
union. Milan Stevanovic and Frances Sharpe
balance things out with a beautifully written article
on malunions. When all else fails, Ladislav Nagy
shares his meticulous approach and excellent re-
sults with wrist arthrodesis. Although much of this
issue is devoted to treatment, the role of therapy
cannot be overemphasized. The biomechanics of
fracture healing is used as a template to present
a procedure-specific approach to rehabilitation.
It was a joy to collaborate with some of the true
pioneers in the field of distal radius fracture
fixation as well as some of the up-and-coming
stars. We hope that readers of this issue experience
the same joy. Sometimes more than one approach
may work for any specific fracture pattern, but the
hand.theclinics.com
xiv PREFACE

decision ultimately rests with you. We owe a debt Andrew P. Gutow, MD

of gratitude to Deb Dellapena, the Editor of this Department of Orthopedics
issue, for her gentle guidance and diligent labors Stanford University
on our behalf. Stanford, CA 94305, USA

David J. Slutsky, MD, FRCS(C) Palo Alto Medical Foundation

Assistant Clinical Professor of Orthopedic Surgery 795 El Camino Real
University of California Los Angeles Palo Alto, CA 94301, USA
David Geffin School of Medicine
E-mail address: gutowa@pamf.org
Los Angeles, CA 90095, USA
E-mail address: d-slutsky@msn.com
 Hand Clin 21 (2005) xv

Dedication
Distal Radius Fractures
David J. Slutsky, MD, FRCS(C)
Andrew P. Gutow, MD
Guest Editors

Andrew P. Gutow David J. Slutsky

This issue is dedicated to my teachers and

mentors who taught me to be a better physician so
that I might someday be able to do the same for
others. I also dedicate it to my wife, Mimi
Blaurock, and my children, Joshua, Anna, and
Matthew, who have supported me in this and
many other projects. This issue is dedicated to Michael Zipper. He
lives on in our hearts and minds.

0749-0712/05/$ - see front matter Ó 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.hcl.2005.04.003 hand.theclinics.com
 Hand Clin 21 (2005) 279–288
Essential Radiographic Evaluation for Distal
Radius Fractures
Robert J. Medoff, MD
Department of Orthopaedic Surgery, University of Hawaii, 30 Aulike Street #506, Kailua, HI 96734, USA
Because the interpretation of the radiographs of
distal radius fractures has such a profound impact
on care of these injuries, accurate assessment of
standard radiographs is essential for appropri-
ate management [1,2]. Radiographs are a two-
dimensional representation of a three-dimensional
structure. Subtle changes in radiographic land-
marks can provide significant information that can
be used to understand the pattern of fragmentation
and extent of the injury. Unfortunately much of
this information often goes unnoticed simply
because the physician is not trained to recognize
it. Although computed axial tomography and MRI
can provide more detailed imaging of the fracture
pattern, the extra expense and delay in treatment
from obtaining a CT scan at the time of a reduction
are often practical limitations limiting its routine
use [3–8]. By recognizing detailed features on
standard radiographic images and identifying ab-
normal variation of certain key parameters, the
surgeon can create a more accurate visual image of
the actual osseous deformity, resulting in a more
informed and rational approach to treatment [9].
The purpose of this article is to provide specific
guidelines for improved interpretation of radio-
graphs in patients with distal radius fractures.
Normal radiographic landmarks
Radiographic evaluation of the distal radius
normally includes a posteroanterior (PA) and
lateral projection. Oblique radiographs often are
included as a supplemental view. As is discussed
subsequently, a modified lateral projection in
which the beam is angled 10( proximally should
E-mail address: rmedoff@lava.net
0749-0712/05/$ - see front matter Ó 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.hcl.2005.02.008
be a standard view to assess fracture reduction
and to provide more detailed visualization of the
articular surface.
On the PA projection, several basic anatomic
structures are identified easily (Fig. 1). The radial
styloid is seen in profile; the articular surface of
the distal radius, proximal and distal carpal rows,
distal radioulnar joint, and distal ulna also are
recognized easily. The articular surface of the
distal radius makes a smooth, concentric arc with
the proximal articular surface of the proximal
carpal row. In addition, the arcs of the articular
surfaces on both sides of the midcarpal joint are
congruent and concentrically aligned.
On the PA projection, a transverse, radiodense
line can be seen approximately 3–5 mm proximal
to the distal border of the radius, and it is aligned
with the base of the lunate and proximal pole of
the scaphoid. This feature has been nicknamed the
carpal facet horizon. In the normal radius, the
carpal facet horizon is caused by the projection of
the subcortical bone of the volar rim of the lunate
facet (Fig. 2A). This structure is normally prox-
imal to the distal margin of the radius, because the
normal volar tilt of the articular surface of the
distal radius places the volar rim more proximally
than the dorsal rim. Its projection on the radio-
graph is radiodense, because the subcortical bone
of the volar rim of the lunate facet is aligned
parallel to the radiographic beam.
The relationship of the articular surface of the
distal radius is reversed in a fracture or malunion
in which there is dorsal angulation of the distal
fragment. In this circumstance, the dorsal rim of
the lunate facet migrates proximally and rotates
dorsally in relation to the volar rim. As a result
the subchondral bone of the dorsal rim becomes
oriented parallel to the radiographic beam and
hand.theclinics.com
280 MEDOFF

and for determining whether an implant is posi-

Fig. 1. Standard landmarks on the PA view of the distal
radius.
creates the carpal facet horizon on the PA view
(Fig. 2B). Because this single landmark can
represent two different anatomic structures of
the osseous geometry, it is essential to always
correlate the PA view with the lateral view for
evaluating displacements of the articular surface
tioned properly.
This relationship also provides a method to
distinguish the dorsal and volar corners of the
sigmoid notch on a PA film. This is often critical
in determining whether a displaced fragment
should be approached from the volar or the dorsal
side. In addition, if the interval between the dorsal
or volar corners of the ulnar border of the radius
is widened in relation to the head of the ulna, it
may suggest a displaced distal radioulnar joint.
Because widening of the distal radioulnar joint
removes the osseous stability from seating of the
ulnar head in the sigmoid notch, this finding may
be a contributing source of distal radioulnar joint
(DRUJ) instability.
The lateral projection is an integral part of
a complete examination. Despite this, distortion
of the image may occur if the arm is not positioned
properly. Often a radiograph technician positions
the arm for a lateral film in an extreme position of
supination or pronation of the forearm; in this
circumstance, simply superimposing the radius and
ulna may result in an oblique projection of the
articular surface. A simple solution to this problem
is to use the relative position of the pisiform to the
distal pole of the scaphoid as the reference for
judging the quality of the lateral projection. On
a true lateral projection of the distal radius, the

Fig. 2. Assessing volar and dorsal rim on PA view. (A) Transverse radiodense line (carpal facet horizon) represents the
volar rim of the lunate facet if there is volar tilt of the articular surface, because the radiographic beam is parallel to the
subchondral bone of volar rim. Note the dorsal rim distal to the carpal facet horizon on the PA view. (B) Transverse
radiodense line (carpal facet horizon) represents the dorsal rim of the lunate facet if there is dorsal tilt of the articular
surface, because the radiographic beam is parallel to subchondral bone of the dorsal rim. Note the volar rim distal to the
carpal facet horizon on the PA view.
 DISTAL RADIUS FRACTURES: RADIOGRAPHIC EVALUATION
pisiform should overlap the distal pole of the
scaphoid. If the pisiform is significantly dorsal to
the distal pole of the scaphoid, the forearm is
positioned in relative pronation; if the pisiform is
volar to the distal pole of the scaphoid, the forearm
is positioned in relative supination (Fig. 3A,B).
In a standard lateral projection, the radiograph
beam is oriented perpendicular to the long axis of
the radial shaft. Because the radial inclination of
the ulnar two thirds of the articular surface is 10(
to the long axis of the shaft, this results in an
oblique projection of the joint surface on the
standard lateral view. The 10( lateral projection
positions the articular surface in profile, allowing
direct visualization of any offset in the sagittal
plane and accurate identification of the apical
ridges of the dorsal and volar rims. This pro-
jection is performed simply by elevating the distal
forearm 10( from horizontal or by aligning the
beam 10( proximally (Fig. 4A,B).
The radial styloid is visualized on the lateral
projection as a V-shaped outline superimposed
over the lunate with a base extending from the
dorsal and palmar margins of the distal radius.
Identification of the radial styloid on the lateral
view is important to ensure appropriate placement
Fig. 3. Assessment of the lateral radiograph. (A) With
a true lateral, the pisiform is projected over the distal
pole of the scaphoid. Note the outline of the radial
styloid. (B) If the pisiform is dorsal to the distal pole of
the scaphoid, the wrist is in relative pronation and the
radial column is projected obliquely.
281
Fig. 4. Standard versus 10( lateral projection. (A) The
standard lateral results in an oblique projection of
the articular surface. (B) The 10( lateral view projects
the ulnar two thirds of the articular surface in sharp
profile. Note the teardrop or the U-shaped outline of the
volar rim of the lunate facet, which is seen on both views
but is defined more clearly on the 10( lateral film.
of trans-styloid K-wires or a radial column plate
(see Fig. 3A).
The articular surface of the distal radius nor-
mally forms a smooth, unbroken arc on the lateral
view that is normally concentric with the arc of the
proximal lunate; this feature is especially promi-
nent with the 10( lateral projection. Normally the
lunate is located centrally within the articular
surface of the distal radius and is congruent with
the teardrop on the palmar side (Fig. 4B). Incon-
gruency of the base of the lunate with the articular
margin of the radius can indicate displaced intra-
articular fracture elements or subluxation or dislo-
cation of the radiocarpal joint (Fig. 5).
The radius of curvature of the distal radius
articular surface should match the radius of
curvature of the proximal pole of the lunate.
Flattening of the arc of curvature of the distal
radius implies dissociation and incongruency of
the articular surface across the dorsal and volar
margins of the lunate facet. Occasionally this
subtle feature may be the only radiographic
evidence of articular disruption (Fig. 6).
The central axis of the lunate is normally collin-
ear with the volar cortex of the radial shaft. Migra-
tion of the central axis of the lunate to the volar
side suggests significant radiocarpal instability.
282
Fig. 5. Radiograph showing a markedly abnormal AP
distance and migration of the carpus with dorsal
fragmentation, dislocating dorsally from the articular
surface of the volar rim (teardrop).
The teardrop is the U-shaped outline of the
volar rim of the lunate facet; it is identified easily
on the lateral view and is particularly distinct on
the 10( lateral projection (see Fig. 4A,B). The
relationship of the lunate to the articular surface
of the teardrop can be critical in defining the
direction of carpal instability. In addition, dorsal
rotation of the teardrop, often seen in conjunction
with axial loading injuries, can produce significant
articular incongruity that can be overlooked easily
even if radial inclination and volar tilt have been
Fig. 6. Radiograph showing flattening of the arc of
curvature of the articular surface of the distal radius as
compared with the arc of curvature of the proximal pole
of the lunate. This indicates discontinuity between the
dorsal and volar rims of the lunate facet.
MEDOFF
restored. Careful assessment of the teardrop
should be a standard part of radiographic evalu-
ation for distal radius fractures.
Radiographic parameters
Posteroanterior view
Radial inclination is well recognized as a useful
measurement of the radial slope on the PA pro-
jection. Historically this parameter has been de-
scribed as the angle between the long axis of the
radial shaft and a line connecting the tip of the
radial styloid with the ulnar corner [10]. Because
the ulnar corner may be a different anatomic
structure with volar and dorsal angulation of the
distal articular surface, this measurement should
use a reference point midway between the volar
and dorsal ulnar corners to eliminate variation
caused by dorsal angulation. This central refer-
ence point is defined as the CRP (Figs. 7 and 8).
A similar problem is encountered in measuring
ulnar variance, defined as the difference in axial
length between the ulnar corner of the distal
radius and the most distal extent of the ulnar
head on the PA view. For reasons described
previously, the measurement of ulnar variance is
more accurate and consistent when defined as the
difference in axial length between the ulnar head
and the CRP. Similarly the measurement of radial
height is more accurate when defined as the
difference in axial length between the tip of the
radial styloid and the CRP (Fig. 9).
The radiocarpal interval is a measurement of
the articular interval across the radiocarpal joint
and represents the combined thickness of the
articular cartilage on both sides of the joint. The
Fig. 7. Central reference point (CRP) of the ulnar
border, used for measuring radial inclination, radial
height, and ulnar variance to reduce variation caused by
excess dorsal or volar angulation of the distal fragment.
 DISTAL RADIUS FRACTURES: RADIOGRAPHIC EVALUATION
Fig. 8. Measurement of radial inclination and ulnar
variance to the CRP.
parameter is measured as the separation between
the proximal pole of the scaphoid to the distal
radius (Fig. 9). Intra-articular fractures with
impaction of the proximal carpal row into a frac-
ture defect reduce this value; a radiocarpal in-
terval in excess of 3 mm implies overdistraction of
the joint, usually in the context of an external
fixator, and has been associated with increased
potential for morbidity and complications [11].
Lateral view
Volar tilt is measured on the lateral view as the
angle formed between a perpendicular to the
longitudinal axis of the radial shaft and a line
formed by connecting the apex of the volar and
dorsal rim (Fig. 10) [10]. In practice, the apices of
Fig. 9. Measurement of radial height to the CRP, and
articular separation from the proximal pole of the
scaphoid to the scaphoid facet.
283
the dorsal and volar rim are identified more
clearly on the 10( lateral view.
On the lateral view the teardrop is identified
easily and represents the volar rim of the lunate
facet. This radiographic landmark is even more
prominent on the 10( lateral view. Normally
a line drawn down the central axis of the teardrop
(parallel to the subchondral bone of the volar rim)
creates an angle of 70( to a line extended from the
central axis of the radial shaft (Fig. 10). In extra-
articular fractures of the distal radius with dorsal
angulation of the distal fragment, the teardrop
angle is reduced by the amount of dorsal rotation.
As normal volar tilt is restored with reduction of
the fracture, the teardrop angle returns to normal.
Axial loading injuries, however, create a differ-
ent set of circumstances that can affect adversely the
teardrop angle. In these cases, the lunate is driven
into the lunate facet, resulting in dissociation of the
volar and dorsal articular surfaces. As the lunate is
impacted further into the metaphyseal cavity it
causes the volar rim to rotate dorsally into the
metaphyseal defect, resulting in severe articular
incongruity between the dorsal and volar sides of
the joint surface. Because of the large loads pro-
duced by the wrist and finger flexors on the volar
surface of the radiocarpal joint, these are particu-
larly unstable injuries. In this situation, reduction
maneuvers may restore volar tilt and radial in-
clination measurements back to normal, only to
retain significant abnormalities of the teardrop
angle. This depression in the teardrop angle repre-
sents significant residual dorsiflexion of the volar
rim fragment and frequently is the only evidence
that reduction is incomplete and articular incon-
gruity remains.
Fig. 10. Measurement of volar tilt and teardrop angle.
284 MEDOFF

In a normal distal radius, the distance between

the apex of the dorsal rim and the apex of the volar
rim of the lunate facet is fixed and defines the
anteroposterior (AP) distance. This parameter is
measured between the apex of the dorsal and volar
rims as seen on the lateral view (Fig. 11). Distal
radius fractures, particularly axial loading injuries,
can cause the volar and dorsal rim fragments to
explode away from each other as the lunate is
driven into the articular surface. Again, the 10(
lateral projection allows more accurate identifica-
tion of these landmarks. If the AP distance is
elevated above normal values, discontinuity be-
tween the volar and dorsal rims is implied
(Fig. 12). Frequently this is the only evidence of
discontinuity across the sigmoid notch.
Radiographs of 40 wrists in 20 healthy volun-
teers ranging in age from 19–85 years were
obtained to determine normal values for the
parameters discussed previously. The sample
studied was typical of the local population in the
state of Hawaii, with most patients having mixed
ethnic backgrounds (Caucasian, Hawaiian, Poly-
nesian, Filipino, and Asian mixtures); the sample
contained an equal number of men and women.
On the PA view, radial inclination, ulnar variance,
radial height, radial width, and radiocarpal in-
terval were measured. Measurement of radial
inclination, ulnar variance, and radial height was
modified to use the central reference point be-
tween the dorsal and volar corners of the ulnar
border of the radius. Volar tilt, AP distance, and
teardrop angle were measured on the standard
lateral view and on the 10( lateral view. In
addition, mean values for radial width, radio-
carpal interval, AP distance, and teardrop angle
were determined. A student’s t-test was used to
calculate whether any differences between genders
were statistically different. In addition, a student’s
t-test was used to calculate whether values mea-
sured on the standard lateral radiograph were
Fig. 11. Measurement of the AP distance.
Fig. 12. Distal radius fracture treated with external
fixation. Note the increased AP distance indicating
major discontinuity of the dorsal and volar rim frag-
ments and the marked depression of the normal
teardrop angle.
significantly different from corresponding values
measured on the 10( lateral film.
Normal values for these parameters are sum-
marized in Tables 1–3. The 10( lateral radio-
graph, which shows the articular surface of the
distal radius in greater detail and allows more
precise identification of the points of reference,
did not significantly affect measurement of volar
tilt, AP distance, and teardrop angle as compared
with the standard lateral radiographs. AP distance
was the only parameter that demonstrated statis-
tic differences between genders.
Miscellaneous
In addition to the radiographic landmarks and
parameters present in a normal wrist, two addi-
tional parameters may be useful in the context of
a distal radius fracture. The first is articular step-
off, which represents a translational discontinuity
or ledge in the articular surface [12–14]. This
abnormality usually is identified on the PA view
(Fig. 13A), but may be noted on the standard or
10( lateral view also.
Articular separation is a second parameter that
is useful to identify gaps in the articular surface
caused by incomplete apposition of articular
elements [15]. Although no long-term studies
have quantified what threshold of articular sepa-
ration adversely affects clinical outcome, it would
 DISTAL RADIUS FRACTURES: RADIOGRAPHIC EVALUATION 285

Table 1
Normal radiographic parameters of the wrist, PA projection
Radial inclination (() Radial height (mm) Ulnar variance (mm) Radiocarpal interval (mm)
Average 23.62.5 11.61.6 ÿ0.60.9 1.90.2
Women 24.72.5 11.21.5 ÿ0.60.8 1.90.2
Men 22.52.1 12.01.6 ÿ0.61.0 2.00.2
T value 2.13 ÿ1.15 0.00 ÿ1.11
P 0.04 0.26 1.00 0.28
Average data, n=40; gender-based data, n=20.

stand to reason that large segmental defects in the
articular surface would be associated with long-
term morbidity. For instance, a significantly wid-
ened AP distance on the lateral view would
suggest articular separation across the lunate
facet, with potential for the lunate to collapse
into a metaphyseal defect (Fig. 13B).
Patterns of injury
Fractures of the distal radius typically occur in
defined patterns. By identifying the actual physi-
cal components and the mechanism of injury,
a rational approach to treatment can be formu-
lated that is based on the fracture components
present and on the predominant direction of
instability.
Fragment specific classification
The fragment specific classification system is
a useful tool to identify the five major cortical
fracture elements that are commonly associated
with distal radius fractures either alone or in any
combination. Specifically these fracture compo-
nents are the radial column, ulnar corner, dorsal
wall, volar rim, and free intra-articular fragments
(Figs. 14 and 15).
The radial column fragment is typically the
largest fragment element (Fig. 16). This fragment
often involves more than simply the tip of the
radial styloid and extends proximally into the
tricortical column of bone; typically, this fragment
includes the very terminal fibers of the brachior-
adialis insertion. This fragment is identified easily
on the PA view. Although often present as a single
fracture component, comminution of the radial
column can occur and indicates a more unstable
fracture pattern (see Fig. 15). Reduction of the
radial column fragment should restore radial
length and radial inclination; radial translation
of this fragment with a radial buttress plate can
close the sigmoid notch against the ulnar head and
help stabilize the DRUJ. Segmental defects be-
tween the radial column and the proximal shaft
should be identified and often require structural
graft to maintain length of the radial column.
The ulnar corner fragment can be identified on
the PA or oblique view and often is displaced
proximally (Fig. 16). It consists of the dorsal
corner of the DRUJ and may include a portion of
the dorsal surface of the lunate facet. Shortening
or widening of the ulnar corner fragment in
relation to the ulnar head can result in abnormal-
ities of the DRUJ and should be corrected.
Dorsal bending and axial loading injuries to
the distal radius often result in comminution of
the dorsal wall, with one or more dorsal wall

Table 2
Normal radiographic parameters of the wrist, standard Table 3
lateral projection Comparison of standard lateral to 10( lateral projection,
normal wrists
Volar tilt AP dist Teardrop angle
(mm) (mm) (() Volar tilt AP distance Teardrop
(() (mm) (()
Average (n=40) 11.24.6 19.11.7 70.74.2
Women (n=20) 12.25.6 17.81.0 70.84.7 Normal lateral 11.24.6 19.11.7 70.74.2
Men (n=20) 10.23.2 20.41.1 70.53.7 10( lateral 8.94.0 18.71.7 71.64.1
T-value 0.98 ÿ5.5 0.16 T-value ÿ1.19 ÿ7.40 0.84
p 0.35 <0.01 0.87 p 0.24 0.48 0.42
Average data, n=40; gender-based data, n=20. n=40.
286 MEDOFF
Fig. 13. Articular step-off and articular separation with intra-articular fractures. (A) Articular step-off seen as
discontinuity of the carpal facet horizon. (B) Articular separation seen on the lateral projection; note the elevation of the
AP distance and the marked depression of the teardrop angle.
fragments that may rotate into dorsiflexion. The
dorsal wall fragment is recognized easily by close
inspection of the lateral radiograph. The presence
of a dorsal wall fragment implies dorsal instabil-
ity; in middle aged and older patients it often is
associated with a significant metaphyseal defect as
well. Occasionally the dorsal wall fragment may
rotate 90( in an orientation parallel to the
radiographic beam and may appear as a radio-
dense line crossing transversely at the proximal
extent of the fracture. A similar finding is seen less
commonly in the context of a volar bending injury
with volar rotation of a volar wall fragment. By
correlating the lateral radiograph to the PA view,
Fig. 14. Fragment classification system showing the
common cortical fracture components, the radial col-
umn, ulnar corner (dorsal), volar rim, dorsal wall, and
free intra-articular fragments. Most intra-articular
fracture patterns contain a subset of these five major
cortical fragments. (Courtesy of Trimed, Inc., Valencia,
CA; with permission.)
the correct fracture pattern can be differentiated
despite the similar radiographic appearance of
this radiodense linear feature.
Occasionally dorsal wall fractures also may
occur with dorsal shearing injuries. In this situa-
tion, translation of the carpus dorsally is recog-
nized by displacement of the lunate dorsally off
the teardrop as seen on the lateral view. Dorsal
fixation and palmar translation of the carpus is
required for treatment of this type of fracture
pattern.
Impacted intra-articular fracture elements can
be visualized on the PA or lateral projection by
noting the subchondral bone of the articular
surface within the metaphyseal bone. Occasion-
ally an intra-articular fragment may be rotated
Fig. 15. Comminuted fracture from an axial loading
injury demonstrating all five major cortical fragments.
 DISTAL RADIUS FRACTURES: RADIOGRAPHIC EVALUATION
Fig. 16. Simple intra-articular fracture with large radial
column and ulnar corner fragment.
a full 180( and facing proximally. Impacted
articular fragments are almost always associated
with axial loading injuries.
Volar rim fracture elements commonly are
comminuted. Typically two patterns of displace-
ment are noted. In the first, the fracture element is
translated into the palmar soft tissue; this type is
usually the result of volar bending or shearing
injuries. In this mechanism, simple buttress sup-
port of the volar rim is usually adequate for stable
reduction and fixation.
The second category of volar rim injuries is
caused by an axial loading mechanism and results
in dorsiflexion of the volar rim fragment into the
metaphyseal cavity (see Fig. 15). This type of
instability is more difficult to control and can be
associated with subluxation of the carpus from the
articular surface. These injuries are associated
with depression of the teardrop angle and an
incongruity between the arc of curvature of the
volar fragment and dorsal fragment on the lateral
view. Restoration of articular congruency and
stability is accomplished only if the teardrop angle
is corrected.
Summary
Fractures of the distal radius can be complex
injuries, often generating multiple fragments with
distortion of the normal anatomy in all three
dimensions. Superficial assessment of the injury
on the standard PA and lateral radiographs often
can result in incomplete recognition of the
injury pattern and a misdirected approach to
treatment. In addition, failure to recognize subtle
287
radiographic findings may result in the acceptance
of a reduction that has significant residual incon-
gruency and articular surface disruption.
Standard radiographs of the distal radius can
provide a wealth of information about the topog-
raphy of the bone if the surgeon knows what
to look for. The ability to recognize detailed
landmarks and parameters on the radiographic
images and convert this information into a three-
dimensional visual image is a skill that requires
education and training. As more aggressive treat-
ments have emerged for anatomic restoration of
the bony and articular anatomy, accurate identi-
fication of the pattern of injury has become
essential.
Parameters such as the teardrop angle, AP
distance, and articular separation have been
recognized only recently. Because these parame-
ters reflect the congruency of the articular surface,
it would be natural to assume that postreduction
films in which these parameters are abnormal
would compromise clinical outcome. Because
nearly all historical studies do not include routine
evaluation of these parameters, knowledge of
radiographic correlation with clinical outcome is
still incomplete. At the same time, previous
studies to assess outcome of distal radius fractures
may be compromised by the failure to recognize
residual deformity and articular incongruency
that would have been evident with measurement
of these parameters.
With careful understanding of the radiographic
landmarks, radiographic parameters, and patterns
of injury, the surgeon can visualize a more accu-
rate picture of the fracture itself and the reduction.
As a result, treatment decisions for distal radius
fractures can be based on a more thorough un-
derstanding of the anatomy of the injury, and
future grading of radiographic results may reflect
more accurately the precision of the articular
restoration.
Acknowledgment
The author would like to thank David Green,
MD, for his help with the preparation of this
article.
References
[1] Andersen DJ, Blair WF, Steyers CM Jr, Adams
BD, El-Khouri GY, Brandser EA. Classification
of distal radius fractures: an analysis of interobserver
288 MEDOFF
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[2] Bozentka DJ, Beredjiklian PK, Westawski D, Stein-
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[3] Cole RJ, Bindra RR, Evanoff BA, Gilula LA,
Yamaguchi K, Gelberman RH. Radiographic evalu-
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[4] Katz MA, Beredjiklian PK, Bozentka DJ, Steinberg
DR. Computed tomography scanning of intraartic-
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[5] Metz VM, Gilula LA. Imaging techniques for digital
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[6] Rozental TD, Bozentka DJ, Katz MA, Steinberg
DR, Beredjiklian PK. Evaluation of the sigmoid
notch with computed tomography following intra-
articular distal radius fracture. J Hand Surg 2001;
26(2):244–51.
[7] Spence LD, Savenor A, Nwachuku I, Tilsley J,
Eustace S. MRI of fractures of the distal radius:
comparison with conventional radiographs. Skel
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[8] Waters PM, Mintzer CM, Hipp JA, Snyder BD.
Noninvasive measurement of distal radius instability.
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[9] Friberg S, Lundstrom B. Radiographic measure-
ments of the radiocarpal joint in normal adults.
Acta Radiol Diagn (Stockh) 1976;17:249–56.
[10] Van der Linden W, Ericson R. Colles’ fracture. How
should its displacement be measured and how should
it be immobilized? J Bone Joint Surg [Am] 1981;
63(8):1285–8.
[11] Kaempfe FA, Walker KM. External fixation for dis-
tal radius fractures: effect of distraction on outcome.
Clin Orthop 2000;1(380):220–5.
[12] Fischmeister MF, Foltin E. Unfalkrankenhaus der
Allgemeinen Unfallversicherungsanstalt in Linz.
Handchir Mikrochir Plast Chir 1991;23(1):11–4.
[13] Knirk JL, Jupiter JB. Intra-articular fractures of the
distal end of the radius in young adults. J Bone Joint
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[14] Fernandez JJ, Gruen GS, Herndon JH. Outcome of
distal radius fractures using the short form 36 health
survey. Clin Orthop Relat Res 1997;341:36–41.
[15] Catalano LW III, Cole RJ, Gelberman RH, Evanoff
BA, Gilula LA, Borelli J Jr. Displaced intra-articular
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term results in young adults after open reduction
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 Hand Clin 21 (2005) 289–294
Predicting the Outcome of Distal Radius Fractures
David J. Slutsky, MD, FRCS(C)
Private Practice, 3475 Torrance Blvd., Suite F, Torrance, CA 90503, USA
The anatomic results of fracture treatment
have no meaning unless they are considered in
light of the functional outcome [1]. There are
myriad factors affecting the clinical result follow-
ing a distal radius fracture. It is useful to identify
those factors that have some predictive value with
regard to fracture instability, patient satisfaction,
and hand function. These variables are discussed
in light of the specific outcome of interest.
Predictors of fracture instability
A fracture of the distal radius is considered to
be unstable if it is unable to resist displacement
once it has been reduced anatomically. There are
difficulties in predicting fracture instability re-
liably based on the radiographs alone. MacKen-
ney and Adolphson et al [2] have devised scoring
systems to calculate the probability of fracture
instability on the basis of the initial presentation
and the injury films. In a prospective study of 80
patients, both scoring systems were found to
underestimate the degree of fracture instability
and to have a poor correlation with the predicted
and the actual instability [3].
The standard radiographic parameters of the
distal radius include a radial inclination of 23
(range, 13 –30 ), a radial length of 12 mm (range,
8–18 mm), and an average volar tilt of 12 (range,
1 –21 ) [4–7]. Lafontaine et al identified several
risk factors associated with secondary fracture
displacement despite a satisfactory initial reduc-
tion. These included the presence of dorsal tilt
O20 , comminution, intra-articular involvement,
an associated fracture of the ulna, and age greater
than 60 years. If three or more of these factors
were present there was a high likelihood of
E-mail address: d-slutsky@msn.com
0749-0712/05/$ - see front matter Ó 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.hcl.2005.03.001
fracture collapse [8]. Several studies have deter-
mined that the severity of the initial radial
shortening alone seems to be a reliable indicator
of instability [9–11].
In patients older than 60 years of age, Leone
et al found that the degree of radial shortening and
volar tilt and the amount of dorsal comminution
were predictive of early or late failure. An un-
expected finding was that in patients older than 65
years of age, one third of the initially undisplaced
fractures subsequently collapsed [12]. Nesbitt et al
determined that age was the only statistically
significant predictor of secondary displacement.
After obtaining an acceptable initial closed re-
duction, those patients who were more than 60
years of age had four times the risk for failure
within the initial 4 weeks as compared with
younger patients. The risk for displacement in-
creased with each subsequent decade [13].
It is apparent that late fracture displacement is
common in elderly patients, which may be related
to their lower bone density. Thought should be
given to adjuvant percutaneous or external fixation
in the healthy, active elderly patient if there is a loss
of fracture position in the first month. Greater
force is necessary to fracture the radius in younger
patients because of their higher bone density,
which can result in more comminution and a higher
risk for subsequent fracture collapse [14]. Supple-
mental internal or external fixation is indicated in
younger patients for fractures with O2 mm of
radial shortening and O15 of dorsal tilt following
a closed reduction, especially if there is comminu-
tion of two or more cortices [15,16].
Predictors of osteoarthritis
Knirk and Jupiter retrospectively reviewed 43
intra-articular fractures in 40 young adults (mean
age, 27.6 years) with a mean follow-up of 6.7
hand.theclinics.com
290
years. Thirty-eight fractures were treated with cast
or pins and plaster. Accurate reduction of the
articular surface was the most critical factor in
achieving a successful result. Radiographic evi-
dence of arthritis developed in 100% of the
fractures whose articular incongruity was 2 mm
or more, in contrast to only 11% of the fractures
that healed with a congruous joint [17]. Altissimi
et al analyzed the outcomes of 59 patients with
comminuted intra-articular fractures of the distal
radius who had received conservative treatment,
at an average follow-up of 3.5 years. Thirty-one
percent of the patients with greater than 2 mm of
residual articular malalignment were noted to
have degenerative arthritis [18]. Catalano et al
studied 21 patients younger than the age of 45
years who had undergone internal fixation of
displaced intra-articular fractures. At an average
of 7.1 years, osteoarthrosis of the radiocarpal
joint was radiographically apparent in 16 wrists
(76%). A strong association was found between
the development of osteoarthrosis of the radio-
carpal joint and residual displacement of articular
fragments at the time of bony union (P ! 0.01)
[19]. Fernandez et al observed that intra-articular
incongruence of 1 mm or greater resulted in the
development of arthrosis [20].
The predictive value of these studies is that
articular incongruity following a distal radius
fracture is the most significant factor in the
development of radiocarpal osteoarthritis (OA).
Articular displacement that is identified on the
initial injury films thus warrants a more aggressive
surgical approach.
Predictors of residual disability
Radiographic predictors
Many studies have supported the link between
late deformity and functional outcome following
a distal radius fracture since the landmark article
by Garland and Werley [21]. Fujii et al determined
that fractures that had healed with 6 mm or more
of radial shortening were likely to have a poor
functional outcome [22]. In a study of 92 patients
older than the age of 55 years, Aro and Koivunen
found that even minor axial shortening of the
radius with a Colles fracture carried an increased
risk for permanent disability. The functional end
result was unsatisfactory in 4% of the patients
with an acceptable anatomic result, in 25% of the
patients with radial shortening of 3–5 mm, and
in 31% of patients with shortening of more than
SLUTSKY
5 mm [23]. This finding does not seem to change
over time. Eighty-five patients with displaced
Colles fractures were reviewed 10 years after the
injury. Initial and 10-year radial shortening and
early finger stiffness significantly correlated with
final outcome. Dorsal angulation influenced early
but not 10-year function [24].
Combined deformities are also of significance.
Fractures healing with more than 2 mm of axial
compression and O15 of dorsal angulation have
compromised outcomes [25,26].
Intracarpal lesions
Arthroscopic evaluation of extra- and intra-
articular distal radius fractures has revealed that
triangular fibrocartilage (TFC) and interosseous
ligament tears are much more common than
suspected previously [27,28]. These chondral and
ligamentous lesions may explain poor outcomes
after seemingly well healed fractures in young
adults and [29]. Although preoperative radio-
graphs had no predictive value for interosseous
ligament injury, those patients with TFC tears had
greater radial shortening and dorsal angulation
[27].
Post-traumatic osteoarthritis
Experimental work on displaced intra-articular
distal radius fractures has measured significant
changes in mean contact stresses with step-offs as
small as 1 mm [30]. Wrist pain has related
significantly to the size of the intra-articular step
[31]. These findings have prompted some inves-
tigators to recommend surgical treatment for
residual articular incongruity of R1 mm [15,32].
Ulnar wrist pain
A study of 109 Colles fractures treated with
closed reduction and casting determined that the
most important factor for predicting ulnar wrist
pain was incongruity of the distal radioulnar joint
(DRUJ) secondary to residual dorsal angulation
of the radius [33]. Others have found that an
increase in the ulnar variance was the most
important radiologic parameter affecting outcome
[34]. Ulnocarpal impingement and DRUJ incon-
gruency are related to the amount of radial
shortening and are a common cause of ulnar-
sided wrist pain [35]. In young patients, DRUJ
instability is another cause of residual pain
following a distal radius fracture. Lindau et al,
however, could not correlate this instability with
any specific radiographic parameter [36].
 PREDICTING THE OUTCOME OF DISTAL RADIUS FRACTURES
Grip strength loss
More than 10 of dorsal tilt leads to a dorsal
carpal shift with compressive forces, which causes
pain and insecurity with gripping. This has been
associated with increased difficulty with everyday
activities and work [37]. Dorsal angulation of
O20 and reduction of the radial angle to less
than 10 can result in a reduction in grip strength
[38].
Others have found that grip strength correlated
negatively with the degree of osteoarthrosis [39].
Work-related injury
Injury compensation is a predictive factor with
regard to patient-reported pain and disability. In
a prospective study of 120 patients sustaining
a distal radius fracture, the most influential pre-
dictor of pain and disability at 6 months was
injury compensation. Wrist impairment was cor-
related moderately with patient-reported pain and
disability [40]. Fernandez et al found that patients
with work-related injuries were more than four
times less likely to return to work than those
injured while away from work [20].
The message gleaned from these data is that
aggressive efforts should be made to achieve
a congruent joint reduction and to circumvent
an excessive loss of radial length or abnormal tilt
of the articular surface to prevent residual im-
pairment and pain. Intracarpal pathology should
be suspected in patients with persistent wrist pain
despite acceptable bony alignment. Patients with
work-related injuries are apt to have poorer out-
comes regardless of the anatomic result.
Predictors of loss of wrist motion
Experimentally, dorsal tilt of up to 30 and
radial translation of up to 10 mm leads to no
significant restriction in forearm pronation or
supination. Radial shortening of 10 mm, however,
reduces forearm pronation by 47% and supina-
tion by 29%. Five mm of ulnar translation
deformity results in a mean 23% loss of pronation
[41]. Clinical experience has shown that radial
shortening of 2 mm or greater and dorsal angu-
lation of more than 15 was directly related to
diminished range of motion [25]. Hove et al found
that the total movement in all directions was
diminished with an ulna plus deformity and that
pronation and supination were related to the
initial radial length and dorsal angulation [39].
291
Comminution and intra-articular involvement
also predispose toward a loss of movement [38]. In
a study of 169 distal radius fractures in adults
younger than age 50, fracture union with a step in
the radiocarpal articular surface was associated
with loss of wrist mobility and difficulty with fine
dexterous tasks [37].
The predictive value of this evidence is that if
a loss of motion is caused by bony malalignment,
prolonged therapy is of no benefit.
Predictors of patient satisfaction
Wrist pain/grip strength
Fifty-three items were evaluated by a group of
55 patients recovering from a fracture of the distal
radius, which established the prevalence, mean
severity score, and overall severity score (or
impact) of each item as it relates to physical
function and social/emotional impact. The
amount of residual wrist pain influenced patient
satisfaction more than motion did. Hand domi-
nance was also a significant factor [42].
Trumble et al devised a combined injury score
rating system that included grip strength, range of
motion, and pain relief to grade the results
following internal fixation of displaced intra-
articular distal radius fractures. In this retrospec-
tive study 43 patients were evaluated at a mean of
38 months. Patient satisfaction seemed to corre-
late best with pain relief and grip strength rather
than the postoperative loss of palmar tilt or radial
tilt. Preoperative step-off and gap and radial
shortening were equated with worse outcomes
[16].
In other clinical trials, Fujii et al noted that the
grip power was the most significant factor related
to subjective evaluation [22]. A prospective study
of 31 patients recovering from unstable fractures
of the distal radius investigated the association
between objective variables and the level of post-
traumatic disability of the wrist as measured by
the patient-rated wrist evaluation (PRWE) score.
Grip strength was shown to be a significant pre-
dictor of the PRWE score and seemed to be
a sensitive indicator of return of function of the
wrist [43].
Osteoporosis
A study of the bone mineral densitometry in
women older than age 40 years who sustained
a distal radius fracture demonstrated that the
292
clinical results correlated better with bone mineral
density than with the radiologic parameters [44].
The gist of these observations is that a loss of
bony alignment does not always equate with
disability. Although surgeons continue to strive
for perfection, some degree of malalignment
seems to be well tolerated. Patient satisfaction
often hinges on pain relief and return of grip
strength rather than anatomic restoration. This
was affirmed by one prospective study of 85
patients who were randomized to bridging exter-
nal fixation or plaster immobilization for treat-
ment of a Colles type distal radial fracture.
Despite a high level of radiographic malunion
(50%), overall function, range of movement, and
activities of daily living were not limited [45]. It
does seem that involvement of the dominant hand
and osteopenia may influence the end result.
Factors not invariably predictive of outcome
Acceptable reduction
The relationship between form and function is
not invariable. MacDermid et al found that an
acceptable radiographic reduction of dorsal/volar
tilt criteria was not associated with better self-
reported functional outcomes or increased satis-
faction at 6 months in elderly patients with
conservatively treated distal radius fractures [46].
In the evaluation of the outcomes using the
Short form 36, a study of 50 patients with a mean
age of 49.6 years found no correlation with
residual radial height, radial tilt, or palmar tilt
following internal or external fixation of distal
radius fractures. Intra-articular incongruence of 1
mm or greater, however, did correlate with a lower
score [20].
Malunion
Gliatis et al assessed the outcome of 169
fractures of the distal radius in adults younger
than age 50 years at a mean follow-up of 4.9 years.
No measure of intra- or extra-articular malunion
influenced the severity or frequency of persistent
wrist pain [37]. A retrospective study of Colles
fractures in patients 60 years or older revealed an
82% incidence (11 patients) of good to excellent
outcomes in undisplaced fractures as compared
with a 68% incidence (25 patients) in re-displaced
fractures [47].
Dayican et al analyzed the results of 108 patients
older than 70 years of age with intra-articular distal
SLUTSKY
radial fractures who would not consent to an
operation. At a mean follow-up of 39.5 months,
88.9% were considered to have good and excellent
functional results even though 25.9% of the pa-
tients had fair and poor anatomic scores [48].
Kelley et al studied 30 elderly patients with
moderately displaced Colles’ fractures (10 –30 of
dorsal angulation and !5 mm of radial shorten-
ing) who were randomly assigned to manipulation
under Bier block or plaster immobilization alone.
There was no detectable difference between the
groups in any of the outcome measures. Two
thirds of the correction of dorsal angulation
achieved by manipulation was lost by 5 weeks.
They concluded that up to 30 of dorsal angula-
tion and 5 mm of radial shortening may be
accepted in selected elderly patients [49]. This
finding was duplicated by Beumer and McQueen.
In a series of 60 fractures with a mean patient age
of 82 years (range, 65–93 years), 53/60 fractures
healed in a malunited position. They found no
correlation between fracture classification, initial
displacement, and final radiographic outcome. On
the basis of these observations they concluded
that reduction of fractures of the distal radius is of
minimal value in old and frail, dependent, or
demented patient [50].
Osteoarthritis
The radiographic presence of OA does not al-
ways affect adversely the functional outcome [45].
In a series of 21 patients with surgically treated
intra-articular fractures, osteoarthrosis of the
radiocarpal joint was radiographically apparent
in 16 (76%) of the wrists at an average follow-up
of 7.1 years. The functional status, however, did
not correlate with the magnitude of the residual
step and gap displacement at the time of fracture
healing. All patients had a good or excellent
functional outcome irrespective of radiographic
evidence of osteoarthrosis of the radiocarpal or
the DRUJ [19].
Wrist motion
Forearm rotation and flexion and extension of
the wrist were not significantly associated with the
PRWE score [43]. Absolute wrist motion has been
found subjectively to be less relevant than grip
strengths and residual wrist pain [42].
One can see that wrist impairment is not
always synonymous with a poor functional out-
come.
 PREDICTING THE OUTCOME OF DISTAL RADIUS FRACTURES
Summary
There are myriad factors that affect patient
satisfaction following a distal radius fracture, in-
cluding anatomic alignment, age, motion, pain,
and hand dominance to name a few. The seeming
contradictions in the literature serve to illustrate
that individual outcomes are not entirely predict-
able because of the different functional demands,
expectations, and pain tolerance for each patient.
Elderly populations may tolerate greater degrees
of residual deformity because of a more sedentary
lifestyle. Unrecognized intracarpal pathology
may account for poor results despite acceptable
radiographic alignment. Possessing a knowledge
of the predictive factors that affect adversely the
functional outcome, however, does allow the
surgeon to manage complications proactively to
maximize the potential for an acceptable end
result.
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 Hand Clin 21 (2005) 295–305
Avoidance and Treatment of Complications
of Distal Radius Fractures
Andrew P. Gutow, MDa,b,*
a
Department of Orthopedics, Stanford University, Stanford, CA 94305, USA
b
Palo Alto Medical Foundation, 795 El Camino Real, Palo Alto, CA 94301, USA
The treatment of a distal radius fracture con-
sists of a series of discrete events and encounters
over a course of time, and at each of these times the
treating surgeon should actively consider how to
achieve optimal outcome and prevent complica-
tions. The most frequent complications reported
following distal radius fractures include persistent
neuropathy, arthritis, stiffness, and malunion
[1–4]. Almost all possible complications have
been reported following closed reduction and
cast treatment, including stiffness, tendonitis, mal-
union, arthrosis, carpal tunnel syndrome, delayed
extensor tendon rupture, infection, compartment
syndrome, and complex regional pain syndrome
[1–3,5–15]. Percutaneous fixation and external
fixation adds increased risk of nerve injuries,
tendon irritation, and infection [3,16–19]. Compli-
cations of internal fixation include tendon rupture,
nerve injury, and deep infection [4,20–24]. The use
of internal or external fixation to restore preinjury
alignment and articular congruity may decrease
the risk of malunion, arthritis, and late carpal
tunnel syndrome relative to cast treatment, but at
the risk of surgical complications.
At the first encounter, an appropriate diagno-
sis of the fracture must be made, including
detection of any co-occurring injuries. The sur-
geon must not miss an open fracture, a scaphoid
fracture, a carpal ligament injury, or acute carpal
tunnel syndrome. Assessing fracture stability,
as detailed by Slutsky [25], can prevent an
* Palo Alto Medical Foundation, 795 El Camino
Real, Palo Alto, CA 94301.
E-mail address: AGutow@comcast.net.
0749-0712/05/$ - see front matter Ó 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.hcl.2005.04.004
unexpected malunion. A treatment plan must be
made, selecting from options on a continuum
running from removable splinting, through cast-
ing in place, closed reduction and casting, to the
whole gamut of surgical techniques. The selected
closed treatment or surgery must be performed in
a manner that adequately restores the anatomy
without causing a complication. If a surgical in-
tervention is elected, knowledge of the technique
and devices chosen can help minimize the risks of
complications such as nerve and tendon injury or
irritation.
Following the initial treatment, follow-up and
outpatient monitoring must be used to allow
appropriate timely diagnosis of complications
such as carpal tunnel syndrome, compartment
syndrome, complex regional pain syndrome, and
infection. Radiographic monitoring for loss of
reduction is needed. An appropriately supervised
rehabilitation program must be instituted to
maximize functional return. Internal or external
support must be maintained long enough to allow
bone healing to prevent malunion and late frac-
ture subsidence.
Initial evaluation
An adequate initial history, physical examina-
tion, and imaging are important to avoid compli-
cations. Previous history of fractures with resultant
abnormal anatomy and history of carpal tunnel
syndrome are important to elicit. An appropriate
index of suspicion should be maintained for open
fractures in the context of small wounds. If open
fractures are present, history of the environment
of the injury should be confirmed to allow for
hand.theclinics.com
296 GUTOW

Fig. 1. A 7-year-old child had a fall off a wall onto dirt and grass and suffered an open radius and ulna fracture, treated
with operative irrigation, debridement, reduction with splinting, and 48 hours of intravenous first-generation
cephalosporin antibiotic. At 7 days after injury, the patient returned with loss of perfusion of the hand. Operative
debridement demonstrated necrotic tissue with thrombosed vessels, necessitating amputation (A,B). Pathology and
microbiology showed clostridium infection, probably from direct inoculation from dirt. Initial treatment might have
been aided by penicillin-type antibiotics and aggressive washout of the fractured bones.

appropriate antibiotic coverage (Fig. 1). Careful
neurologic examination to assess for acute carpal
tunnel syndrome is also needed. Acute carpal
tunnel syndrome is found more frequently in
patients who have more severe, comminuted, or
dislocated fractures and in patients treated with
multiple reductions or splinting in extreme flexed
postures [26]. Mild median nerve sensory deficit,
however, may be consistent with contusion and can
be observed. If symptoms of median nerve com-
pression progress, become worse after closed re-
duction, or if surgical intervention is planned that
may increase swelling, then carpal tunnel release is
indicated, with best long-term results if urgent
action is taken [26–28]. Acute compartment syn-
drome can occasionally develop in cases of high-
energy injuries before surgical intervention
(Fig. 2), rarely occurs in cases of low-energy injury,
and also can occur after surgery [3,5,6,29,30].
The interval from injury to occurrence of the
compartment syndrome has been reported to range
from 12 to 54 hours [6,31].
Vascular injuries are rare in closed fractures,
but high-energy displaced fractures can result in
injuries to either the radial or ulnar artery, the
specific treatment of which is determined by the
vascular status of the hand (Fig. 3) [32].
Imaging examination, as detailed by Medoff
[33], should be used to fully understand the fracture
and to confirm the absence of co-occurring carpal
fractures (Fig. 4) and static carpal ligament in-
juries. Scaphoid fractures and intercarpal ligament
injuries were reported as initially missed in 0.7%

Fig. 3. A 39-year-old woman was in a motor vehicle

Fig. 2. A 32-year-old man suffered a closed distal radius
fracture in a motor vehicle crash. In the first 24 hours
following the injury, the patient developed severe pain in
the injured forearm and was treated with compartment
release, external fixation, and pinning of his fractures.
Subsequent closure was performed with skin graft, as seen.
crash with a closed left distal radius fracture, as seen.
Immediate closed reduction was performed, with good
perfusion to the hand but decreased sensation in the
median nerve distribution. Subsequent open volar re-
duction and carpal tunnel release were performed, at
which time she was found to have a completely avulsed
radial artery. No arterial repair was performed because
there was adequate perfusion. Return of normal sen-
sation did not occur until over 1 year following injury.
 DISTAL RADIAL FRACTURE COMPLICATIONS 297

Fig. 4. A 19-year-old man fell while rope climbing and presented with a shortened and dorsally angulated distal radius
fracture (A). Careful review of his radiographs also demonstrated a minimally displaced scaphoid waist fracture at risk
of displacement with manipulation of the distal radius fracture. Percutaneous fixation of the scaphoid fracture was
performed before closed reduction and pinning of the radius fracture (B).

and 0.9% of cases respectively in a series of 565
fractures compiled by Cooney and colleagues [1].
Scaphoid fractures co-occurring with distal radius
fractures should be treated with internal fixation
[34], as detailed by Slade and coauthors [35].
Failure to identify and treat scaphoid lunate
ligament injuries with acute pinning has been
shown to adversely affect outcome [36]. Small
volar avulsion fractures with dorsal dislocation
represent complete disruption of the volar carpal
ligaments (Fig. 5), and can be difficult to treat
because they require direct repair of the volar
structures and have poor outcome, even with the
best treatment [36,37]. Combined ulnar-sided in-
juries need to be considered both at the time of
presentation and intraoperatively at the time of
surgery, as reviewed by Lindau [38]. Ulnar styloid
fractures that are displaced or at the base of the
styloid increase the risk of late distal radial ulnar
joint instability if not treated (Fig. 6) [39].
Complications of closed reduction and cast
treatment
The methods described by Fernandez [40] can
decrease the incidence of the complications of
closed reduction. One needs to be mindful of the
risks of loss of reduction, compartment syndrome,
skin tearing during reduction, acute carpal tunnel
syndrome, stiffness, and complex regional pain

Fig. 5. A 36-year-old man suffered an open distal radius dorsal fracture dislocation, along with a femur and tibia
fracture, in a motor vehicle crash. Radiographs show a small volar lip radial fragment displaced along with the carpus
(A,B). Irrigation/debridement, external fixation, and open volar fixation were performed. At 1-year follow-up, ulnar
carpal translocation had occurred because of failure to heal of the torn volar ligamentous structure.
298
Fig. 6. A combined distal radius and displaced ulnar styloid base fracture creates a risk of distal radial joint instability if
the ulnar injury is not addressed (A). Minimal open pinning of the ulnar styloid fragment was performed (B).
syndrome. Closed reduction performed under
brachial plexus or general anesthesia appears to
have a lower rate of complications than reduction
performed under local block, perhaps because of
better relaxation and less forceful manipulation.
As important as the type of block used is the use of
less forceful manual reduction, via disimpaction
with longitudinal traction (hanging of arm in finger
traps) before reduction [1]. The use of finger traps
to assist in reduction in older individuals can also
prevent over-vigorous manual traction resulting in
torn skin. Cloth tape placed over the fingers before
hanging them in metal finger traps reduces the skin
injury from these traps. Initial splinting with
a sugar tong splint as opposed to a circumferential
cast may have reduce risk of compartment syn-
drome [7]. Compartment syndrome following
closed reduction done under local hematoma block
anesthesia has been reported, and the block
suggested as a risk factor for compartment syn-
drome [41]; however, because this is one of the
most commonly used methods of anesthesia, the
exact contribution of hematoma block to compart-
ment syndrome has not been shown. Most impor-
tant to preventing postreduction compartment
syndrome is sensitivity to both adult and pediatric
patients complaining of continued severe pain
[1,42]. These patients, whether in hospital or at
home, require urgent evaluation and loosening or
removal of their casts or splints [1].
Splinting in extreme flexion of more than 15 
of palmar flexion increases the risk of acute carpal
tunnel syndrome, digital stiffness, and complex
regional pain syndrome (also know as reflex
sympathetic dystrophy or Sudek’s dystrophy)
[1,8,40,43–46]. A hyperflexed wrist position has
been shown to increase the pressure in the carpal
GUTOW
tunnel in patients with distal radius fractures
(average 47 mm of Hg at 40  flexion compared
with 18 mm Hg at neutral flexion) [47], with
increased risk of subsequent carpal tunnel syn-
drome, which has been suggested as a contributor
to complex regional pain syndrome [1,8,44,46].
Careful splinting that allows full flexion of the
metacarpal phalangeal (MCP) joints is important
to preventing MCP joint extension contractures
and more proximal tendon adhesions. Patients
treated with closed reduction need to be closely
followed to observe for loss of reduction; de-
velopment of stiffness of the digits, elbow and
shoulder; and symptoms of median nerve com-
pression. If loss of reduction occurs, immediate
surgical reduction and fixation can be successfully
performed if the patient’s general conditions
is favorable to reoperation [40,48]. Urgency is
greater for early fixation of intra-articular mal-
union than for extra-articular malunions, and in
some cases it may be better to allow the homeo-
stasis of the limb to be re-established before
surgery [49,50]. Caution should also be exercised
in the immediate revision of percutaneous or
external fixation to internal fixation, because of
the risk of deep infection.
Persistent median neuropathy following distal
radius fracture can be due to nerve injury at the
time of injury or reduction, but is also highly
correlated with fracture malunion [1,2,51,52].
If the neuropathy is secondary to malunion,
osteotomy can help in the treatment of the nerve
compression [50]. Surgical release of the median
nerve should be performed in an open and
extensile manner, releasing both the transverse
carpal ligament and the distal antebrachial fascia
[53].
 DISTAL RADIAL FRACTURE COMPLICATIONS
One case of osteomyselitis with Staphylococcus
aureus following a hematoma block for reduction of
a distal radius fracture has been reported [9], which
emphasizes the need for sterility when using this
technique. Hematogenously spread osteomyelitis
has also been described in a child following a distal
radius fracture treated in a closed manner [10].
Tendon irritation and tendon rupture can
occur with closed cast treatment. Rupture of the
extensor pollicis longus tendon is the most fre-
quently reported rupture, occurring most often in
adults in cases of nondisplaced fractures at an
average of 7 weeks postfracture (range 2 weeks to
11 months) [11], with an incidence reported from
0.3% [13] to 3% [11,12]. The mechanism of
rupture has been suggested to be attrition of the
tendon held in the closed third compartment over
the enlarging healing bone and vascular compro-
mise. Rupture has been reported in children as
young as 12 [14,15]. Diagnosis is usually made
after rupture, but Skoff [12] has described di-
agnosing and treating prerupture cases of tendon-
itis with release of the third dorsal compartment
in patients who have persistent dorsal wrist pain
and a retroflexion sign. Because direct repair is
usually not possible, treatment can consist of
either extensor indicis proprius tendon transfer
or interposed graft [12,13].
Tendonitis of the first dorsal compartment and
of the extensor carpi ulnaris (ECU) is also seen
following distal radius fractures. First dorsal com-
partment tendonitis can usually be treated with
steroid injection. ECU tendonitis must be differen-
tiated from an underlying triangular fibrocartilage
tear or other injury to the ulnacarpal ligamentous
complex. Steroid injection is usually effective for
acute ECU tendonitis.
Complications of percutaneous and external
fixation
Percutaneous fixation of distal radius fractures
can result in nerve injury and irritation, tendon
injury and irritation, infection, and loss or re-
duction with malunion [16–18]. Percutaneous pin
fixation has the greatest risk of loss of reduction in
older individuals and fractures with comminution
involving greater than 50% of the metaphyseal
diameter [18]. Crossed percutaneous pinning in
the Kapandji style has been shown in a random-
ized trial by Strohm and coworkers [54] to have
a lesser risk of collapse than pinning through the
radial styloid alone. The addition of external
fixation to percutaneous pinning can reduce the
299
incidence of loss of reduction, but adds the risks
of additional complications such as pin site
fracture, radial nerve injury, carpal tunnel syn-
drome, complex regional pain syndrome, intra-
carpal ligament injury, and digital stiffness. [19].
Risk of loss of reduction with external fixation can
be reduced by the use of bone graft or graft
substitute in metaphyseal defects [55]. The addi-
tion of arthroscopic evaluation can provide great-
er accuracy in the restoration of the recommended
less than 1 or 2 mm of articular step-off than
fluoroscopy alone, reducing the potential for
future arthritis [56,57]. If relying on fluoroscopic
imaging alone to assess articular step-off, obtain-
ing a posteroanterior (PA) image parallel to the
joint surface is helpful, as is the tilted lateral view
suggested by Lundy and associates [58].
The nerve at greatest risk of injury from
percutaneous pin fixation and external fixation
of the distal radius is the dorsal sensory branch of
the radial nerve. Both the anatomic location of the
nerve (exiting from underneath deep fascia be-
tween the brachioradialis and the extensor carpi
radialis longus) and its tightly tethered nature,
which gives it little slack for sliding over closely
placed implants, put the dorsal sensory branch of
the radial nerve at risk of injury and irritation
from radial placed pins [59]. Damage to the dorsal
sensory branch of the radial nerve can be avoided
from the proximal radial pin sites by using an
open approach to pin placement (Fig. 7). At the
Fig. 7. Injury to the dorsal sensory branch of the radial
nerve (seen here volar and below the external fixator
pins) can be prevented when applying external fixators if
an open proximal incision is used to identify the radial
nerve as it surfaces between the brachioradialis and
extensor carpi radialis longus. Placing the pins between
the extensor carpi radialis longus and extensor carpi
radialis brevis tendons can decrease risk of injury to the
nerve.
300 GUTOW

level of the radial styloid, making a small incision
and spreading to bone can reduce the risk of direct
injury to a distal branches.
When applying an external fixator, overdis-
traction of the carpus and placement of the wrist
in a nonfunctional position of extreme flexion and
ulnar deviation should be avoided (Fig. 8) [45].
Overdistraction of the carpus via external fixation
is thought to be a risk factor for complex regional
pain syndrome. Positioning of the wrist in ex-
tremes of flexion and ulnar deviation can also lead
to digital stiffness because of poor mechanical
function of the extrinsic flexor muscles, and to
carpal tunnel syndrome with the potential for
secondary complex regional pain syndrome. Re-
duction should be maintained not by extreme
flexion, but by supplemental Kirschner wire fixa-
tion, or the palmar translocation described by
Agee and colleagues [45]. One should be careful,
however, of applying too much palmar trans-
location, because this can create an abnormal
volar midcarpal translocation. Holding the index
finger MCP joint fully flexed while applying the
fixator pins to the second metacarpal can prevent
soft-tissue tethering from blocking index finger
MCP flexion postoperatively. An immediate post-
operative rehabilitation program also prevents the
development of digital, elbow, and shoulder
stiffness in all patients (Fig. 9). Superficial pin
site infections have been a common complication
of percutaneous pin fixation and external fixation.
For Kirschner wires, infection rates of 34% for
wires left out of the skin and 7% for buried wires
have been reported [17]. For external fixators,
incidences of pin tract infections from 21% to
37% have been reported [4,19]. Despite these high

Fig. 8. A 32-year-old farmer fell off his grain silo and suffered bilateral closed distal radius fractures with significant
dorsal dislocation and displacement on the left side, seen here (A,B). Initial treatment was with external fixation and
pinning in an extreme flexed position (C). The patient subsequently presented for re-evaluation with median nerve
paresthesias. Adjustment of his external fixation to a more neutral position was performed, along with an extensile carpal
tunnel release showing the hourglass and bruised median nerve (D). At 8 months follow-up, median sensory function had
returned.
 DISTAL RADIAL FRACTURE COMPLICATIONS 301

Fig. 9. A 76-year-old was treated with external fixation in slight flexion and pinning of a displaced distal radius fracture.
Early digital ROM (A,B) as well as forearm, elbow, and shoulder motion (C) was instituted. Placement of the distal
external fixator pins in the metacarpal with the MCP joints fully flexed can prevent tethering of the extensor tendons to
the radial fingers, which can limit early digital flexion.

superficial infection rates, deep osteomyelitis has
rarely been reported as a complication of external
fixation; however, it is recommended to leave
percutaneous Kirschner wires in place for no
longer than 8 weeks [19]. When combining
Kirschner wires with other internal fixation plates,
the wires should be buried because percutaneous
wires can serve as a bacterial pathway to the deep
implant.
Ulnar-sided wrist instability following distal
radius fracture due to triangular fibrocartilage
tears can lead to poorer long term outcome [60]. A
conscious check of distal ulnar joint stability
should be performed following radius fixation,
and repair of the triangular fibrocartilage complex
performed if needed [38].
Complications of internal fixation
Rigid internal fixation has advantages of de-
creased risk of loss of reduction and earlier mobili-
zation, with the trade-off of risk of soft-tissue
302 GUTOW

damage from the surgery and the plates, with

complications including nerve injury, nerve irrita-
tion, tendon rupture, intra-articular screw place-
ment, compartment syndrome, and infection.
Although the risk of deformity-induced carpal
tunnel syndrome is lower with internal fixation,
late neuropathy of the median nerve has still been
reported with an incidence of up to 6% following
internal fixation [3]. Dorsal plating with full-sized
plates has a high incidence of extensor tendon
irritation and tendonitis requiring later plate
removal [3,20–22]. Use of smaller fragment-spe-
cific dorsal plates, as discussed by Bae and Koris
[61] and Tavakoloan and Jupiter [62], has a lower
incidence of tendon irritation. Fragment-specific
plating on the dorsal radial aspect of the radius
along the radial styloid risks irritation and injury
to the dorsal sensory branch of the radial nerve
(Fig. 10), with painful scarring around the radial
nerve occasionally occurring [23]. Volar plating
generally has a lower risk of tendon irritation and
injury than dorsal plating, but injury to the radial
artery and the palmar cutaneous branch of the
median nerve may occur during implantation.
Loss of the sensation in the distribution of the
palmar cutaneous branch has been seen following
volar plating. This risk of injury may be increased
in cases in which the volar approach of Henry is
extended distally across the path of the palmar
cutaneous branch to the palm to perform a carpal
tunnel release. The distal volar radius (DVR)
plate designed by Orbay, which sits flush to the
volar radius and does not reach the volar margin
of the radius, has low reported incidence of flexor
tendon irritation [63]. Other volar plate designs
with more prominence and distal location have
Fig. 10. Placement of a plate over the dorsal radial
aspect of the wrist, such as the radial spring plate in this
fragment-specific fixation system, can result in irritation
or injury to the dorsal sensory branch of the radial
nerve.
an incidence of flexor pollicis (FPL) rupture of
up to 12%, as reported by Drobetz and Kutscha-
Lissberg [24].
Compartment syndrome following internal
fixation of distal radius fractures is a rare com-
plication, most likely related to tissue damage and
swelling from the initial high-energy injury being
aggravated by the second insult of surgery [3].
Treatment requires early diagnoses and complete
release of the forearm and median nerve, in-
cluding the carpal tunnel [31]. Closure can be
done early with skin grafting (see Fig. 2), or via
delayed primary closure performed 7 to 14 days
after the release [6].
Infection following internal fixation of distal
radius fractures has rarely been reported [3], but

Fig. 11. A 42-year-old woman suffered a closed distal radius fracture in a fall. This was initially treated with open
reduction internal fixation, with development of an early infection that required removal of the internal fixation
hardware and external fixation. A shortened malunion was achieved, with treatment of the infection with local antibiotic
beads (A). Repeat debridement and culture before osteotomy, bone grafting, and internal fixation were performed, which
demonstrated a deep sequestrum in the radius (B).
 DISTAL RADIAL FRACTURE COMPLICATIONS
does occur (Fig. 11). Treatment should be focused
first on obtaining union and then on eradication of
the infection, with maintenance of internal hard-
ware until union if possible. If the infection cannot
be controlled with washout and suppressive anti-
biotics, then the internal hardware can be removed,
with conversion to spanning external fixation.
Summary
The treatment of distal radius fractures con-
tinues to be fraught with complications. The more
widespread use of internal fixation and supple-
mental bone grafting with external fixation has
decreased the incidence of malunions from closed-
cast treatment and percutaneous pinning, but
increased the risk of the complications specific to
surgical intervention. Careful diagnosis, surgical
planning, surgical technique, and postoperative
rehabilitation can help optimize outcome in these
difficult fractures.
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 Hand Clin 21 (2005) 307–316
Closed Manipulation and Casting of Distal
Radius Fractures
Diego L. Fernandez, MD
University of Bern, Department of Orthopaedic Surgery, Lindenhof Hospital, CH-3012, Bern, Switzerland
Given that most epidemiologic studies [1–5] on
fractures of the distal radius have combined
several different fracture patterns, it is still difficult
to assess the real incidence of extra-articular and
intra-articular injuries, and it is even more com-
plex to appreciate the occurrence of stable and
unstable fracture types. For this reason it is
impossible to produce an accurate estimate on
the overall percentage of distal radius fractures
that can reliably be treated conservatively. In an
exhaustive review of 2,141 fractures McQueen [5]
using the AO classification identified 1,029 extra-
articular (type A) fractures accounting for 48% of
the population, 219 (10%) partial articular frac-
tures (type B), and 893 (42%) complete articular
fractures (type C). Of the extra-articular group
(48%) 15% were minimally displaced (A2.1
types), and therefore theoretically amenable to
cast immobilization, whereas the most common
fracture pattern was the dorsally displaced with
dorsal metaphyseal comminution (A3.2 types,
26%). This group most probably included the
more unstable fracture patterns, for which cast
treatment is usually contraindicated.
In view of the current overwhelming sophisti-
cation of surgical management of distal radius
fractures with predictable outcomes, it has be-
come difficult for the younger generation to
recognize which fracture types may be treated
with a classic closed reduction and plaster immo-
bilization and still guarantee a good functional
result. It is important to keep in mind that to
achieve anatomic results with conservative treat-
ment, the surgeon must possess the same or even
better technical abilities when applying a plaster
E-mail address: diegof@bluewin.ch
0749-0712/05/$ - see front matter Ó 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.hcl.2005.02.004
cast than those needed to perform external or
internal fixation of a wrist fracture. Conservative
fracture treatment is more cumbersome, because
frequent radiographic and clinical controls and
possible cast changes are necessary to assess the
quality of reduction and to prevent secondary
displacement or detect misdiagnosed unstable
fracture patterns that may require early secondary
external or internal stabilization. To a certain
extent this may explain why many fractures that
perhaps would heal in a cast in an acceptable
position are primarily over-treated with external
or internal fixation just to eliminate the risk for
secondary displacement in a cast. Furthermore, in
patients who demand early use of the hand, some
distal radius fractures that may fall into the
category of displaced but stable are fixed in-
ternally but would otherwise be amenable to
cast treatment.
The basic decision that has to be taken when
dealing with a distal radius fracture is whether or
not it can be treated conservatively (closed manip-
ulation and cast immobilization) or surgically.
Several factors, such as age, bone quality, occupa-
tion, and general condition of the patient, together
with characteristics of the fracture, associated
lesions, and the surgeon’s experience with different
treatment modalities, must all be taken into con-
sideration to select the best treatment. Although
occasionally a fracture that, because its character-
istics represent an absolute surgical indication, has
to be treated in a cast because of the bad general
condition of the patient, the basic parameters to
decide for a conservative management are whether
or not the fracture is reducible with closed manip-
ulation and if it remains stable after reduction; in
other words, those fractures in which the tendency
to re-displace in plaster is minimal.
hand.theclinics.com
308 FERNANDEZ

The aims of conservative treatment are to

obtain and maintain anatomic realignment of
the fracture for a period of 4 weeks, the time at
which bony union is well advanced, so that the
risk for secondary displacement at that stage is
practically nonexistent. It must be kept in mind,
however, that contrary to skeletal fixation by
a bridging implant that controls interfragmentary
motion, the position of the distal fragment is
maintained indirectly by external cast contact,
tension on soft tissue structures, and by the
hydraulic pressure of the soft tissue envelope.
The greater the initial displacement, cortical
comminution, and cancellous bone impaction,
the greater the amount of settling of the fracture
in the cast is therefore to be expected, despite the
use of a meticulous casting technique.

Indications for conservative treatment

Conservative treatment of distal radius frac-
tures in adults is recommended and reliable for
nondisplaced extra-articular and intra-articular
fractures, for displaced fractures that remain
stable following closed reduction, and certain
unstable fractures in elderly patients, in which
the surgeon accepts the possibility of a tolerable
amount of secondary displacement, which falls in Fig. 1. Natural history of an unstable extra-articular
the category of an asymptomatic, well functioning dorsal bending fracture. (A) Initial anteroposterior and
malunion. lateral radiographs demonstrate wide displacement of
the distal fragment. The radiographs fail to depict
The decision making for nonoperative man-
accurately the comminution of the dorsal metaphyseal
agement is based on a large body of clinical and cortical and cancellous bone. (B) Initial AP and lateral
experimental evidence [6–15] that has demon- radiographs following fracture reduction and plaster
strated a strict correlation between the quality of immobilization. (C) As early as 1 week after reduction
reduction, the radiographic result, and the func- the radiographs demonstrate loss of reduction with the
tional outcome and also on the analysis of the distal fragment beginning to displace in a dorsal and
radiographic criteria of instability [16,17]. Frac- radial direction. (D) At 6 weeks after fracture it has
tures that show on initial radiographs more than nearly returned to its original position. (E) At 8 weeks’
20( of dorsal (or palmar) angulation, a displace- postinjury extreme displacement has occurred with
ment of more than two thirds the width of the deformity involving the radiocarpal and radioulnar
articulations.
shaft in any direction, metaphyseal comminution,
more than 5 mm of shortening, intra-articular
component, an associated ulnar fracture, or ad-
vanced osteoporosis are considered unstable, with angulation less than 5( and shortening less than
a high risk for secondary displacement in a cast, 2 mm (Fig. 2).
despite acceptable initial reduction and correct
plaster techniques (Fig. 1). On the other hand,
stable fractures are those that do not displace at Conservative management
the time of presentation or following manipulative
Nondisplaced fractures
reduction [18–21]. Abbaszadegan et al [22] defined
stable extra-articular fractures as those present- Bending fractures of the distal radius that
ing with minimal displacement having dorsal present with little or no displacement result in
 DISTAL RADIUS FRACTURES: CLOSED MANIPULATION, CASTING
the great majority of cases with an excellent
functional outcome and have a long-term favor-
able prognosis [23–26]. Fractures with minimal
displacement (5( of dorsal tilt and shortening less
than 2 mm) or impacted fractures are stable even
when supported with elastic bandages rather than
plaster casts (Fig. 2). The author, however, prefers
to immobilize them for a period of 3–4 weeks in
a dorsal splint or a well molded below-elbow cast
followed by a removable wrist brace until the
patient feels comfortable, usually 5–6 weeks
following injury. One complication that seems to
be uniquely associated with nondisplaced distal
radius fracture is the spontaneous rupture of the
extensor pollicis longus tendon [27–29]. Most of
these ruptures occur within the first 2 months after
the fracture, their etiology attributed to attrition
and hypovascularity of the tendon at the level of
Lister’s tubercle.
Displaced fractures
Closed reduction is indicated for displaced
fractures in which there is radiographic evidence
that a stable realignment of the fracture fragments
can be achieved and that the minimal residual
Fig. 2. (A) Minimally displaced dorsally impacted distal radius fracture. (B) No reduction necessary, dorsal plaster splint
support. (C) Radiographs at 5 weeks showing fracture healed in the initial position.
309
interfragmentary motion can be controlled with
meticulous casting technique.
Adequate anesthesia, depending on the local
soft tissue conditions, is imperative. Fracture
hematoma block, intravenous regional, brachial
plexus block, and general anesthesia have specific
indications. The first two usually are selected for
low energy displaced fractures without significant
swelling.
With dorsally displaced fractures, the author
prefers to infiltrate the fracture site following
aspiration of the hematoma with 5–10 cm of 1%
or 2% Lidocaine without epinephrine, with the
point of entrance of the needle on the volar side,
because the dorsally impacted cortex may not
always permit the needle to enter the fracture site
easily. A second injection is recommended in the
area of the distal radioulnar joint and ulnar
styloid. The two most common disadvantages of
the fracture hematoma block are insufficient
analgesia and muscle relaxation. For these rea-
sons fracture hematoma block should be reserved
for simple, readily reducible fracture patterns.
Axillary blocks are indicated especially if a difficult
reduction is anticipated, as in fractures seen late,
in re-manipulations, and in instances in which
local skin and soft tissue contusions or open
310 FERNANDEZ
wounds and significant edema contraindicate the
use of local anesthesia. General anesthesia is
reserved for pediatric fractures or for patients
allergic to local anesthetics.
Methods of closed reduction
Reduction of displaced fractures of the distal
radius has been based on two approaches: (1)
direct manipulation of the fracture fragments, and
(2) indirect fracture reduction with longitudinal
traction.
Manual reduction
The technique of direct manipulation of the
fracture with disimpaction of the distal fragment
before reduction has been attributed to Sir Robert
Jones [30]. It requires an assistant to provide
countertraction on the arm above the elbow
(Fig. 3). The first step is to disimpact the fracture
by increasing the initial deformity. Reduction then
is obtained with the opposite force to the one
responsible for the fragment displacement (mech-
anism of injury). For Colles fractures, therefore,
while traction is maintained the surgeon manipu-
lates the distal fragment into a volar and ulnar
direction with the opposite hand applying coun-
terpressure on the shaft fragment. The final
maneuver is to lock the fracture by placing the
patient’s hand and distal fragment into pronation.
The hand thereafter is allowed to rest without
support to assess the stability of the reduced
fracture clinically. Smith fractures, which present
with increased volar tilt, shortening, and pro-
nation of the distal fragment, are reduced with
Fig. 3. Technique of manipulative reduction of dorsally
displaced extra-articular bending fractures. (A) The
surgeon uses both hands to stabilize the forearm,
hand, and wrist while the fracture deformity is increased
by extending the wrist. (B) While traction is maintained,
the distal fragment is manipulated in a volar and ulnar
direction. (C) The fracture is locked in place, and (D) the
patient’s hand and fracture fragment is rotated into
slight pronation.
longitudinal traction, extension, and supination
maneuvers.
Longitudinal traction
This technique, initially popularized by Böhler
[31,32] during the 1920s, is based on strong
longitudinal traction applied to the patient’s
thumb and digits against a fixed and flexed elbow,
while the fracture is manipulated directly by the
surgeon. This method, which requires at least one
assistant but often two, was simplified by the
introduction of metallic finger traps by Caldwell
in 1931 [33]. The hand now could be suspended
with a counterweight over the upper arm, pro-
viding continuous longitudinal traction without
the need of assistants (Fig. 4). Although length,
distal radioulnar congruency, and ulnar inclina-
tion are invariably achieved, restoration of volar
tilt requires an additional palmarly directed force
by translating the hand volarly, as advocated by
Agee [34]. This displaces the capitate palmarly,
which in turn volarly rotates the scaphoid and
lunate, effectively forcing the distal fragment into
flexion (Fig. 5). A similar observation was re-
ported by Gupta in 1991 [35], in which, with
careful modeling of the cast with the wrist in
neutral or slight extended position, the same effect
was obtained with a low incidence of fracture re-
displacement. Agee [36] further advocated radio-
ulnar translation to realign the distal fragment
with the radial shaft in the frontal plane. This is
controlled by tension on the soft tissue hinge of
the first and second dorsal compartment. For
adequate reduction in the frontal plane it is
important to restore the anatomic relationship
of the sigmoid notch and the ulnar head. The
application of a dorsopalmar reduction force to
restore volar tilt should be kept in mind, because
it offers better anatomic restoration with immo-
bilization of the hand in a more physiologic and
functional position.
Cast immobilization
Despite the widespread acceptance of cast
immobilization, questions remain regarding the
optimal position, the duration of immobilization,
and the need to extend the cast above the elbow.
Having reduced the fracture, the author prefers to
immobilize initially all distal radius fractures in
a sugar tong splint that is maintained for the first
2–3 weeks (Fig. 6). Its advantages are that the
splint is applied easily while the upper extremity is
 DISTAL RADIUS FRACTURES: CLOSED MANIPULATION, CASTING 311

Fig. 4. (A) Finger trap-traction with the hand suspended and counterweight around the upper arm. Notice C-arm for
fluoroscopic control. (B) Following disimpaction through continuous traction the distal fragment can be manipulated
easily into the desired final position.

still suspended with the finger trap traction, and as
the cast sets, the hand can be translated palmarly
and placed in the definitive position of immobili-
zation. Because the U part of the splint comes
around the elbow, the sugar tong controls forearm
rotation and therefore efficiently maintains the
desired position of pronation or supination ac-
cording to the fracture type. Furthermore, the
sugar tong splint immobilizes the distal radioulnar
joint, and patients have less pain as compared
with those immobilized in a short arm cast.
Colles fractures are immobilized initially in
15( of palmar flexion, 10(–15( of ulnar devia-
tion, and slight pronation (25() for the first 2
weeks. To maintain a stable reduction it is
imperative to follow the details of the three-point
contact casting technique described by Charnley
[37] (Fig. 7). This implies the application of two
points of contact proximally and distally to the
fracture on the side of the concavity of the initial
angulation, and a counterpoint of contact at the
fracture level on the convexity of the initial
angulation. A slight bend to the splint or cast
(10(–15( and slight ulnar deviation) places the
soft-tissue hinge (periosteum and overlying
tendons) under tension, provided that the oppo-
site cortex has good contact (tension-band prin-
ciple). For a Colles type fracture, the counterpoint
or fulcrum (definition: point on which a lever
turns) is the volar cortex (Fig. 8). If reduction of
the volar cortex is anatomic without overlapping
of the fracture edges and the dorsoradial soft
tissue hinge is maintained under tension, the
chances of secondary displacement are minimal.
With increasing osteoporosis, however, a greater
amount of settling and shortening is to be
expected.
For the first 2 weeks the sugar tong splint is
maintained and follow-up radiographs are per-
formed 3, 7, and 12 days following reduction; this
enables detection of early loss of reduction and
whether or not settling and residual deformity is
acceptable. During the first 2 weeks the initial
splint should be adapted and remolded as soon as
soft tissue swelling decreases. This is achieved with
tighter wrapping of the splint with elastic ban-
dages at the time of the radiographic controls. In
this way a continuous and sufficient pressure
is maintained throughout the early postreduc-
tion period, reducing the possibility of secondary
312
Fig. 5. (A) Longitudinal traction with finger traps can
restore skeletal length. (B,C) Restoration of the normal
volar tilt of the distal radius articular surface, however,
may require palmar translation force of the mid-carpus.
(Courtesy of Hand Biomechanics Lab, Sacramento,
California; with permission)
displacement. At 2 weeks the splint is changed to
a short forearm cast for another 3–4 weeks, taking
care to maintain the three-point contact principle,
avoiding bulky padding of the cast.
Smith (or reversed Colles fractures) require
20( of dorsiflexion and 40( of supination to
maintain a stable reduction. Because the prona-
tory deformity of the distal fragment is always
present, above-elbow fixation to control forearm
Fig. 6. Technique of application of the sugar tong
splint. Notice minimal padding using thin layer of felt.
The splint is wrapped with elastic bandages while the
cast begins to set.
FERNANDEZ
Fig. 7. Schematic representation of the three-point
contact cast. If the volar cortex is reduced perfectly
(compression side), the dorsoradial soft tissue hinge is
maintained under tension with slight flexion and ulnar
deviation of the hand.
rotation is mandatory for the first 4 weeks
(Fig. 9).
Duration of immobilization
Most well reduced extra-articular fractures
heal by 4–5 weeks after injury [38]. Wahlström,
using 99Tc bone scans, observed well advanced
new bone formation by 28 days after injury. He
suggested that little additional immobilization is
required beyond this point [39]. In contrast,
Kristiansen et al observed early trabecular healing
39  2 days after fracture, with initial cortical
bridging at 50  3 days [40].
In the author’s experience, impacted and
minimally displaced fractures should be immobi-
lized for 3–4 weeks, and displaced fractures with
increasing comminution for 6 weeks (2–3 weeks in
a sugar tong and 3–4 weeks in a short arm cast)
(Fig. 10). Thereafter a protective removable wrist
orthesis is worn by the patient for an additional
month while active range of motion exercises are
begun. During that month the patient is weaned
progressively from the brace.
During the period of immobilization and also
during the period of weaning from the splint, all
patients are instructed to keep their fingers mo-
bile by performing the six-pack exercises as
 DISTAL RADIUS FRACTURES: CLOSED MANIPULATION, CASTING 313

Fig. 8. (A) Dorsally displaced extra-articular bending fracture with dorsal metaphyseal comminution. (B) A good
reduction was obtained in axillary block anesthesia. Notice anatomic reduction of the volar cortex. (C) At 12 days,
reduction is stable and a short cast was maintained for 6 weeks. (D) Roentgenograms at 6 weeks showing the fracture
healed with minimal dorsal settling and shortening. (E) Follow-up radiographs at 1.6 years reveal a remodeled fracture
in acceptable position. The patient had pain-free full wrist range of motion.

popularized by Dobyns [41] and by active elbow Summary

and shoulder mobilization at least three times
Closed reduction and cast treatment of distal
a day. Physiotherapy measures are indicated
radius fractures renders satisfactory results in
solely for those patients who have trouble re-
fractures that are reducible and stable and do
storing joint motion and forearm rotation follow-
not re-displace in plaster in the first 2 weeks
ing cast removal.
314 FERNANDEZ

Fig. 9. (A) Smith fracture with metaphyseal comminution and rotational malalignment. (B) Roentgenograms following
anatomic reduction that was maintained for 6 weeks in an above-elbow cast with the hand in dorsiflexion and mid-
supination (bottom). (C) Radiographs at 3 months show an excellent radiographic result.

following reduction [10,12]. Intra-articular and
unstable fractures have a high risk for re-displace-
ment in plaster [11] and therefore represent
a contraindication for cast treatment. A fracture
that re-displaces in plaster despite perfect casting
technique is most probably an unstable type that
requires skeletal fixation. A fracture that re-
displaces in a non-molded, loose, or over-padded
cast because of insufficient technique is, however,
in the author’s view, the only clinical situation in
which re-manipulation is worth the effort [8].
The tolerable amount of residual deformity has
been radiographically defined by Fourrier et al in
an analysis of 64 malunions of the distal radius
and correlated the functional impairment with the
residual deformity of the distal radius. They
concluded that the lower limits of deformity, at
which symptoms are likely to be present, are
 DISTAL RADIUS FRACTURES: CLOSED MANIPULATION, CASTING 315

Fig. 10. (A) Radiographs before and after closed reduction of a dorsally displaced distal radius fracture. Notice flexion
and ulnar deviation of the wrist. (B) At 4 weeks the wrist was brought to neutral position with careful dorsal molding of
the cast. (C) Fracture healed at 6 weeks showing perfect restoration of the wrist anatomy.

a radial deviation of 20(–30(, a sagittal tilt of
10(–20(, and a radial shortening of 0–2 mm [42].
In addition, experimental evidence suggests that
a sagittal tilt of 20(–30( should be viewed as
a pre-arthrotic condition [13,14,43]. Although
these figures are useful for decision making,
acceptance of deformity when treating fractures
conservatively varies individually according to
the age, osteoporosis, and functional demands
of the patient. Anatomic restoration, however,
should remain the primary goal of conservative
management.
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 Hand Clin 21 (2005) 317–328
Treatment of Distal Radius Fractures with Intrafocal
(Kapandji) Pinning and Supplemental Skeletal
Stabilization
Wayne M. Weil, MD, Thomas E. Trumble, MD*
Division of Hand and Microvascular Surgery, Department of Orthopaedic Surgery, University of Washington,
Harborview Medical Center, Box 356500, Seattle, WA 98195-6500, USA
Fractures of the distal radius account for one
sixth of all fractures seen and treated in emergency
rooms [1]. These fractures are the most common
fracture occurring in adults, yet there is no clear
consensus on their management [2–8]. The goal of
treatment is to restore congruity to the radio-
carpal and distal radio-ulnar joint surfaces and to
restore and maintain the length of the radius
[9,10]. When stable, extra-articular fractures and
minimally displaced intra-articular fractures have
been treated successfully with closed reduction
and cast immobilization [11,12]. Many surgical
techniques are used to fix unstable distal radius
fractures, including percutaneous pinning, exter-
nal fixation, and plate fixation. The goal of
surgical treatment of distal radius fractures is
early restoration of hand and wrist function
through the restoration of alignment and articular
surface congruity.
Healing without malunion reduces the limita-
tion of motion and arthrosis of the radiocarpal
joint and the distal radioulnar joint. The distal
radioulnar joint is the most likely site of symp-
toms when an extra-articular malunion of the
radius is present [13–17]. Although cast immobi-
lization alone avoids surgery and complications
related to pin placement and pin removal, casts
cannot maintain distraction to correct length or
control the rotation of the distal fragment when
* Corresponding author.
E-mail address: trumble@u.washington.edu
(T.E. Trumble).
0749-0712/05/$ - see front matter Ó 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.hcl.2005.01.006
comminution is present [11,16,18–20]. Intrafocal
pinning using the percutaneous technique de-
scribed by Kapandji provides control of distal
fragment rotation and length [5,21–23]. Intrafocal
pinning is defined as the insertion of pins into the
fracture site that can be used to lever the
displaced distal fragment into position. Once
adequate reduction is achieved, the pins are
driven into the metaphysis of the proximal
fragment of the radius. The pins act to buttress
the distal fragments while maintaining fracture
reduction. Distal radius fractures with significant
comminution may also require supplemental skel-
etal stabilization to preserve the length of the
radius. Supplemental skeletal stabilization in-
cludes external fixation and internal spanning
bridge plate techniques. This article reviews the
current literature, describes surgical technique,
and summarizes the University of Washington
Medical Center and Harborview Medical Center
experience with percutaneous fixation of distal
radius fractures.
Review of the literature
The goal of treatment of extra-articular
distal radius fractures
Clearly, the goal of treatment is not only to
heal these fractures but also to achieve patient
satisfaction with the functional result. Patient
satisfaction correlates best with pain relief and
grip strength rather than range of motion [5].
There is both clinical and biomechanical evidence
that the hand surgeon must restore the length of
hand.theclinics.com
318 WEIL & TRUMBLE

the radius and at least partially correct the palmar
tilt and the radial inclination [10,13,16,24–35].
Biomechanical studies have demonstrated that
dorsal angulation of the articular surface of the
radius increases the load concentration of the
scaphoid and lunate contact areas, and loss of
the radial inclination is associated with increased
load on the lunate contact area [34,35]. The
assumption is that these increased loads on the
articular surface of the radius will correlate with
the early onset of degeneration of the radiocarpal
joint. Clinical studies have not been able to
associate palmar tilt and radial inclination with
patient outcome as clearly as the loss of radial
length. However, patients with painful malunions
usually have a combined dorsal tilt of 15  and
a radial inclination of less than 10  , which results
in a loss of radius length from a geometrical
standpoint as well as a loss of radial length of
greater than 2 mm [18,34,36–39]. Correction
of radial length resulted in substantial return of
function and an increased likelihood of return to
work, pain relief, and range of motion. The
correction of both radial length and inclination
results in the optimal functional outcome [5].
Studies have also shown that early range of
motion does not significantly contribute to better
long-term functional outcomes [40,41].
Intrafocal pin fixation of extra-articular
distal radius fractures
Nonnenmacher and Neumeier noted that 92%
of their patients subjectively had good results,
99% by objective criteria, although they did not
list their criteria [42]. Kapandji and Hoel noted
that the results were uniformly excellent by sub-
jective criteria, even for Smith’s type fractures and

Fig. 1. (A) A dorsal Kirschner wire is inserted using a power wire drive near Lister’s tubercle avoiding the extensor
pollicis longus tendon. (B) The loss of palmar tilt is corrected using the wire as a lever. (C) The dorsally inserted wire is
driven across the volar cortex to maintain the reduction of the palmar tilt. (D) Loss of radial inclination is corrected
using a Kirschner wire inserted into the fracture site using a power wire driver. (E) The Kirschner wire is then used as
a lever to correct the loss of radial inclination and radial translation of the distal fragment. (F) The wire is driven across
the cortex of the radius proximal to the fracture site. Distally, the wire acts like a buttress to maintain the reduction.
 INTRAFOCAL PINNING & SUPPLEMENTAL SKELETAL STABILIZATION 319

Fig. 1 (continued )

volar Barton’s fractures [21,22,43]. However,
another study found that the results of intrafocal
pinning were not any better than trans-styloid
pinning of distal radius fractures [44]. Trumble
and colleagues [5] showed that intrafocal pinning
in patients under 55 years of age with
comminution of a single cortex would yield
a 96% chance of a good and excellent result
when combined with casting for treatment of
extra-articular distal radius fractures.
320
Fig. 2. By using the interval between the extensor carpi radialis brevis and extensor carpi radialis longus for insertion of
the pins, injury to the sensory branch of the radial nerve can be avoided.
Intrafocal pinning with cast immobilization
or external fixation
Some reports have indicated that pin fixation
without cast immobilization is sufficient for the
treatment of displaced distal radius fractures
[21,22,39]. Lenoble and colleagues [44] prospec-
tively compared trans-styloid fracture pinning and
cast immobilization to the intrafocal or Kapandji
technique without immobilization and found
a greater incidence of reflex sympathetic dystro-
phy in the group treated with the Kapandji pins.
Intrafocal pinning in older patients
Three studies have found that elderly osteopo-
rotic patients treated with intrafocal pinning alone
did not have good results [5,23,42]. Intrafocal
pinning alone in this patient population does not
WEIL & TRUMBLE
maintain radial length and leads to poor outcome
[5].
External fixation of distal radius fractures
External fixations of distal radius fractures
differ from that used on long bones because the
device is applied across the radiocarpal joint so
that ligament tension, or ligamentotaxis, is re-
quired to maintain fracture alignment [45–49].
This is based on Vidal’s theory of ligamentotaxis,
in which reduction is obtained and maintained
through distraction forces working on capsuloli-
gamentous structures attached to the fracture
fragments [49]. The effectiveness of external fixa-
tion in the treatment of distal radius fractures has
been reported in multiple prospective studies, with
acceptable healing rates ranging from 78% to
92% [32,36,50–58].
 INTRAFOCAL PINNING & SUPPLEMENTAL SKELETAL STABILIZATION 321

Fig. 3. (A) Posterior–anterior view demonstrating an extra-articular fracture that is extremely comminuted with
extensive shortening and collapse of the fracture. (B) Using an intrafocal pinning and an external fixation device, the
length and alignment of the radius is restored along with the alignment of the distal ulna.

Treatment algorithim fractures are treated with open reduction and

Upon initial presentation, a closed reduction is
performed in the emergency room and held in
a ‘‘sugar tong’’ plaster of paris splint. Reduction
adequacy is judged using parameters described
previously [37]. If the fraction pattern is deemed
stable and reduction is maintained, the fraction is
treated by closed means. If the reduction cannot
be maintained, then operative intervention is
undertaken. Unstable displaced extra-articular
fractures and nondisplaced intra-articular frac-
tures can be treated with closed reduction and
percutaneous fixation. Displaced intra-articular
internal fixation to restore joint congruity.
Surgical technique
Indications
Distal radius fractures with persistent extra-
articular displacement despite closed reduction,
including fractures with a nondisplaced intra-
articular component can be treated with closed
reduction and percutaneous pinning as initially
described by Kapandji [21,22]. Persistently
322
Fig. 4. (A) Skin incisions for the placement of an internal spanning plate. (B) The interval between the extensor carpi
radialis longus and extensor carpi radialis brevis is developed to expose the cortex of the radius. The index metacarpal is
also exposed. (C) The plate is inserted into the proximal incision and slid down supra-periosteally, underneath the
extensor tendons. (D) The plate is affixed to bone using a combination of nonlocked and locked screws.
displaced fractures are defined as fractures that
demonstrate greater than 15  of dorsal angulation,
less than 15  of radial tilt or more than 2.0 mm
of radial shortening after closed reduction.
Previous experience has demonstrated that dorsal
angulation of the distal fragment is associated
with comminution of at least one metaphyseal
surface [10].
Radiographic evaluation
Radiographs in the posterior–anterior, pro-
nated oblique, and lateral positions are obtained
before fracture reduction and after reduction and
splinting. Measurements are then made of ulnar
variance, radial inclination and palmar tilt to
determine whether acceptable reduction has been
achieved. Posterior–anterior radiographs should
be obtained using the standard zero rotation view
to accurately assess ulnar variance [38].
Surgical technique
After adequate anesthesia is achieved, a closed
reduction is performed. The reduction is main-
tained with 5 to 10 lbs. of finger trap traction. The
reduction is then assessed using fluoroscopy in
both the anterior–posterior and lateral planes. A
small incision is made at the site of pin insertion,
and the tissue protector for the 1.5-mm drill
(Synthes, Inc., Paoli, Pennsylvania) is used to
prevent injury to the sensory branches of the
WEIL & TRUMBLE
radial nerve. Kirschner wires (0.062 inch) are used
as the intrafocal pins. The pins required to correct
radial inclination are driven into the radial cortex,
and pins required to correct dorsal tilt are driven
into the dorsal cortex. The pins are then levered to
redirect them proximally before driving them
across the opposite cortex in both the posterior–
anterior plane and in the lateral plane (Fig. 1).
Dorsal rotation is corrected first. Three to four
pins are usually required. Loss of radial inclina-
tion and/or radial translation are corrected with
one to three 0.062-inch Kirschner wires using one
pin placed between the first and second compart-
ment, one just dorsal to the second compartment,
and one placed into Lister’s tubercle, taking care
to avoid the extensor pollicis longus. In most
cases, the Kirschner wires are buried underneath
the skin. The buried Kirschner wires are removed
8 to 16 weeks after the index surgery.
Supplemental skeletal fixation: external fixation
When distraction is necessary to maintain
fracture reduction, a small Association for the
Study of Internal Fixation external fixation device
is used with the 2.5-mm partially threaded tip
Steinman pins (Synthes, Inc.). In this series, these
smaller partially threaded pins avoid the problems
with skin irritation and pin tract infection seen
with the 3.5-mm pins. A 2-cm skin incision at the
junction of the middle and distal third of the
dorsal radial forearm is made. Blunt dissection
 INTRAFOCAL PINNING & SUPPLEMENTAL SKELETAL STABILIZATION 323

Fig. 5. (A) Posterior–anterior radiograph demonstrating radial shortening, radial inclination, and a concomitant
scaphoid fracture. (B) Lateral radiograph demonstrating loss of palmar tilt and dorsal comminution. (C) Postoperative
posterior–anterior radiograph demonstrates restoration of radial length, radial tilt, and reduction of the scaphoid
fracture. The distal radius fracture is stabilized using a combination of the Kapandji technique and an internal
radiocarpal spanning fixator plate. (D) Postoperative lateral radiograph demonstrates that the palmar tilt is corrected
using the buttress effect of the Kapandji technique and an internal radiocarpal spanning fixator plate. (E) Three-month
postoperative posterior–anterior radiograph. The fracture is healed and reduction has been maintained. The hardware is
ready to be removed. (F) Three-month postoperative lateral radiograph. The fracture is healed and reduction has been
maintained. The hardware is ready to be removed.

with tenotomy scissors through the interval be-
tween the extensor carpi radialis longus and the
extensor carpi radialis brevis is performed down
to expose the bone. A 2-mm drill guide is then
placed directly on the cortex of the radius. The
threaded 2.5-mm Steinman pins are placed be-
tween the extensor carpi radialis longus and the
extensor carpi radialis brevis to avoid injury to the
sensory branch of the radial nerve. The key is to
hold the fracture in a reduced position when the
threaded Steinman pins are inserted so that there
is no skin traction against the pins with the
fracture in the reduced position. A second incision
is then made over the index finger metacarpal,
radial to the extensor tendons. Two 2.5-mm
Steinman pins are placed, one at the base of the
metacarpal at the metaphyseal flare and the
second one 2 cm proximal to the metacarpal–
phalangeal joint (Figs. 2, 3).
Supplemental skeletal fixation: internal spanning
fixation
Alternatively, and more recently, the authors
have begun using an internal radiocarpal joint–
spanning bridge plate or a 2.4-mm mandibular
locking plate (both from Synthes, Inc.). The
surgical technique is similar to that of external
fixation [39,59]. A 2-cm incision is made over the
bare area of the forearm overlying the radius. The
interval between the extensor carpi radialis longus
and extensor carpi radialis brevis is developed to
expose the radius. A second 2-cm incision is made
324 WEIL & TRUMBLE

Fig. 5 (continued )

over the second metacarpal. Care is taken to
protect the extensor tendon and first dorsal
interosseous muscle. A 2.4-mm locked plate is
then inserted supra-periosteally under the exten-
sor tendons across the radiocarpal joint and over
the second metacarpal. The plate is then affixed to
both the second metacarpal and the radius using
a combination of 2.4-mm nonlocked and locking
screws. The most proximal screw in the forearm is
place first in nonlocked fashion. The second screw
is placed in the most distal hole of the metacarpal,
also in nonlocked fashion. Then three more
locked screws are placed in the radius, and three
locked screws are placed in the metacarpal (Figs. 4, 5).
The plate is then left in for 3 months before
removal.
Immediately postoperatively, patients are
placed in a sugar tong splint for 2 weeks and
then changed to a short arm cast at their first
postoperative clinic visit. The short arm cast is
worn for another 4 weeks. After these 6 weeks of
immobilization, the patient is given a removable
wrist splint for support when not performing
therapy exercises. Immediate finger range of
 INTRAFOCAL PINNING & SUPPLEMENTAL SKELETAL STABILIZATION 325

Fig. 5 (continued )

motion is begun postoperatively under the di-
rection of a hand therapist. Forearm rotation is
begun once the patients are placed in a short arm
cast. Active wrist range of motion exercises are
started at post-operative week 6, and passive
exercises are started the following week. Patients
treated with supplemental radiocarpal spanning
fixation are started on wrist range of motion after
their hardware is removed, typically at 3 months.
For patients with less than 120  of combined
pronation and supination by the eighth week after
surgery, static progressive splinting is started
(Fig. 6). For patients treated with radiocarpal
spanning fixation, static progressive splinting is
started 8 weeks after hardware removal.
Complications
The most common complication is wound
infection caused by pins left out of the skin. By
burying the Kirschner wires, the incidence of
wound problems is dramatically reduced, but
this does require a second procedure for pin
removal. These same complications are found
326 WEIL & TRUMBLE
Fig. 6. For patients with less than 120  of combined
pronation and supination by the eighth week after
surgery, static progressive splinting is started.
when using the external fixator and was the
impetus to start using the internal spanning bridge
plate technique for fracture patterns that require
distractive forces to maintain radial length
[52,57,60–62]. There have been two cases of
extensor tendon laceration when using the in-
ternal spanning plate technique. One tendon was
lacerated during insertion of the plate, the second
was lacerated during plate removal. Both tendon
lacerations occurred while using the 2.4-mm
mandibular locking plates. Presently, a lower pro-
file plate designed specifically to be an internal
radiocarpal spanning fixator is used.
University of Washington/Harborview Medical
Center experience
Between 1988 and 1993, 73 patients were
treated with either intrafocal pinning (Kapandji
technique) alone or in combination with external
fixation for extra-articular fractures of the distal
radius (with or without a nondisplaced extension
into the radiocarpal articular surface) with in-
adequate alignment after initial closed reduction.
Sixty-one patients were available for follow-up
examination retrospectively at an average of 34
months (range: 24–71) [5]. The patients all had
dorsally displaced extra-articular fractures, al-
though 56% had a nondisplaced extension of the
fracture into the radiocarpal joint and 46% had
a nondisplaced fracture extending into the distal
radioulnar joint. The patients were separated into
groups based on age degree of comminution, and
whether or not external fixation was used in
addition to the percutaneous intrafocal pins. In
the older patients, the range of motion, grip
strength, and pain relief were significantly better
when external fixation was used, even when only
one cortex of the radius demonstrated comminu-
tion. In the younger patients, good results in terms
of range of motion, grip strength, and pain relief
were obtained when percutaneous intrafocal pins
were used alone in patients with comminution of
only one surface of the radius (!50% of the
metaphyseal diameter). When two or more sides
of the radial metaphysis were comminuted, the
patients with external fixation had better results
than those without external fixation. Although the
correction of the palmar tilt and radial tilt did
result in better functional results, the restoration
of radial length had the most significant effect on
range of motion and grip strength [5].
Summary
The technique of intrafocal pinning was origi-
nally described by Kapandji [21,22]. This tech-
nique, along with the addition of supplemental
external or internal bridging fixation, can be
performed quickly with minimal soft tissue dam-
age. This technique is indicated for the treatment
of unstable extra-articular or minimally displaced
intra-articular fractures of the distal radius. Stud-
ies demonstrate that young patients with displaced
extra-articular distal radius fractures and minimal
comminution can be treated by percutaneous
intrafocal pin fixation alone, whereas, patients
over 55 years of age and younger patients with
comminution involving two or more surfaces of
the radial metaphysis (or O50% of the metaphy-
seal diameter) require bridging fixation besides
percutaneous pin fixation [5,10,23,24,42,63,64].
The use of this technique achieves the goal of
surgical treatment of distal radius fractures: resto-
ration of hand and wrist function through the
restoration of alignment and articular surface
congruity.
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 Hand Clin 21 (2005) 329–339
Biomechanics and Biology of Plate
Fixation of Distal Radius Fractures
Alan E. Freeland, MD*, Kurre T. Luber, MD
Department of Orthopaedic Surgery and Rehabilitation, University of Mississippi Medical Center,
2500 North State Street, Jackson, MS 39216-4505, USA
The fracture management principles of ana-
tomic or near anatomic reduction, fracture stabi-
lization, minimal operative trauma, and early
joint motion are paramount in managing unstable
distal radial fractures. The operative approach
and plate selection should correlate with the
fracture configuration. Plates have the advantages
of providing secure fixation throughout the entire
healing process without protruding wires or pins
and allowing early and intensive forearm, wrist,
and digital exercises. Disadvantages include addi-
tional operative trauma, including fragment de-
vascularization; some additional risk for wrist
stiffness; occasional tendon rupture; and at times,
the need for plate removal. New developments in
plate and screw design and operative strategies,
fragment specific fixation, and plate strength have
improved results with plate fixation. Fixed angle
blades and locking screws and pegs enhance
overall plate stability, support the articular sur-
face of the distal radius, and are effective in
fractures occurring in osteopenic bone.
Anatomic or near anatomic restoration, frac-
ture stabilization, atraumatic surgery, pain con-
trol, and early progressive joint mobilization
constitute the basic principles of the operative
management of fractures that cannot be reduced
or maintained satisfactorily within accept-
able parameters by nonoperative methods [1,2].
No funding was received for this article. The senior
author receives departmental and institutional support
from AO North America and royalties from Elsevier
Publishing Company.
* Corresponding author.
E-mail address: afreeland@orthopedics.umsmed.edu
(A.E. Freeland).
0749-0712/05/$ - see front matter Ó 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.hcl.2005.03.002
Although perfect anatomic restoration is the
ideal, good to excellent functional results may be
achieved with near anatomic reduction, owing to
some tolerance of mild deformity.
Loss of length may be linear along the axis of
the radius or may be caused or accentuated by
loss of dorsal articular tilt or displacement of the
fracture. The distal radius may accommodate
up to 2–3 mm of shortening and a loss of up to
15  –20  of articular angulation in the frontal and
sagittal planes with little functional loss [3–10].
Dorsal translation of the lunate in the distal radial
fossa with secondary midcarpal collapse owing to
loss of dorsal angulation may be an indication for
fracture restitution [11]. Up to 1–2 mm of distal
radial articular surface incongruity may not
increase appreciably the risk for later post-
traumatic arthritis [12,13]. Fractures not meeting
these criteria may be candidates for open re-
duction and plate stabilization.
Open reduction and internal plate fixation may
be used to achieve fracture restoration and
stability throughout the entire healing process
without protruding wires or pins and to allow
early intensive rehabilitation. These advantages
may offset the disadvantages that include addi-
tional operative trauma, fragment devasculariza-
tion, and some additional risk for wrist stiffness;
occasional tendon rupture; and at times, plate
removal. Plates must be matched to the fracture
configuration and selected according to the sur-
geon’s judgment and skills. Bone grafting of
defects enhances distal radius fracture stability
and healing capacity. This article discusses the
operative approaches and plate designs that have
evolved in an effort to achieve and maintain
sufficient biomechanical fracture support while
hand.theclinics.com
330 FREELAND & LUBER
improving plate biocompatibility with fracture
healing.
Approaches
Sharp low energy incisions are designed to
approach directly the fracture in a single plane
and to minimize bone fragment devascularization
and scar tissue formation. Nevertheless, open
reduction, periosteal stripping, and internal fixa-
tion convert a closed fracture into a complex open
fracture. The opportunity for good fracture re-
duction and adequate stability to allow otherwise
unimpaired fracture healing and early wrist mo-
tion may warrant this method of treatment.
Traditionally, dorsally displaced distal radial
plates have been approached dorsally, and pal-
marly displaced fractures from the palmar side,
allowing reliable buttressing of the metaphyseal
fragments. Furthermore a plate applied adjacent
to the comminuted side and opposite to a side
with cortical contact is substantially stronger than
the opposite configuration [14]. Conversely the
high frequency of postoperative symptoms and
complications resulting after dorsal plating has
led to the development of smaller low profile
plates, fragment specific plates and operative
approaches, and plates that may be inserted on
the palmar side of the fracture for all fracture
configurations.
Dorsal approach
Dorsal plate application may result in over-
lying wrist extensor tendon adhesions, irritation,
attrition, and occasional extensor tendon rupture;
skin irritation from the plate; and wrist stiffness.
Nevertheless some distal radius fracture configu-
rations may be stabilized more reliably and bone
graft or substitute applied under direct vision
using the dorsal approach. Dorsally applied plates
may prevent re-displacement more reliably in
some instances of dorsally displaced metaphysial
fragments than palmar plating.
Plate spurs caused by trimming some of the
holes of the plate stem or bar may be a substantive
source of extensor tendon irritation, attrition, or
rupture. Subcutaneous transposition of the exten-
sor pollicis longus to the radial side of the wrist
and repair of the third dorsal compartment
retinaculum over the plate may limit these com-
plications. Although extensor pollicis longus
transposition may restrict the extremes of thumb
extension, this is rarely a significant problem.
Newer plates have beveled edges, tapered ends,
and smooth nonadherent surfaces to prevent soft
tissue irritation and adhesions. Despite these
precautions and a variety of lower profile design
changes, plate removal may be necessary more
frequently for dorsally applied plates than for
those positioned on the palmar side.
Palmar approach
Tendon problems may be more inherent to the
dorsal approach than attributable to specific plate
characteristics [15,16]. There is less space available
between bone and tendons on the dorsal side of
the radius than on the palmar side. The palmar
side of the radius, owing to the increased space
available between the bone and the flexor tendons,
also may accommodate a thicker and thus stron-
ger plate to accommodate the increased plate
loads generated using this configuration.
Plates inserted on the palmar side of the distal
radius may be covered partially by the pronator
quadratus, providing additional protection to the
extrinsic flexor tendons. Extrinsic flexor tendon
attrition or rupture is rare with palmar plating.
Proper rotational fracture fragment realignment
may be facilitated more easily on the palmar side of
the radius, owing to the flat palmar surface of the
radius as compared with its rounded dorsal side.
Conversely a palmar incision requires elevation
of the pronator quadratus to approach the frac-
ture and placement of a portion of the plate
between the pronator quadratus and the bone,
diminishing the palmar blood supply of distal
radial fragments and impairing their revasculari-
zation from this source [17]. Occasionally the
distal muscular portion of the flexor pollicis
longus must be raised to fit the plate stem on
the bone. Although early discomfort on the
palmar radial side of the distal forearm and
thumb stiffness may result, symptoms are usually
transient. Although the extended flexor carpi
radialis approach preserves the important ulnar
circulation to the distal radius, it substantially
extends the dissection and compromises the blood
supply of a second side of the fracture, the lateral
radius [18]. Bone grafting dorsal defects from the
palmar side of the radius may be more problem-
atic even with the extended approach, owing to
difficulty in visualizing the defect.
Biomechanics of fracture reduction
Traction, ligamentotaxis, periosteotaxis, and
manipulation are the mainstays of fracture
 PLATE FIXATION OF DISTAL RADIUS FRACTURES 331

reduction. The brachioradialis is the only muscle proportionate to the number of screws holding the
attached to the distal radial fracture fragment. stem [21].
Sarmiento et al recognized the resistance and
deforming force of the brachioradialis on the
distal radial metaphyseal or styloid fragment Evolution of distal radius plates
during the wrist flexion and forearm pronation Basic distal radius T-plate
maneuvers of classically applied closed reduction
techniques [19]. The brachioradialis also may In 1973 Mathys designed metallic T-shaped
remain a deforming force following closed frac- small fragment plates (Synthes; Paoli, Pennsylva-
ture reduction. Sarmiento et al reported and nia) that were proportionate to the size of the
advocated fracture reduction, positioning, and distal radius [1,2] (Fig. 1). These plates were
cast bracing with the forearm in a supinated among the first generation of modern plates
position to relax brachioradialis tension during manufactured specifically for distal radius fracture
and after fracture reduction. Orbay et al have fixation. Distal radius plates support or buttress
popularized brachioradialis tendon insertion re- distal radius fractures. Their stem is affixed to the
lease or lengthening to achieve the same effect, diaphyseal fragment and a bar supports and
facilitating the biomechanics of open reduction of incorporates the metaphyseal fragment or frag-
extra-articular distal radius metaphyseal or intra- ments. These plates may be bent and contoured to
articular styloid fragments [18]. The brachioradia- coapt to the bone.
lis tendon is approached by incising the radial
septum, the fascia separating the flexor and
Low profile, low contact plates
extensor compartments of the forearm proximally
and containing the insertion of the brachioradialis Plate design has evolved continually toward
tendon and the tendons of the first extensor smaller, lower profile implants in an effort to
compartment distally over the radial styloid. maintain biomechanical fracture stability and
Brachioradialis release is especially helpful in improve biocompatibility [22–26]. Relieved areas
inveterate fractures and nascent malunions. of the plate stem, bar, and undersurfaces decrease
The rule of the majority, also known as the the amount of plate surface in contact with the
vassal rule, may be helpful in assembling the
fracture fragments. This rule states that the major
fragments should be realigned and that the
smaller or vassal fragments follow the major
fragments into position. Replacement of each of
the articular fragment components before defini-
tive plate fixation may avoid some of the difficul-
ties that may be encountered in reducing ulnar
die-punch fragments following radial styloid fixa-
tion. Fluoroscopy or arthroscopy may be useful in
achieving fracture and articular alignment.
Kirschner wires may be used for provisional
fixation before plate insertion.

Plate biomechanics
Plate strength is proportionate to the cube of
its thickness and inversely proportionate to the
cube of its length [20]. Screws enhance plate
strength and holding power at the plate–bone
interface. Wider spacing of screws in the stem
increases the bending strength of plate–screw–
bone fixation. The torsional strength of plate stem
fixation is independent of screw spacing and is
Fig. 1. (A) AO/ASIF small fragment distal radius T-
plate (long stem). Arrow (1), conventional 3.5-mm
round plate hole. Arrow (2), elliptical 3.5-mm conven-
tional plate-stem hole; allows minor plate position
adjustments after initial screw insertion. (B) Undersur-
face of conventional distal radius T-plate (short stem)
(Synthes).
332 FREELAND & LUBER
Fig. 2. (A) Lower profile dorsal distal radius pi plate.
Arrow (1), round 2.4-mm threaded plate hole for
conventional screw or locking peg. Arrow (2), round
2.7-mm conventional plate-stem hole. Arrow (3), notch
to accommodate Lister tubercle. (B) Under surface of pi
plate. Arrow 4, lateral area of plate-stem relief (Synthes).
bone and facilitate revascularization of the bone
segment under the plate [27]. The pi plate and its
T-plate analog (Synthes) were among the early
plates of lower profile design (Figs. 2 and 3). The
use of the pi plate in distal radial fractures,
however, has not demonstrated any appreciable
decrease of extensor tendon irritation, attrition,
and rupture compared with its predecessors [22].
Fig. 3. (A) Low profile T-plate. Arrow (1), round 2.4-
mm threaded plate hole for conventional screw or
locking peg. Arrow 2, elliptical 2.7-mm conventional
plate-stem hole; allows minor plate position adjustments
after initial screw insertion. Arrow 3, conventional 2.7-
mm round plate-stem hole. (B) Undersurface of low
profile distal radius T-plate. Arrow 4, lateral area of
plate-stem relief (Synthes).
Fig. 4. Fragment specific fixation of palmar ulnar die-
punch fragment with 2.7-mm mini T-plate. (A) Pal-
mar view. (B) Lateral view. (C) Cross-sectional view
(Synthes).
Fragment specific fixation
Geissler and Fernandez first reported fragment
specific fixation in 1991 using a mini fragment T-
plate for palmar die punch intra-articular frag-
ments [12] (Fig. 4). Leslie and Medoff and Barrie
and Wolfe expanded the concept of fragment
specific fixation, introducing pin plates (TriMed;
Valencia, California) designed to fit the lateral
contour of radial styloid fragments and for volar
and dorsal die-punch and marginal lip fragments
[25,26] (Fig. 5). These smaller plates sometimes
may be inserted through smaller incisions, but
when more than one plate is used, may require
one or two additional incisions.
Rikli and Regazzone have divided conceptually
the distal radius into longitudinal radial and in-
termediate columns corresponding to similar car-
pal columns [28–31] (Fig. 6). The radial and
Fig. 5. Pin plates. (A) Arrow (1), pin plate for marginal
lip or die-punch fragments. (B) Arrow (2), styloid
fragment pin plate (Trimed).
 PLATE FIXATION OF DISTAL RADIUS FRACTURES 333

radius plate sets (Fig. 7). Two flexible low profile

plates, one supporting each column of the frac-
tured distal radius and applied in an orthogonal
configuration with the plane of the radial column
(radial styloid) plate 50  –70  in relation to the
plane of the intermediate column (dorsal or palmar
die-punch fragment) plate, are stronger than a sin-
gle conventional T-plate or pi plate and individu-
ally contain the fragments of both columns (Fig. 8)
[32,33]. Orthogonal bicolumnar plating may allow
earlier and more intensive rehabilitation and may
have a favorable effect on outcome, but it probably
does not diminish the operative dissection neces-
sary for plate application.

Fixed angle principle

Fig. 6. Diagram of the corresponding wrist and distal
radius columns.
intermediate columns support the areas of high
impact and force on the distal radial articular
surface generated by the scaphoid and lunate,
respectively. There is also an ulnar column. An
array of fragment specific low profile plates that
individually support the articular fragments of
each column are now available in several distal
The working portion of a buttress plate is the
bar, that distal segment of the plate supporting
the metaphyseal fracture fragments. Support of
the metaphysic fragments and overall plate–bone
construct strength may be improved by blades
affixed to the plates or screws or pegs locked into
the screw or peg holes of the bar by matching
threads. Each fixed angle blade or locking screw
or peg provides an additional point of fixation
within the plate and increases plate stability [34–
37]. Fixed angle blades or locking screws or pegs
in the bar of the plate also provide additional
support for the articular surface of the distal
radius against axial loads. The subchondral sup-
port (SCS) plate (Avanta; San Diego, California)
has fixed angle blades [34] (Fig. 9). Several plates
have a fixed angle screw or peg option for the bar

Fig. 7. Distal radius low profile locking plates for fragment specific fixation of (A,B) the radial styloid, (C,D) palmar
metaphyseal fragments, and (E–J) intra-articular metaphyseal fragments. Arrow (1), threaded round bar-holes for 2.4-
mm conventional screws or locking screws or pegs. Arrow (2), 2.7-mm combiholes. Arrow (3), elliptical combiholes
allow minor plate position adjustments after initial screw insertion. Arrow (4), notched low contact plate undersurfaces
(Synthes).
334
Fig. 8. Distal radius low contact orthogonal bicolumnar
locking double plate fixation. (A) Dorsal view. (B) Cross-
sectional view (Synthes).
of the plate (Fig. 10). The increased stability of
fixed angle blades or locking screws or pegs may
be especially advantageous in osteopenic bone
[38,39].
The distal volar plate (DVP) (Hand Innova-
tions; Miami, Florida) and similarly designed
plates combine fixed angle locking screws or pegs
in the stem of the plate with robust design so that
Fig. 9. Subchondral support (SCS) fixed angle blade
plate. (A) Large dorsal plate. (B) Small dorsal plate. (C)
Palmar plate (Avanta).
FREELAND & LUBER
Fig. 10. (A) Threaded standard screw. (B) Partially
threaded standard screw. (C) Threaded locking screw.
(D) Locking peg. Arrows to (C) and (D) indicate a space
between the locking plate and the bone. Standard holes
and flexible bushings in locking holes allow up to 15  of
screw angulation from the perpendicular position
(Universal Distal Radius System; Striker Leibinger
Micro Implants).
they may be applied to the palmar side of the dis-
tal radius for almost all fracture configurations
regardless of the direction of instability
[15,16,38,40–42] (Fig. 11). The goal of this plate
design is to avoid dorsal plate application and its
consequences consistently. Fixed angle pegs follow
the articular contour, are directed to support the
articular surface, and help to assure fixation of
commonly found articular fragments. The radial-
most pegs are directed into the styloid and the
ulnar-most pegs into the dorsal ulnar edge of the
radius to incorporate styloid and dorsal die-punch
fragments, respectively. Failure to incorporate the
dorsal die-punch fragment may lead to loss of
reduction and arthrosis [43]. The distal palmar edge
of the plate supports palmar die-punch fractures,
which also may be incorporated with pegs.
Locking plate stems and combination plate holes
(combiholes)
The fixed angle principle also may be applied to
the plate stem. Elliptical plate holes (combiholes)
 PLATE FIXATION OF DISTAL RADIUS FRACTURES 335

Fig. 11. (A) First generation DVR plate. (B) Undersurface first generation DVR plate with a row of locking pegs
(arrow) designed to parallel and support the subchondral portion of the articular surface of the distal radius. (C) Second
generation distal volar radial plate. (D) A proximal row of screws (arrow 1) or pegs (arrow 2) may be inserted to
incorporate or support the dorsal lip or fragments of the distal radius (Hand Innovations; Miami, FL).

have been added to the stems of the AO/ASIF

distal radius locking plate set (Synthes) [35–37]
(Fig. 12). Combiholes allow the option of inserting
a fixed angle locking screw or a conventional screw.
Standard screws compress the plate onto the bone
and stabilize the fracture owing to friction between
the plate and the bone. Locking screws inserted
into the stem of the plate provide an additional
point of fracture fixation, prevent screw toggle, and
increase plate resistance to axial loads compared
with conventional screws, owing to locking screw
head thread engagement in corresponding threads
within the locking plate hole. Distal radius locking
plates are precontoured and do not have to be
shaped to or rest flush on all parts of the bone, and
in essence may act as an internal fixator (ie, an
implanted external fixator) (Fig. 13). This feature
makes locking plates more biocompatible with the
bone. A locking plate might be envisioned as the Fig. 12. (A) Combihole allows engagement of (B)
ultimate external fixator with the plate (connecting a conventional screw or (C) a locking screw. Arrow
(1), the smooth portion of the combihole accommodates
bar) placed extremely close to the mechanical axis
a standard screw head. Arrow (2), the threaded portion
of the bone, maximizing its stability [35–37]. Lock- of the combihole accommodates a locking screw head.
ing plate stems may be especially advantageous in Arrow (3), space between the fixed angle locking plate
osteopenic bone. and the bone surface (Synthes). Standard screw holes or
The pullout strength of a unicortical screw bushings incorporated in locking plate holes may allow
from bone is approximately 60% compared with a few degrees of angulation from the vertical position.
336 FREELAND & LUBER
Fig. 13. Small fragment locking T-plate used as an
internal fixator with a small space between parts of the
plate and the bone (arrows) (Synthes).
a bicortical screw [37]. The surgeon must decide
whether or not to engage one or both cortices.
Unicortical drilling may minimize damage to the
endosteal circulation of the distal radius and
eliminates the need to measure screw length.
Physiology of fracture healing
The distal radius receives its diaphyseal intra-
medullary blood supply on its ulnar surface from
the anterior and posterior interosseous arteries
through one or more nutrient arteries [18,44]. The
palmar and dorsal wrist arterial arches supply the
periosteum of the cortical surfaces of distal radial
metaphysis directly and through the adjacent joint
capsule and ligaments [45]. Muscles adjacent to
fractures provide blood supply that may enhance
fracture healing [17]. Muscular blood supply of
the distal radius is confined to that from the
pronator quadratus.
Enchondral peripheral calcification of frac-
tures escalates at 10–21 days after injury and
progresses in a centripetal fashion as fracture
stability increases [46,47]. Plates substitute for
external (periosteal) callus, but their application
requires devascularization of some of the bone
surface, resulting in some initial temporary bone
necrosis and consequent potential delay in frac-
ture healing, especially in areas in which the plate
contacts the bone [48,49]. This disadvantage is
compensated for somewhat by the immediate
stability, pain control, and early and more in-
tensive active exercises provided for and allowed
by plate fixation. Smaller, newer generation low
contact plates allow more rapid recovery of the
bone circulation under the plate than do larger or
full contact plates.
Fracture callus is typically apparent on radio-
graph at 4–6 weeks after injury or surgery. The
fracture is locked by the callus at this point and
rehabilitation may be pursued in earnest,
including the initiation of progressive strengthen-
ing and conditioning exercises. Local clinical
signs, including pain, swelling, discoloration,
heat, and tenderness, diminish as fracture healing
progresses. The plate transcends from load bear-
ing at the time of application to load sharing as
healing processes, until the completely healed
bone bears almost the entire load of stresses [14].
Complications
Plates have an internal memory for fatigue
stresses and may fail (bend or break) as a result of
repetitive bending stresses at the fracture site
before bone healing. Repetitive bending forces
accumulate within the plate over time and may
lead to plate breakage if bone healing is delayed
[14]. Plates should be contoured by bending in
only one direction. Bending a plate back elimi-
nates a significant portion of the plate’s fatigue
strength. Screw breakage or pullout also may
occur from axial or bending forces between the
plate and bone surfaces. There is in essence a race
between bone healing and plate or screw failure.
Fractures with defects, comminution, or osteope-
nia increase the risk for implant failure. As forces
between the plate and bone interface increase in
strength, intensity, and frequency, conventional
screws applied through round and elliptical plate
holes are at risk for loosening, toggling, or
dislodgement. Bone grafting or bone graft sub-
stitutes inserted into major fracture defects and
locking screws may relieve plate stresses and
enhance fracture healing. Implants customarily
are removed only if symptomatic after fracture
healing.
There are disadvantages of locking screws [37].
The surgeon has no tactile feedback of the quality
of screw purchase into the bone. Locking screws
stop advancing when their heads are seated into
the plate, regardless of bone density. The surgeon
is unable to alter the angle of the screw. Polyaxial
locking screws with an expandable bushing inside
the plate hole (Versalok, Dupuy; Warsaw, In-
diana; Striker Leibinger Micro Implants; Portage,
Michigan) have been developed and allow some
freedom of screw angulation, but currently testing
is limited [37]. The locking plate cannot be bent or
contoured without risk for distorting the plate
hole and preventing screw head engagement. The
fracture components must be reduced adequately
before locking plate and screw or peg insertion.
Any malaligned fragment is held rigidly, which
could result in nonunion, malunion, or implant
 PLATE FIXATION OF DISTAL RADIUS FRACTURES
failure. Locking screws may become cold-welded
to the plate, rendering removal more difficult.
Torque-limiting screw drivers may minimize this
concern.
Discussion
Plate application compounds the closed distal
radial fracture and is selected because the surgeon
believes that it provides a favorable benefit to risk
ratio in relation to other choices for the desig-
nated fracture. The plate needs to secure the
fracture independently only until bone healing
occurs, as signaled by the appearance of fracture
callus on radiograph and the resolution of local
signs and symptoms on clinical examination. Plate
strength is therefore but one consideration in plate
selection. Fractures with extra-articular commi-
nution or bone loss may require stronger plates
and plates with longer stems. Operative trauma
should be minimized. Although palmarly applied
plates may be less abrasive to surrounding soft
tissues than dorsally applied plates, structural
stability and ease of application may dictate
a dorsal approach. Fixed angle blades or locking
screw or pin options offer additional stability.
Locking screws, pins, and plates may be especially
advantageous in osteopenic bone.
There is a plethora of plating systems available
and a fury of effort to market them with claims
and counterclaims that may be largely unsubstan-
tiated by adequate follow-up and reliable statistics
[50–54]. Conflicts of interest exist and must be
taken into consideration [55]. Look for uncon-
flicted collaborative conformation from sources
independent of the manufacturers and innovators.
Evidence-based medicine is important, and in the
absence of clearly defined valid choices there may
be no substitute for common sense [56]. Previous
expectations have not always been fulfilled, even
when based on sound theory [22].
Implants may come and go, but fracture
management principles remain constant [1,2].
Plates should be selected to correspond with
fracture configuration as closely as possible.
Several plates and plating systems satisfy these
criteria. In the authors’ view, there is no single
plate that matches up with all myriad fracture
patterns. There may be more than one right
surgical approach or combination of approaches
and more than one right plate or aggregate of
plates to treat each fracture. The judgment of the
surgeon remains paramount in plate and surgical
approach selection.
337
There are some practical considerations. Most
of us are restricted in how many plate systems
our hospitals buy for us. Plate cost is a consider-
ation in plate and plating system selection, espe-
cially in comparable situations. It may be helpful
to have as many plate designs available as possible.
Use by consignment for each patient may be
accommodating.
Acknowledgments
The authors would like to acknowledge the
advice and assistance of David Little, I.V. Hall,
Michael Schenk, Bill Buhner, Kyle Cunningham,
Clint Clardy, Bill Dixon, and Patrick Harmon in
the preparation of this manuscript.
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[23] Simic PM, Weiland AJ. Fractures of the distal ra-
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 Hand Clin 21 (2005) 341–346

Dorsal Plating for Distal Radius Fractures

Jason D. Tavakolian, MDa, Jesse B. Jupiter, MDb,*
a
The Curtis National Hand Center, Union Memorial Hospital, 3333 North Calvert Street,
Baltimore, MD 21218, USA
b
Department of Orthopaedics, Massachusetts General Hospital, ACC 525, 15 Parkman Street,
Boston, MA 02114, USA

Despite the trend toward the operative fixation
of unstable distal radius fracture from a palmar
approach, there remain a variety of fracture
patterns that are not amenable to this technique
requiring more extensile exposure through a dorsal
approach. Several factors have evolved to make
the dorsal approach more predictable with less soft
tissue complications. These factors include a
greater understanding of the structural anatomy
of the distal end of the radius and distal radioulnar
joint, more precise definition of fracture patterns
and surgical exposures, and newer, angularly
stable low-profile implants designed specifically
for the anatomic fracture patterns. This article
outlines the history of dorsal plating, describing
early experiences, advances in implant design and
application, and the current state of the art.
Early dorsal plating experiences
Dorsal plate fixation gained popularity in the
mid to late 1980s as the importance of articular
reconstruction became better defined. Multiple
case series subsequently demonstrated that artic-
ular alignment and joint congruity could be
restored reliably from a dorsal approach, even
with complex AO-type C2 and C3 fractures [1–4].
Overall outcomes, however, were sometimes com-
promised by stiffness and extensor tendon com-
plications [1–4].
In a series of 16 patients from the Mayo clinic
treated predominantly through a dorsal exposure
* Corresponding author.
E-mail address: jjupiter1@partners.org (J.B. Jupiter).
0749-0712/05/$ - see front matter Ó 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.hcl.2005.02.001
with T-plate fixation, for example, 13 patients had
a good or excellent score according to the system
of Gartland and Werley [5]. When more rigorous
standards were applied to strength and motion, as
is the case with the modified Green and O’Brien
system [6,7], however, 9 of the 16 patients rated
good or excellent. Similarly, Fitoussi [3] found 20
good or excellent results according to the stringent
criteria of Green and O’Brien versus 28 good or
excellent results according to the more lenient
criteria of Gartland and Werley.
Whether the stiffness found in these series is
caused by the dorsal approach, the severity of the
injury itself, or both, remains unknown. Dorsal
exposure clearly affords excellent articular expo-
sure, however, allowing consistently near-
anatomic reductions of the joint surface. Axelrod
and McMurtry, for example, obtained good or
excellent joint congruity in 15 of 17 patients fixed
predominantly with dorsal plates [1]. Jupiter and
Lipton also noted excellent congruity after dorsal
fixation, with only one patient out of six demon-
strating radiographic evidence of arthrosis at 2.5
years follow-up.
Complication rates were often high with the
dorsal exposure, though. Axelrod and McMurtry
found 15% early and 35% late complications, in-
cluding five cases of extensor tenosynovitis. Jupi-
ter and Lipton, too, found problems with the wrist
extensors after dorsal fixation, noting one EPL
rupture and one case of extensor tenosynovitis.
Likewise, Hove et al [8] found two cases of EPL
rupture in a group of 20 patients who underwent
dorsal T-plate fixation. Routine implant removal
did not guard against complications, because Fi-
toussi found a 26% complication rate despite im-
plant removal at 4–6 months [3].
hand.theclinics.com
342 TAVAKOLIAN & JUPITER
Column theory
Rikli and Regazzoni advanced understanding
of the mechanics of distal radius fractures with
their description of the distal radius and ulna as
a three-column construct [9]. They defined the
medial column as the distal ulna, triangular
fibrocartilage complex (TFCC), and distal radio-
ulnar joint (DRUJ). The intermediate column
consisted of the medial part of the distal radius,
including the lunate fossa and the sigmoid notch.
Finally, the lateral radius, including the scaphoid
fossa and radial styloid, comprised the lateral
column. Because a dorsally displaced fracture
generally is radially deviated in the frontal plane
and supinated in the transverse plane, stabilization
after reduction was believed to require buttressing
of the intermediate and lateral columns [9].
Based on their concept, these investigators
initially used two separate 2.0 T-plates to buttress
these columns [9]. These small implants allowed
Lister’s tubercle to be left intact and the implants
were covered with a periosteal flap and parts of
the extensor retinaculum (Fig. 1). In a series of 73
consecutive patients, all of the patients except 2
with additional injuries returned to work and
daily activities without limitations [10]. The ana-
tomic results were excellent or good in all but one
patient, who had only fair results. There was still
an overall 20% rate of complication, including
four cases of extensor tendonitis (three of which
Fig. 1. Anatomical comparison of a single, dorsally
placed 3.5 mm plate with two 2.0 mm plates on the
radial and intermediate columns. Note the preservation
of Lister’s tubercle with the use of the smaller plates.
improved after implant removal and one of which
improved spontaneously) and five cases of exten-
sor tendon rupture. All cases of extensor rupture
were attributed to dorsoulnar T-plates cut to
form L-plates. After stopping this practice, there
were no further cases of rupture. Implants were
removed in 23% of patients.
Distal radius specific implants
Overall encouraging results with commonly
used implants such as the AO T-plate (Synthes;
Paoli, PA) motivated the design of a new genera-
tion of implants. These low-profile plates were
precontoured to the anatomy of the distal radius
with the intention of making fracture fixation
technically simpler and reducing rates of wrist
stiffness and extensor tendon irritation.
The Pi plate (Synthes) was among the fore-
runners of distal radius-specific plates that af-
ford angular stability through locked bolts or
screws [11] (Fig. 2). It was designed with two
proximal longitudinal limbs connected by a pre-
contoured juxta-articular band to buttress articu-
lar comminution. In an initial prospective
multicenter trial of the Pi plate in 22 predomi-
nantly AO-type C2 and C3 fractures, there were
13 good or excellent results according to the scale
of Gartland and Werley. With the modified Green
and O’Brien rating, however, there were only 2
good results, with 13 fair and 7 poor. Some of
these fair and poor results were qualified by a short
follow-up interval—as little as 6 months in some
patients—resulting in less than maximal return of
grip strength and range of motion. Five of the 22
patients developed extensor tendonitis, but there
Fig. 2. Left and right Pi plates. Note the pre-contoured
juxtaarticular band.
 DORSAL PLATING FOR DISTAL RADIUS FRACTURES
were no cases of extensor ruptures and routine
implant removal was not deemed necessary. All
participating surgeons found it notably simpler to
achieve adequate fixation with the Pi plate than
with their previous treatment technique, although
six patients (27%) still required supplemental
fixation to the Pi plate.
Campbell described a series of 25 patients
treated with the Pi plate, 21 of whom had C3
type fractures [12]. At a slightly longer follow-up
interval than in the initial Pi plate pilot study (16
months; range, 12–26 months), Campbell found
15 good and excellent results according to the
scale of Gartland and Werley. Thirteen fractures
had no articular stepoff, seven had 1 mm, and
only one fracture had 2 mm of articular stepoff
at final follow-up radiograph. There were five
total complications, including three plate re-
movals and one extensor digitorum communis
rupture.
In a prospective randomized study of 43
patients comparing the Pi plate with two dorsal
quarter-tubular plates, however, subjective and
objective results of the Pi plate were disappointing
[13]. Only 56% of patients in the Pi plate group
obtained a good or excellent result, versus 82 good
or excellent results in patients with two quarter-
tubular plates. There were three complications
(14.3%) in the Pi plate group, including two cases
of extensor tenosynovitis versus 0% complication
in the quarter-tubular group. Wrist motion also
was significantly better in the quarter-tubular
plate group.
The Forte plate (Zimmer; Warsaw, Indiana)
also was designed specifically for dorsal fixation of
distal radius fractures. In a prospective, multicen-
ter study of 73 fractures, satisfactory open re-
duction was obtained in 93% and maintained in
88%. At an average follow-up of approximately
1.5 years, 70 of the 73 fractures had obtained
a good or excellent result by the criteria of Gart-
land and Werley. Thirteen patients underwent
plate removal, but there were no cases of tendon
rupture [14].
Complications
Despite their decreased bulk and more ana-
tomic contour, the first generation of distal
radius-specific implants did not eliminate the
extensor tendon problems seen with dorsal plat-
ing. The Pi plate in particular seemed to pre-
dispose to extensor complications. Kambouroglou
343
reported on a series of complications with the Pi
plate [15]. In eight uses, five patients had a total of
12 complications, including two cases of extensor
rupture and five cases of extensor tenosynovitis.
Both cases of rupture were associated with fracture
of the radial arm of the Pi plate. Lowry presented
a case of extensor rupture 7 months postoperatively
attributed to poor plate placement (ie, off the bone
on radiograph) without plate fracture [16]. The
leading edge of the Pi plate was implicated in
another case report of extensor rupture [17].
A further case of extensor rupture was attributed
to a loose screw in the distal limb of the Pi plate
[18].
Use of a retinacular flap was advocated to help
prevent against tendon irritation and rupture [11],
but this practice was shown to be insufficient for
the Pi plate. In a series of 20 consecutive patients
treated with Pi plates and retinacular flaps, there
was one extensor digitorum communis (EDC)
tendon rupture, a 60% incidence of dorsal wrist
pain, and a 45% incidence of plate removal [19].
The use of titanium in the Pi plate confounded
the issues of complications attributable to plate
design and placement. Titanium particles create
increased levels of tumor necrosis factor-alpha
and interleukin-6 in monocytes [20], which may
incite extensor tenosynovitis. On the other hand,
Rozental found no difference in complication rate
or severity between titanium and stainless plates
used for dorsal plating.
Contemporary implants and techniques
The authors have extensive experience using
2.4-mm fragment-specific implants manufactured
by the AO/ASIF (Synthes Ltd, Paoli, Pennsylva-
nia) for dorsal plate fixation of complex fractures.
The indications have included dorsal shearing
fractures, double die-punch lunate facet fractures,
dorsal radiocarpal fracture dislocations, and com-
plex high-energy fractures with extension into the
metaphysis.
The implants include a radial column plate
and T- and L-shaped plates for application onto
the dorsal intermediate column. Several design
features were made specifically to limit some of
the soft tissue complications inherent in prior
dorsal plating techniques. These features include
polished surfaces with smooth, tapered edges,
precontouring to limit the need for bending or
cutting, low profile sizing 2.4-mm size screws, and
angular stability with locking screws, adding to
fixation of osteoporotic fractures.
344 TAVAKOLIAN & JUPITER

Fig. 3. (A,B) X-ray and CT scan demonstrating a comminuted, intraarticular fracture pattern. (C) Restoration of
extraarticular and intraarticular alignment with use of two small dorsal plates.

Following the initial clinical experience of 115 Technique

fractures treated by a variety of surgeons, a pro-
The radial column and intermediate column
spective multicenter study was established and has
fixation can be accomplished through a single
been following 192 patients over a 2-year period.
dorsal incision. The retinaculum of the third
Although the data are still being generated, there
extensor compartment is opened, elevating the
have been few associated soft tissue problems
extensor pollicis longus. The radial column can be
noted in the patients treated with dorsally-placed
approached through an interval between the first
implants (Fig. 3).
 DORSAL PLATING FOR DISTAL RADIUS FRACTURES 345

Fig. 3 (continued )

and second extensor compartments and the frac-
ture provisionally fixed with a 0.062-in Kirschner
wire passed from distal to proximal through the
radial styloid.
The intermediate column next is approached
by a separate retinacular exposure between the
fourth and fifth compartments or by elevating
subperiosteally the fourth compartment. Fixation
of the dorsal–ulnar fragment can be accomplished
with a T- or L-plate.
The radial column now can be fixed definitively
with a contoured radial column plate with the
reductions and plate positions monitored with
image control throughout the procedure (Fig. 4).

Fig. 4. Stepwise placement of locked dorsal plates on the intermediate and radial columns. The fracture is provisionally
fixed with a 0.062 inch Kirschner wire, followed by fixation of the dorsal-ulnar fragement with an ‘‘L’’ plate and,
ultimately, the radial column with a radial column plate.
346 TAVAKOLIAN & JUPITER
The retinacular openings can be closed, leaving
the extensor pollicis longus above the retinaculum
and soft tissues closed over a drain.
Before closure, the authors believe stability of
the DRUJ must be evaluated. If unstable and
associated with an ulnar styloid fracture, stable
fixation of the ulnar styloid restores stability in
most cases.
Postoperatively a volar splint is left in place for
approximately 10–14 days, after which motion is
encouraged. Resistance exercises are to be avoided
for the first 6 weeks.
Summary
A dorsal approach to the distal radius for
comminuted intra-articular fractures affords ex-
cellent exposure of the joint surface. Dorsal
plating can reliably buttress the joint, leading
to low rates of arthrosis, but at the expense of
wrist stiffness and high rates of extensor tendon
problems. New, smaller implants may prove
capable of supporting the joint with lower rates
of extensor irritation.
References
[1] Axelrod TS, McMurtry RY. Open reduction and
internal fixation of comminuted, intraarticular frac-
tures of the distal radius. J Hand Surg [Am] 1990;
15(1):1–11.
[2] Bradway JK, Amadio PC, Cooney WP. Open reduc-
tion and internal fixation of displaced, comminuted
intra-articular fractures of the distal end of the radi-
us. J Bone Joint Surg [Am] 1989;71(6):839–47.
[3] Fitoussi F, Ip WY, Chow SP. Treatment of dis-
placed intra-articular fractures of the distal end of
the radius with plates. J Bone Joint Surg [Am]
1997;79(9):1303–12.
[4] Jupiter JB, Lipton H. The operative treatment of
intraarticular fractures of the distal radius. Clin
Orthop Rel Res 1993;292:48–61.
[5] Gartland JJ Jr, Werley CW. Evaluation of healed
Colles’ fractures. J Bone Joint Surg [Am] 1951;33:
895–907.
[6] Green DP, O’Brien ET. Open reduction of carpal
dislocations: indications and operative techniques.
J Hand Surg [Am] 1978;3(3):250–65.
[7] Cooney WP, Bussey R, Dobyns JH, Linscheid RL.
Difficult wrist fractures. Perilunate fracture–disloca-
tions of the wrist. Clin Orthop Rel Res 1987;214:
136–47.
[8] Hove LM, Nilsen PT, Furnes O, Oulie HE,
Solheim E, Molster AO. Open reduction and inter-
nal fixation of displaced intraarticular fractures of
the distal radius. 31 patients followed for 3–7 years.
Acta Orthop Scand 1997;68(1):59–63.
[9] Rikli DA, Regazzoni P. Fractures of the distal end
of the radius treated by internal fixation and early
function. A preliminary report of 20 cases. J Bone
Joint Surg [Br] 1996;78(4):588–92.
[10] 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 [see comment]. J Bone Joint Surg [Br]
2000;82(3):340–4.
[11] Ring D, Jupiter JB, Brennwald J, Buchler U,
Hastings H Jr. Prospective multicenter trial of a
plate for dorsal fixation of distal radius fractures
[see comment]. J Hand Surg [Am] 1997;22(5):
777–84.
[12] Campbell DA. Open reduction and internal fixation
of intra articular and unstable fractures of the distal
radius using the AO distal radius plate [see com-
ment]. J Hand Surg [Br] 2000;25(6):528–34.
[13] Hahnloser D, Platz A, Amgwerd M, Trentz O. Inter-
nal fixation of distal radius fractures with dorsal
dislocation: pi-plate or two 1/4 tube plates? A pro-
spective randomized study. J Trauma Injury Infect
Crit Care 1999;47(4):760–5.
[14] Carter PR, Frederick HA, Laseter GF. Open reduc-
tion and internal fixation of unstable distal radius
fractures with a low-profile plate: a multicenter
study of 73 fractures. J Hand Surg [Am] 1998;
23(2):300–7.
[15] Kambouroglou GK, Axelrod TS. Complications of
the AO/ASIF titanium distal radius plate system
(pi plate) in internal fixation of the distal radius:
a brief report [see comment]. J Hand Surg [Am]
1998;23(4):737–41.
[16] Lowry KJ, Gainor BJ, Hoskins JS. Extensor tendon
rupture secondary to the AO/ASIF titanium distal
radius plate without associated plate failure: a case
report. Am J Orthop 2000;29(10):789–91.
[17] Lucas GL, Fejfar ST. Complications in internal
fixation of the distal radius [comment]. J Hand
Surg [Am] 1998;23(6):1117.
[18] Schnur DP, Chang B. Extensor tendon rupture
after internal fixation of a distal radius fracture
using a dorsally placed AO/ASIF titanium pi
plate. Arbeitsgemeinschaft fur Osteosynthesefragen/
Association for the Study of Internal Fixation. Ann
Plast Surg 2000;44(5):564–6.
[19] Chiang PP, Roach S, Baratz ME. Failure of a
retinacular flap to prevent dorsal wrist pain after
titanium Pi plate fixation of distal radius fractures.
J Hand Surg [Am] 2002;27(4):724–8.
[20] Blaine TA, Rosier RN, Puzas JE, et al. Increased lev-
els of tumor necrosis factor-alpha and interleukin-6
protein and messenger RNA in human peripheral
blood monocytes due to titanium particles. J Bone
Joint Surg [Am] 1996;78(8):1181–92.
 Hand Clin 21 (2005) 347–354
Volar Plate Fixation of Distal Radius Fractures
Jorge Orbay, MD
Miami Hand Center, 8905 Southwest 87 Avenue, Suite 100, Miami, FL 33176, USA
Reliable internal fixation for the comminuted
or osteoporotic distal radius fracture finally be-
came available with the introduction of fixed
angle fixation implants [1,2]. These implants
function as neutralization devices; they provide
distal stability by direct support of the subchon-
dral bone and do not depend on distal screw
purchase to maintain reduction. Most distal
radius fractures are dorsally displaced [3] and
surgeons have long been familiar with the concept
of buttress plating. Also, the dorsum of the radius
is subcutaneous and of easy access. For these
reasons, the initial experience with fixed angle
internal fixation of dorsally displaced distal radius
fracture was through the dorsal approach [1,4–
13]. Because there is little space available on the
dorsal aspect of the distal radius, implant related
extensor tendon problems were reported and these
tempered the enthusiasm for the new technique
[1,8–10,12,14–21]. Volar fixed angle fixation of
dorsally displaced distal radius fractures was
introduced to circumvent the problems related to
the dorsal approach [22]. This new method pre-
sented many advantages and new challenges, all of
which are the subject of this article.
Anatomic considerations
There are several reasons why the dorsal aspect
of the radius is a poor site for the placement of
internal fixation hardware: little space is available
between the skin and the bone surface and it is
occupied fully by extensor tendon sheaths; the
dorsal surface of the radius is convex, inducing
extensor tendons to rub forcefully against dorsal
implants, therefore increasing their likelihood of
injury; blood vessels to the distal fragments are
E-mail address: jlorbay@aol.com
0749-0712/05/$ - see front matter Ó 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.hcl.2005.02.003
mainly on the dorsal aspect, exposing them to
harm during dissection; the dorsal cortex usually
is comminuted, increasing the difficulty of the
procedure; and finally, dorsal scars are less well
tolerated [20,23]. The volar aspect is a better
choice for implant application for the following
reasons: more space is available, because flexor
tendons are located far from the volar radial
surface and the pronator quadratus is conveni-
ently interposed; the concave surface of the distal
radius protects flexor tendons from hardware
irritation; blood supply is less likely to be dis-
turbed by a volar approach; the volar cortex
usually is less comminuted, facilitating volar
osteosynthesis; and finally, volar scars are better
tolerated [20,23] (Fig. 1).
Careful examination of the volar aspect of the
distal radius reveals anatomic features that must
be considered to optimize the technique of volar
fixed angle fixation. The concave surface of the
volar radius is limited distally by a transverse
ridge or watershed line. Distal to the watershed
line, the radius slopes in a dorso-distal direction
and receives the proximal attachments of the volar
wrist capsule and the volar capsular ligaments.
This ridge lies close (2 mm) to the joint line on its
ulnar aspect and well proximal (10–15 mm) from
the joint line on its radial aspect. Although not
a straight line, its overall trajectory is roughly
normal to the axis of the radius, not following the
radial inclination of the joint surface. Fixation
implants must be placed proximal to and their
profile must not project above the watershed line
for them not to come in contact with flexor
tendons. Implants placed over or projecting above
the watershed line can impinge on flexor tendons
and can cause injury. The fractured volar rim of
the lunate fossa or volar marginal fragment is
found on the ulnar aspect of the distal radius [12].
It is critical for stability of the radiocarpal joint
hand.theclinics.com
348
Fig. 1. The volar aspect is a better environment for the
application of fracture implants. Although extensor
tendons are in intimate contact with dorsal plates (1),
flexor tendons are well separated from volar plates (2)
and only approach at the watershed line (").
[7,23–27]; its failure to unite can result in volar
dislocation of the carpus. The distal location of
the watershed line on this fragment permits its
safe stabilization by buttressing implants (Fig. 2).
On the other hand, the styloid process of the
radius rarely needs buttressing [4], but rather is
fixed by properly directed pegs. This is fortunate,
because the watershed line is proximal on this
fragment and the essential volar capsular liga-
ments, which originate from its volar surface,
must be preserved at all costs.
Fig. 2. A properly designed volar plate must provide
sufficient distal buttressing surface to control the volar
marginal fragment (2) but must not project beyond or
above the watershed line (1) to prevent contact with
flexor tendons.
ORBAY
Distal radius fractures are easy to reduce
closed when the fractures are recent and the
hematoma has not yet organized. A few days
after the fracture, as the healing process begins,
they become much more difficult to reduce. It then
becomes necessary to débride the organizing
fracture hematoma to obtain an acceptable re-
duction; this is particularly true of intra-articular
fractures. The traditional volar approach provides
access only to the volar surface of the radius.
Although sufficing for volar fractures, this expo-
sure is insufficient to manage complex dorsally
displaced fractures, because the dorsal hematoma
is not accessible. The extended flexor carpi radialis
(FCR) approach was introduced to manage com-
plex dorsal fractures through a volar incision.
Exposure is provided by releasing the radial
septum and pronating the proximal radius out
of the way to access the dorsal aspect of the
fracture (Figs. 3 and 4). This maneuver allows
debridement of the fracture hematoma or callus
and therefore reduction of complex articular
injuries. To pronate the radius and to facilitate
reduction, the brachioradialis tendon, which in-
serts on the floor of the first extensor compart-
ment, must be released. This is accomplished best
by opening the proximal aspect of the first
extensor compartment, finding the insertion of
the brachioradialis, and releasing it with a step-cut
tenotomy; this facilitates its subsequent repair.
This tendon has substantial proximal insertions
and therefore does not retract; its repair, on the
other hand, allows the proper anchoring of
sutures for reattaching the pronator quadratus.
Fig. 3. At the level of the distal radial metaphysis, the
radial septum is a complex fascial structure that includes
the insertion of the brachioradialis (1) and the first
extensor compartment (2) (Courtesy of Dr. Eduardo
Gonzales, MD).
 DISTAL RADIUS, VOLAR PLATE, FIXED ANGLE FIXATION
Fig. 4. The extended FCR approach allows the volar
management of complex articular fractures. Pronation
of the proximal fragment out of the way provides the
access necessary to débride the fracture site and reduce
articular fragmentation (Courtesy of Dr. Eduardo
Gonzales, MD).
It is important to maintain blood supply to the
proximal radial fragment by preserving branches
of the anterior interosseous artery. These supply
the radial shaft along its ulnar border and are
located on the surface of the interosseous mem-
brane. Most severe dorsally displaced distal radius
fractures present with a rupture of the pronator
quadratus that occurs commonly at its distal edge,
where separation of the muscle fibers from the
distal fibrous tissue occurs. This rupture is located
several millimeters proximal to the rim of the
radial concavity or watershed line. To achieve the
exposure of the volar radial surface required for
fracture reduction and plate application, it is
usually necessary to dissect off the fibrous tissue
found distal to the zone of rupture but proximal
to the origin of the volar wrist capsule. This zone
of thick fibrous tissue and periosteum is called the
intermediate fibrous zone (IFZ) (Please provide
year of communication for Nelson and Bindra
reference. D. Nelson and R. Bindra, personal
communication). It is best raised as a narrow
ulnar-based soft tissue flap by incising along the
watershed line and lifting it up by means of sharp
dissection (Fig. 5).
After completion of osteosynthesis, replacing
the pronator quadratus back into place improves
stability of the distal radioulnar joint and restores
the soft tissue layer underneath the flexor tendons.
The IFZ flap is repositioned first, covering the
distal edge of the plate. Subsequently the muscu-
lar part of the pronator quadratus is sutured to it
349
Fig. 5. Typically, dorsally displaced fractures present
a rupture of the pronator quadratus. Separation occurs
between the muscle belly (2) and the intermediate fibrous
zone (1), a zone of thick fibrous tissue and periosteum
located proximal to the wrist capsule. To provide
valuable exposure, it is raised as a narrow ulnar based
soft tissue flap by incising along the watershed line.
and to the previously repaired brachioradialis.
The median nerve and radial artery must be
protected at all times. It is not necessary to dissect
out these neurovascular structures; they should be
kept safe in an intact soft tissue envelope.
Biomechanical aspects
Many severe distal radius fractures present
instability in a dorsal and a volar direction. Under
these circumstances loads transferred through
bone contact across the fracture are minimal;
therefore a fixed angle implant that restores the
radius to its original length faces the full magni-
tude of the joint reaction force. Putnam reported
that the joint reaction force on the distal radius is
three to five times the measured grip strength [28].
Light activities of daily living can require 5–10 lb
of grip strength; this induces up to 50 lb across
the implant. Heavier use of the hand generates
proportionally higher forces. Clearly the design of
fixed angle plates for distal radius fractures must
account for loads much higher than those faced by
conventional buttress plates. Surprisingly a volar
fixed angle plate supporting a fracture unstable in
a dorsal and a volar direction is in a more
favorable biomechanical situation than a corre-
sponding dorsal fixed angle plate. This is because
of the particular geometry of the distal radius,
whose articular surface is offset a few millimeters
in a volar direction with respect to the diaphysis.
This places the joint reaction force closer to the
350
volar plate and decreases the induced bending
moment.
Fixed angle distal radius implants provide
distal fixation by means of pegs that can be
smooth or threaded. The latter are known also
as locking screws or angle stable screws. These
fixed angle elements rigidly attach onto the plate
and provide fixation to the distal fragment pri-
marily by buttressing or interference (Fig. 6). In
the presence of osteoporosis, the strongest re-
maining bone on the distal fragment is the
subchondral plate, and smooth pegs and threaded
pegs provide reliable fixation only if applied
immediately below this structure. Because most
distal radius fractures are dorsally displaced, it
is of primary importance to support the dorsal
aspect of the subchondral plate to prevent fracture
redislocation. Dorsal support is provided best by
placing the pegs inclined in a proximal-volar to
distal-dorsal direction in the lateral plane and by
diverging or fanning them out in space to closely
follow the complex 3-dimensional shape of the
articular surface. The inclination of the pegs in the
lateral plane neutralizes dorsal displacing forces
while inducing a volar force. This force vector
tends to displace the distal fragments in a volar
direction, an effect that must be opposed by
a properly configured volar buttressing surface.
In essence, fixed angle volar fixation of dorsally
unstable distal radius fractures entails capturing
the distal fragments between distally inclined
subchondral support pegs and a volar buttressing
plate. Threaded pegs find application in the event
of a coronal fracture plane. Here the force applied
by the lunate tends to spread apart the fragments
Fig. 6. Fixed angle elements can be smooth or threaded.
They are attached rigidly onto the plate and provide
fixation to the distal fragment primarily by buttressing
or interference.
ORBAY
of the lunate fossa; this effect is opposed by the
presence of threads (Fig. 7). In the case of severe
comminution, volar instability, or osteoporosis,
this basic configuration might not be enough to
assure proper fixation and a third fixation element
must be introduced. This is the secondary or distal
peg row, which consists of an additional row of
pegs originating from a more distal position on
the plate and having an opposite inclination. This
distal row therefore crosses the proximal row
approximately at its midline and is intended to
support the more central and volar aspect of the
subchondral bone. It controls dorsal rotation of
a volar marginal fragment and volar rotation of
severely osteoporotic or unstable distal fragments.
Together both rows form a 3-dimensional scaffold
that cradles the articular surface, maintaining
reduction despite extreme instability (Fig. 8).
Because pegs are loaded in a cantilever manner,
the greatest stresses are placed close to the plate–
peg interface. Pegs must be of sufficient strength
and the link between pegs and plate must be
strong enough to resist the high bending loads
that are generated during rehabilitation.
Review of clinical experience
Volar fixed angle fixation of distal radius
fractures was introduced as a solution for the
dorsal fracture shortly after the initial disappoint-
ment with dorsal fixed angle plates. Volar fixed
angle plates designed for the management of volar
fractures were commercially available at that time
and were simply used for the new indication. The
Fig. 7. Threaded pegs are most useful in the event of
a coronal fracture plane where the force applied by the
lunate tends to spread apart the fragments. Fixed angle
K-wires provide temporary stability and anticipate peg
location.
 DISTAL RADIUS, VOLAR PLATE, FIXED ANGLE FIXATION
Fig. 8. Two rows of pegs are necessary to provide
optimal support to the articular surface. Crossing in the
lateral plane, these form a 3-dimensional scaffold that
cradles articular fragments.
new approach quickly revealed its benefits: early
return of function, improved final motion, the
virtual elimination of extensor tendon problems,
and the abolition of routine plate removal.
Because these primitive implants were not de-
signed for this purpose, problems were soon
apparent; plate breakage and failure of distal
fixation was common. These early plates proved
too weak for this application and their inadequate
peg configuration allowed dorsal rotation of the
distal fragment and provided poor support to
comminuted dorsal lunate and radial styloid fossa
fragments. To improve results, the first plates
designed specifically for volar fixation of dorsal
fractures were made stronger and peg distribution
was improved. Plates were designed to project
their pegs underneath the entire span of the dorsal
subchondral plate, requiring the placement of
each individual peg on a unique nonparallel axis.
Threaded pegs also were introduced to aid fixa-
tion of dorsal fragments in the event of commi-
nution through a coronal fracture plane. These
improvements together with refinements of the
surgical approach enabled the routine volar man-
agement of most dorsally unstable fractures.
Naturally these first volar fixed angle plates
designed for dorsal fractures also were used to
stabilize volarly displaced fractures, and experi-
ence with these prompted new improvements.
Small volar marginal fragments that originate
from the volar rim of the lunate fossa occur
occasionally as secondary fracture lines and mostly
in volar directed injuries. These fragments must be
buttressed properly, because they are crucial for
stability of the radiocarpal joint. Improvement of
the volar buttressing function of the volar fixed
351
angle plate was accomplished by extending the
supporting surface distally to just short of the
watershed line while maintaining the pegs in
the already optimized dorsal subchondral posi-
tion. This resulted in a longer buttressing surface,
particularly on the ulnar aspect where it addresses
the volar marginal fragment and a plate profile
presenting a reversed silhouette. In addition, the
enlarged buttressing area allowed the incorpora-
tion of a second and more distal row of pegs
designed to support the volar section of the
articular surface. These distal pegs are inclined
in an opposite direction to the proximal ones to
better neutralize volar displacing forces.
A large number of distal radius fractures occur
in elderly and infirm patients and these have
special requirements: their limited coping abilities
compel that function be restored promptly to
maintain their independence, their poor bone
quality requires particularly capable fixation,
and the risk for anesthesia and surgical morbidity
must be minimized. Volar fixed angle fixation has
proven an adequate treatment method for this
patient population [29], because the technique
relies on the only substantial bone remaining in
advanced osteoporosis, the subchondral plate.
Also, the volar approach is well tolerated and
the procedure can be performed under regional
anesthesia (Fig. 9).
Complications encountered with volar fixed
angle fixation are few and frequently are related
to surgical technique. Failure to achieve anatomic
reduction is usually caused by inadequate surgical
exposure, ie, failure to use the extended FCR
approach for the purpose of fracture debridement.
This usually occurs when the injury is more than
2 weeks old or when there is severe articular
fragmentation and displacement. Extensor tendon
injury still can occur if pegs of excessive length,
which protrude through the dorsal cortex and into
the extensor tendon sheaths, are implanted. Loss
of fixation is uncommon but can occur, especially
in the more complex fractures, if improperly sized
plates are used or if pegs are placed too proximal
to the subchondral bone. To facilitate proper
plate placement, the newer plates permit the
temporary application of specialized fixed angle
K-wires that maintain reduction and anticipate
the final position of the pegs. This allows the
surgeon to optimize the plate’s position by finding
the point at which balance occurs between sup-
port of the dorsal subchondral bone and buttress-
ing of the volar radial surface. Flexor tendon
impingement can occur if the fracture redisplaces
352 ORBAY

Fig. 9. (A,B) PA and lateral preoperative films of a 78-year-old woman with a left osteoporotic intra-articular distal
radius fracture. (C,D) PA and lateral 3-month follow-up views showing the healed fracture with anatomic restitution.
(E) Final wrist extension, flexion pronation, and supination.
 DISTAL RADIUS, VOLAR PLATE, FIXED ANGLE FIXATION 353

Fig. 9 (continued)

into a dorsal deformity and the plate therefore is
lifted off from the volar surface and into the path
of the flexor tendons. Redisplacement into dorsal
deformity must be reoperated early to prevent
flexor tendon injury. Implant breakage is rare,
but, as for any implant, it can occur if fracture
healing is delayed and the race against fatigue
failure is lost. This can be prevented by the proper
use of bone graft and careful technique to preserve
vascularity of the diaphyseal fragment. Delayed
healing is rare in fresh fractures but more likely
after performing an osteotomy and using non-
autologous bone graft or a synthetic substitute.
Stiffness and reflex sympathetic dystrophy (RSD)
are uncommon with this technique but must be
watched for and treated aggressively in their early
stages. Allowing the patient to perform early
functional use of the hand is preventive. In
general, vigilance and attention to detail avoid
most complications.
The overall experience with volar fixed angle
fixation for the general treatment of unstable
distal radius fractures has been favorable, and
for this reason the technique has gained wide-
spread acceptance recently. It is an easy to learn,
[10] Leibovic SJ, Geissler WB. Treatment of complex
simple, and reproducible procedure that has
improved the outcome of this common injury.
[11] Fernandez DL, Jupiter JB. Fractures of the distal
References
[12] Carter PR, Frederick HA, Laseter GF. Open reduc-
[1] Ring D, Jupiter JB, Brennwald J, Büchler U,
Hastings H. Prospective multicenter trial of a plate
for dorsal fixation of distal radius fractures. J
Hand Surg Am 1997;22:777–84.
[2] Gesensway D, Putnam MD, Mente PL, Lewis JL.
Design and biomechanics of a plate for the distal
radius. J Hand Surg Am 1995;20:1021–7.
[3] Jupiter JB, Fernandez DL, Toh CL, Fellmann T,
Ring D. The operative management of volar articu-
lar fractures of the distal end of the radius. J Bone
Joint Surg Am 1996;78:1817–27.
[4] Melone CP Jr. Articular fractures of the distal
radius. Orthop Clin N Am 1984;15(2):217–36.
[5] Knirk JL, Jupiter JB. Intra-articular fractures of the
distal end of the radius in young adults. J Bone Joint
Surg Am 1986;68:647–59.
[6] Bradway JK, Amadio PC, Cooney WP. Open re-
duction and internal fixation of displaced, com-
minuted intra-articular fractures of the distal
end of the radius. J Bone Joint Surg Am 1989;
71:839–47.
[7] Fernandez DL, Geissler WB. Treatment of displaced
articular fractures of the radius. J Hand Surg 1991;
16A:375–84.
[8] Peine R, Rikli DA, Duda G, Regazzoni P. Compar-
ison of three different plating techniques for dorsum
of the distal radius: a biomechanical study. J Hand
Surg Am 2000;25:29–33.
[9] Hastings H, Leibovic SJ. Indications and techniques
open reduction: internal fixation of distal radius
fractures. Orthop Clin N Am 1993;24:309–26.
intra-articular distal radius fractures. Orthop Clin
North Am 1994;25:685–706.
radius: a practical approach to management. New
York: Springer-Verlag; 1996.
tion and internal fixation of unstable distal radius
fractures with a low-profile plate: a multicenter
study of 73 fractures. J Hand Surg Am 1998;23:
300–7.
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[13] Rikli DA, Regazzoni P. Fractures of the distal end of
the radius treated by internal fixation and early func-
tion. J Bone Joint Surg Br 1996;78:588–92.
[14] Hove LM, Nilsen PT, Furnes O, et al. Open reduc-
tion and internal fixation of displaced intraarticular
fractures of the distal radius. 31 patients followed for
3–7 years. Acta Orthop Scand 1997;68(1):59–63.
[15] Jakob M, Rikli DA, Regazzoni P. Fractures of the
distal radius treated by internal fixation and early
function. J Bone Joint Surg Br 2000;82:340–4.
[16] Fernandez DL. Correction of posttraumatic wrist
deformity in adults by osteotomy, bone-grafting
and internal fixation. J Bone Joint Surg Am 1982;
64:1164–78.
[17] Fitoussi F, Ip WY, Chow SP. Treatment of dis-
placed intraarticular fractures of the distal end of
the radius with plates. J Bone Joint Surg Am 1997;
79:1303–12.
[18] Axelrod TS, McMurty RY. Open reduction and In-
ternal fixation of the comminuted, intraarticular
fractures of the distal radius. J Hand Surg Am
1990;15:1–11.
[19] Kambouroglou GK, Axelrod TS. Complications
of the AO/ASIF titanium distal radius plate system
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a brief report. J Hand Surg Am 1998;23:737–41.
[20] Fernandez DL. Should anatomic reduction be pur-
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25:523–7.
[21] Nunley JA, Rowan PR. Delayed rupture of the
flexor pollicis longus tendon after inappropriate
ORBAY
placement of the Pi plate on the volar surface of
the distal radius. J Hand Surg 1999;24(6):1279–80.
[22] Orbay JL. The treatment of unstable distal radius
fractures with volar fixation. Hand Surg 2000;5:
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[23] Baratz ME, Des Jardins JD, Anderson DD,
Imbriglia JE. Displaced intraarticular fractures of
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[24] Scheck M. Long-term follow up of treatment of
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[25] Harness NG, Jupiter JB, Orbay JL, Raskin KB,
Fernandez DL. Loss of fixation of the volar lunate
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the radius. J Bone Joint Surg [Am] 2004;86(9):
1900–8.
[26] Melone CP Jr. Open treatment for displaced articu-
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[27] Melone CP Jr. Distal radius fractures: patterns of
articular fragmentation. Orthop Clin N Am 1993;
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[28] Putnam MD, Seitz WH Jr. Advances in fracture
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[29] Orbay JL, Fernandez DL. Volar fixed-angle plate
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 Hand Clin 21 (2005) 355–362

Fragment-Specific Internal Fixation of Distal

Radius Fractures
Donald S. Bae, MDa, Mark J. Koris, MDb,*
a
Department of Orthopaedic Surgery, Children’s Hospital Boston, 300 Longwood Avenue,
Hunnewell 2, Boston, MA 02115, USA
b
Department of Orthopaedic Surgery, Brigham and Women’s Hospital, 75 Francis Street,
Boston, MA 02115, USA

Anatomic reduction, articular reconstitution, congruity ultimately leads to symptomatic arthro-

stable internal fixation, and early wrist motion are
key elements in achieving the best possible func-
tional outcomes following fractures of the distal
radius. Many methods of surgical treatment have
been used to accomplish these goals, including
percutaneous Kirschner wire fixation, augmented
external fixation, and open reduction and internal
fixation using a variety of implants. Recently, the
concept of fragment-specific internal fixation has
been introduced in the treatment of complex distal
radius fractures. Fragment-specific internal fixa-
tion refers to the use of limited open surgical
approaches and low-profile, anatomically con-
toured plate constructs to provide rigid fixation
of each individual fracture fragment. This article
reviews the principles and results of fragment-
specific internal fixation in the treatment of these
injuries.
Historical perspective
The notion of providing internal fixation
specific for individual periarticular fracture frag-
ments is not a novel concept. Indeed, the stable
restoration of normal anatomy allowing for bony
healing and early return of function serves as
the foundation of modern fracture management.
The treatment of distal radius fractures is no
exception.
Knirk and Jupiter [1] have previously demon-
strated that failure to achieve adequate articular
* Corresponding author.
E-mail address: mkoris@partners.org (M.J. Koris).
0749-0712/05/$ - see front matter Ó 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.hcl.2005.04.007
sis, and these findings have been corroborated by
others [2,3]. Kihara and colleagues [4] demon-
strated that accurate reduction of the distal radius
is also important in restoring normal distal radio-
ulnar joint (DRUJ) function. Short and cow-
orkers [5] have previously demonstrated that
imperfect reductions of distal radius fractures
lead to differences in pressure distribution along
the distal radial and ulnar articular surfaces.
Werner and associates [6] have similarly demon-
strated that failure to restore radial length signif-
icantly alters load bearing across the radiocarpal
and ulnocarpal joints. In their clinical study of 43
patients who had intra-articular distal radius
fractures, Trumble and coauthors [7] demon-
strated that restoration of articular congruity
and radial length is critical for pain relief, wrist
motion, and grip strength following treatment.
Previous classification systems have identified
common patterns of intra- and extra-articular
fractures of the distal radius. The Frykman
classification [8], for example, was important in
distinguishing between intra- and extra-articular
injuries and highlighting the involvement of the
DRUJ. The Melone classification of intra-
articular distal radius fractures [9] was among
the first to describe the common fracture patterns,
emphasizing the importance of the dorsal and
volar lunate facet fragmentsdin addition to the
radial styloid componentdin treatment. More
recently, Peine and colleagues [10] and Rikli and
coworkers [11] have introduced the ‘‘three-column
concept’’ of the distal radius and ulna. In this
concept, the radial column is compromised of the
hand.theclinics.com
356
radial styloid and scaphoid facet, the intermediate
column by the lunate facet and sigmoid notch,
and the ulnar column by the distal ulna with its
associated triangular fibrocartilage complex
[10,11]. These classification systems, perhaps
even more so than the mechanistic classification
system of Jupiter and Fernandez [12] or the
universal AO (arbeitsgemeinschaft für osteosyn-
thesefragen) classification system [13], highlight
the common patterns of distal radial fragmenta-
tion seen with these injuries (Fig. 1).
Understanding of these intra-articular anatom-
ical patterns is needed to address these injuries
adequately. Indeed, many of the methods used to
treat extra-articular fractures were applied to
intra-articular injuries with mixed results. Closed
reduction and cast immobilization, although suc-
cessful in stable extra-articular fractures, proved
to be ineffectual in maintaining reduction of
complex intra-articular injuries, because of lack
of ligamentotaxis and inherent instability of
articular fragments [14,15]. External fixation al-
lowed for restoration of length, but did not
control lateral tilt or articular congruity [14,15].
External fixation augmented with percutaneous
Kirschner-wire fixation provided increased stabil-
ity of the articular fragments and restoration of
appropriate lateral tilt; however, the need for
prolonged immobilization and distraction often
resulted in compromised wrist motion and hand
Fig. 1. Schematic diagram depicting the typical fracture
fragments of a comminuted intra-articular distal radius
fracture. Note the radial styloid, dorsal lunate facet,
volar lunate facet, and dorsoulnar fracture frag-
ments. (Courtesy of Trimed, Inc., Valencia, CA; with
permission.)
BAE & KORIS
function [16–18]. Open reduction and internal
fixation (ORIF) with standard 3.5-mm dorsal or
volar plates allowed for direct fracture reduction
and rigid stabilization [9,19–21]. Results of treat-
ment were encouraging and represented an im-
provement upon many prior methods of
treatment. This lead to the use of these standard
internal fixation devices for many different pat-
terns of injury.
A number of concerns arise with this ‘‘one
plate fits all’’ approach to distal radius fracture
management. In some instances, the available
constructs do not provide adequate fracture
stability, particularly for small articular frag-
ments, fractures in osteoporotic patients, and
fractures associated with subchondral or cortical
bone loss. Furthermore, these relatively bulky
implants, by necessity, lie in close proximity to
gliding structures with limited adjacent soft-tissue
coverage. This has led to troubles with tendon
irritation or rupture, particularly in the setting of
dorsally placed implants [19,21]. Finally, the use
of standard internal fixation devices often fails to
address the underlying pathoanatomy. Recently,
Harness and colleagues [22] reported on the loss
of fixation of the volar lunate facet fragment
following ORIF via a volar approach using
a locking plate and screw construct [22,23].
Harness and colleagues comment that failure to
recognize the complex anatomy of the distal volar
radius and pattern of distal radial fracture con-
tributed to the loss of fixation.
These considerations reinforce the concept that
reliance upon a single device or technique for
variable patterns of injury must be avoided. Part
of the problem lies in the inability to compare
outcomes of treatment, as results are reported
using a variety of devices for a variety of injury
patterns, often with nonvalidated or unreliable
outcome measures. More fundamental, however,
is the need for treating surgeons to adequately
recognize the individual pattern of injury and
address each component of the pathoanatomy
appropriately.
Many new tools are now available. Better
elucidation of normal anatomy and the deforming
forces on distal radial fracture fragments have
allowed for newer anatomic approaches [24–26].
Radiographic techniques for assessing fracture
patterns have improved [27]. In particular,
computed tomography (CT), with or without
three-dimensional reconstructions, has provided
surgeons with better understanding of fracture
patterns and congruency of the radiocarpal and
 DISTAL RADIAL FRACTURE FRAGMENT-SPECIFIC FIXATION
radioulnar articulations. Newer implants for dis-
tal radial fixation are currently available, many of
which are anatomically contoured, lower profile,
and able to use locking screw constructs [21,28–
30]. Examples of these plates include the LoConT
(Wright Medical Technology, Arlington, Tennes-
see), Forte (Zimmer, Warsaw, Indiana), Pi (Syn-
thes, Paoli, Pennsylvania), 2.4 mm locking
(Synthes), and DVR (Hand Innovations, Miami,
Florida). Furthermore, there is an increasing
understanding of the potential pitfalls of surgical
treatment.
Most important, however, is an adherence to
the fundamental principle of treatment: to provide
stability of reduction while avoiding soft-tissue
complications. Invoking Melone’s four parts of
distal radius fractures and Peine’s ‘‘three column’’
concept of the distal forearm, the best way to
achieve a stable reduction may be to address these
parts or columns individually [31]. One fracture
fixation system based upon these principles is the
Trimed Wrist Fixation System (Trimed, Valencia,
California), which uses low-profile, anatomically
contoured plates designed specifically for the
dorsoradial, dorsoulnar, and volar aspects of the
distal radius, thus allowing for the reconstruction
of each column. These implants may be applied
through less invasive approaches to the distal
radius, and may be used in combination, accord-
ing to each patient’s fracture pattern.
Biomechanical studies on fragment-specific
fixation
A number of prior biomechanical analyses
support the concept of fragment-specific fixation
in the treatment of distal radius fractures. In their
assessment of percutaneous pin fixation of extra-
articular distal radius fractures, Naidu and col-
leagues [32] concluded that cross-pinning with
both radial styloid pins and dorsoulnar pins
provided the most rigid fixation when tested in
both torsion and cantilever bending. This bio-
mechanical study confirmed that stabilization of
both the radial and intermediate columns is
important in providing rigid fixation, consistent
with the concept of fragment-specific fixation.
Peine and coworkers [10] assessed the bio-
mechanical properties of three different internal
fixation techniques in cadaveric specimens with
simulated extra-articular distal radius fractures.
Four-point bending was applied to specimens
stabilized with dorsal 3.5 mm T plates, dorsal Pi
357
plates, or two 2.0 mm titanium plates (all from
Synthes) applied to the dorsoulnar and dorsor-
adial aspects of distal radius. The double-plating
technique was found to be significantly stiffer in
all bending models compared with the dorsal
3.5 mm T and Pi plates. Trends were also found
for decreased angular deformation and gap for-
mation using the double-plating technique. The
study authors concluded that more rigid fixation
can be attained with smaller implants if applied
appropriately. Invoking the three-column concept
of the distal forearm, the authors believe that
increased stability is provided by buttressing the
radial and intermediate columns, thereby support-
ing radial inclination and lateral tilt, respectively.
These biomechanical results were supported by
the findings of Hems and coworkers [33]. In their
cadaver study of wrists treated with quarter-
tubular plates applied along the radial and ulnar
aspects of the distal radius, cyclical compressive
loads up to an average yield strength of 1000 N
were tolerated, suggesting that orthogonally ap-
plied plates may provide adequate stability to
support early range-of-motion exercises.
Jakob and associates [34] applied these princi-
ples in their prospective analysis of 73 patients
treated with 2.0 mm titanium plates applied to the
radial and intermediate columns at 50  to 70 
from one another. Sixty-nine patients were treated
with immediate early postoperative mobilization.
All patients demonstrated good-to-excellent
anatomic results. The study authors did note,
however, that approximately 20% of patients
underwent subsequent hardware removal and
7% of patients sustained tendon ruptures.
Dodds and coauthors tested the biomechanical
properties of the Trimed Wrist Fixation System in
the fixation of simulated AO C2 and C3 fractures
in cadaveric specimens [35]. AO type C2 fractures
were stabilized with radial and ulnar pin plates,
whereas AO type C3 fractures were fixed with
radial and ulnar pin plates in addition to a wire
form subchondral buttress. Physiologic loads of
38.6 to 98 N were applied via wrist flexor and
extensor tendons after fixation was performed.
Fracture fragment motion under loading was
measured to assess stability. Increased stability
was seen in four-part fractures as compared with
augmented external fixation in all six axes of
motion. The study authors concluded that use of
this fragment-specific fixation system provides
adequate stability for early wrist motion following
fixation of complex intra-articular distal radius
fractures.
358
It is important to recognize the inherent
limitations of biomechanical analyses of distal
radius fracture fixation. Most of these studies use
cadaver models, typically stripped of soft-tissue
support and without the influence of dynamic
muscular forces. Osteotomies are created to sim-
ulate complex fracture patterns. Testing is often
performed under nonphysiologic loading condi-
tions, causing difficulty in applying the findings to
actual patients. Different investigators measure
different biomechanical parameters, with limited
or questionable applicability to physiologic con-
ditions. These limitations do not detract from the
importance or utility of biomechanical analyses;
rather, they highlight the difficulty in applying the
results of biomechanical studies to the fundamen-
tal clinical goal: bony healing and functional
restoration.
Indications
Fragment-specific internal fixation is a concep-
tual approach to treatment. Therefore, the indica-
tions for fragment-specific fixation are identical to
those of open reduction and internal fixation:
specifically, fracture instability and failure to obtain
an acceptable reduction via closed means. Though
the criteria for what is deemed ‘‘acceptable’’ con-
tinues to be debated, current recommendations for
postinjury reduction include restoration of articu-
lar congruity, less than 10  dorsal tilt, greater than
10  of radial inclination, and less than 2 mm of
radial shortening [2,7,36]. Radiographic features of
unstable injuries include comminution beyond the
midaxial line, dorsal tilt greater than 20  , radial
shortening of greater than 5 mm, extension of the
fracture into the articular surface, and patient age
greater than 60 years [37,38]. Although the princi-
ples and techniques of fragment-specific internal
fixation may be effectively applied to all fractures of
the distal radius, including extra articular injuries,
the authors specifically recommend consideration
of fragment-specific techniques in situations of
comminute-d intra-articular fractures.
Surgical technique
Surgery can be performed with regional anes-
thesia using an axillary block or under general
anesthesia. Patients are given a preoperative dose
of antibiotic for infectious prophylaxis. Under
tourniquet control, two incisions are routinely
used. Volarly, a distal Henry approach between
BAE & KORIS
the radial artery and flexor carpi radialis (FCR)
tendon is used [39]. The interval between the
pronator quadratus (PQ) and the volar aspect of
the first dorsal compartment is then developed,
with attention placed on protecting the radial
artery and branches of the radial sensory nerve.
The extensor tendons of the first dorsal compart-
ment are then elevated off the distal aspect of the
radius in a subperiosteal fashion, allowing access
to the radial column. If needed, the brachioradia-
lis tendon may be split longitudinally or elevated
subperiosteally to provide additional exposure.
This window is later used for reduction and plate
application to the radial column fragment(s). The
pronator quadratus is gently elevated to allow
inspection, reduction, and evaluation of stability
of the volar aspect of the distal radius. If needed,
it is possible to place a volar buttress plate onto
the distal radius from this exposure. In situations
of a displaced volar lunate facet fragment, how-
ever, a separate, more ulnar, volar incision may be
employed.
A second dorsal incision is created overlying
the third dorsal extensor compartment. The ex-
tensor retinaculum is incised longitudinally in line
with the skin incision, and the extensor pollicis
longus (EPL) tendon is released and retracted
radially. Subperiosteal exposure of the dorsal
radius is then completed as dictated by the
fracture pattern, with care not to disrupt the
ligamentous or capsular fibers of the dorsal
DRUJ.
Traction and ligamentotaxis assist in general
fracture alignment. Dorsally comminuted fracture
fragments are typically addressed first. If possible,
the ulnar-most fragment is reduced, re-establish-
ing DRUJ congruency. Temporary Kirschner-
wire fixation is used to provide provisional
stabilization of the dorsoulnar fragment. Reduc-
tion of the dorsal fracture fragments is continued
in an ulnar-to-radial direction. A T-shaped cap-
sulotomy may be performed to remove intra-
articular debris and confirm articular congruency.
After the dorsal fragments are aligned and
brought out to length, a combination of small
plates or wire forms are used to provide fracture
fixation (Fig. 2). Frequently, a metaphyseal bony
defect is identified upon restoration of articular
alignment. According to surgeon preference, this
gap may be filled with autologous bone graft,
allograft, or other synthetic bone graft substitutes.
Subsequently, an appropriate length radial pin
plate is applied to the radial column via the first
incision (Fig. 3). Care is taken to reestablish volar
 DISTAL RADIAL FRACTURE FRAGMENT-SPECIFIC FIXATION 359

Fig. 2. (A) Schematic diagram depicting fixation of a dorsoulnar articular fragment using an Ulnar Pin Plate from the
Trimed Wrist Fixation System. (B) Fixation of a similar dorsoulnar articular fragment using a wire-screw construct. (C)
Fixation of a ‘‘die-punch’’ or depressed articular fragment using a wire screw construct to buttress the articular surface.
(Courtesy of Trimed, Inc., Valencia, CA; with permission.)

tilt before application of the plate and radial
styloid pins.
Closure is performed allowing soft-tissue cov-
erage over the implants. In particular, meticulous
repair of the brachioradialis insertion and first
dorsal extensor compartment are performed. The
EPL tendon is routed subcutaneously. An in-
dwelling catheter is placed in the dorsal wound
to provide for post-operative analgesia (ON-Q
Painbuster, I-Flow Corporation, Lake Forest,
California). A bulky dressing and volar plaster
splint are subsequently applied.
Results of treatment
There have been few clinical reports on the
results of surgical treatment for intra-articular
distal radius fractures using fragment-specific
techniques. Jakob and colleagues [34] reported
good-to-excellent results in over 95% of their
patients treated with 2.0 mm titanium plates
placed along the radial and intermediate columns
for distal radial fractures. The majority of these
patients sustained AO C-type injuries. The study
authors report that 69 of the 73 patients in this
prospective analysis were able to initiate an
immediate postoperative mobilization program.
Martinez and coworkers [40] applied similar
principles in their treatment of 12 patients who
had distal radius fractures. Minifragment titanium
plates were used to provide fracture fixation. At
average follow-up of 18 months, there were 11
excellent results and 1 good result according to
the Gartland and Werley Demerit Scale [41]. No
patients had subsequent tendon irritation or need
for hardware removal at most recent follow-up.
Konrath and Bahler [29] reported on the results
of fragment-specific fixation using the Trimed
system in 25 patients who had unstable distal
radius fractures. No patient was treated with
additional immobilization, and all patients ini-
tiated range-of-motion exercises in the immediate
postoperative period. At average follow-up of 29
360 BAE & KORIS

Fig. 3. (A) Schematic diagram of fragment-specific fixation of the radial styloid fragment in comminuted intra-articular
fracture using a Radial Pin Plate from the Trimed Wrist Fixation System. Note the anatomically-contoured, low-profile
implant fixed with Kirschner wires and screws. A similar implant may be used to provide fixation of the radial styloid
fragment in an extra-articular fracture pattern. (B) Schematic depiction of the same implant as viewed from the radial
aspect of the distal radius. (Courtesy of Trimed, Inc., Valencia, CA; with permission.)

months, mean wrist dorsiflexion and volarflexions
were 61  and 54  , respectively. All fractures healed
in acceptable alignment, with one loss of reduction.
Mean Disability of the Arm, Shoulder, and Hand
(DASH) score was 17. Mean Patient-Rated Wrist
Evaluation (PRWE) score was 19. The study
authors conclude that fragment-specific fixation
can be used routinely in unstable distal radius
fractures with excellent clinical results and patient
satisfaction.
Price and associates reported the early out-
comes of fragment-specific fixation on 92 patients
treated with the Trimed wrist fixation system [42].
Average patient age was 50 years, and 70 of the 92
patients had AO C2 or C3 type fractures. At early
follow-up, 85% of patients had good-to-excellent
results according to the Gartland and Werley
Demerit Scale, and average DASH score was 9.4
[43]. Average wrist flexion and extension post-
operatively were 54  and 58  , respectively.
Eighty-two percent of patients had articular
reductions with less than 2 mm of incongruity.
There were no nonunions.
Complications and hardware removal
The usual indication for hardware removal is
tendon irritation or rupture caused by excursion
against the underlying implant. As described
above, this is in part due to the relative paucity
of soft tissue that can be interposed between the
dorsal distal radius and the adjacent gliding struc-
tures. Historically, rate of reoperation for hard-
ware removal is approximately 20% [19–21,
44,45].
Rozental and colleagues [45] studied 28 pa-
tients treated with dorsal plate fixation for un-
stable distal radius fractures. Nine of these 28
patients required subsequent surgery for tendon
irritation or rupture. Ring and coworkers [21]
reported the results of 22 patients treated with
dorsal internal fixation for unstable distal radius
fractures. Five of these patients had tendon
irritation from prominent hardware. Martinez
and coauthors [40] reported no need for hardware
removal due to tendon irritation or rupture in
their series of patients treated with minifragment
titanium plates; however, they duly note that
average follow-up was 18 months in the 12
patients in their study. In their report of early
results of distal radius fractures treated with the
Trimed Wrist Fixation System, Price and col-
leagues [42] reported that 21 of 92 patients
underwent subsequent hardware removal. There
was one extensor tendon rupture in their series.
Hardware removal continues to be a concern
despite advances in anatomic approaches, implant
configuration and design, and techniques of
fixation. Although planned interval hardware re-
moval is not recommended, patients should be
 DISTAL RADIAL FRACTURE FRAGMENT-SPECIFIC FIXATION
advised regarding the possibility of tendon irrita-
tion or rupture, and the need for interval implant
removal.
Summary
The treatment of complex, intra-articular dis-
tal radius fractures can be challenging. Goals of
treatment include the restoration of articular
congruity and maintenance of a stable reduction
to allow for early range-of-motion, prevention of
arthrosis, and ultimately return of upper extrem-
ity function. Proper understanding of individual
fracture patterns is paramount in achieving these
goals and avoiding complications. Through the
use of limited surgical incisions and low-profile,
anatomically contoured implants, fragment-
specific internal fixation provides a rational ap-
proach to the treatment of these complex injuries.
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 Hand Clin 21 (2005) 363–373
Biomechanics and Biology of External Fixation
of Distal Radius Fractures
Randy R. Bindra, MD, FRCS
Center for Hand and Upper Extremity Surgery, University of Arkansas for Medical Sciences,
4301 West Markham Street, Slot 531, Little Rock, AR 72205, USA
External fixation of distal radius fractures is
only one of several ways to approach this complex
injury. In fact, widespread analysis of clinical
outcomes of distal radius fractures still fails to
show improved clinical outcomes from any spe-
cific surgical treatment modality [1]. Loss of
reduction, the commonest complication of distal
radius fractures, can be prevented with the appli-
cation of an external fixator, a simple technique
that is surgically minimally invasive. Complica-
tions such as pin loosening and pin track in-
fection, wrist and finger stiffness, and complex
regional pain syndrome, however, have been
reported following the use of external fixation
for the management of distal radius fractures
[2,3]. In contradistinction to internal fixation of
a fracture with an intramedullary nail or plate by
following a defined operative technique, applica-
tion of an external fixator entails considerable
planning with regard to insertion of the anchoring
pins and construction of the external supporting
frame. In addition, external fixator use also
requires closer supervision and follow-up in the
postoperative period for mechanical (clamp re-
tightening, angular adjustment) and biologic (pin
site care) reasons.
This article reviews the mechanical properties of
external fixation and current concepts of the bi-
ology of bone healing and the pin–bone interface.
In addition, the concept unique to the treatment
of distal radius fractures—ligamentotaxis—is dis-
cussed, with attention to mechanics of reduction
The author has not received any funding or support
for this article.
E-mail address: BindraRandyR@uams.edu
0749-0712/05/$ - see front matter Ó 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.hcl.2005.02.007
and the adverse effects of prolonged traction on soft
tissues.
Types of application
Application of an external fixator to a trauma-
tized extremity may be intended as a temporary
measure or as a definitive one until the fracture
has healed.
Temporary external fixation
Occasionally an external fixator is applied
temporarily to an injured extremity with the
intention of removal after a few days, at which
time it can be replaced by other methods of
fracture stabilization, such as internal fixation.
Indications for such use are:
1. Initial management of severe grade open
fractures with extensive soft tissue loss. The
external fixator provides stability while allow-
ing access to wound care. Once soft tissues
have healed or cover has been achieved with
tissue transfer, the external frame can be
substituted for internal fixation.
2. Temporizing measure to resuscitate a poly-
traumatized patient. This use is almost
exclusive to the pelvis, where an external
fixator applied emergently can significantly
reduce internal hemorrhage, constituting an
important adjunct to primary resuscitation.
3. Pending transfer to a tertiary referral facility
for fracture management. The application of
an external fixator may be considered for the
initial management of severely comminuted
fractures, such as those of the distal radius,
if expert management is not immediately
hand.theclinics.com
364
available locally. The application of the
fixator well away from the zone of injury
does not interfere with subsequent open
reduction maneuvers and facilitates internal
fixation by allowing better imaging studies,
such as CT scanning, and maintains the soft
tissues at the correct length.
Definitive external fixation
The fixator also may be left in place for the
duration of fracture healing rather than just as
a temporizing measure pending soft tissue repair.
Soft tissue management is not usually the primary
concern, and external fixation is applied for the
management of closed fractures that are deemed
too comminuted to consider open reduction and
internal fixation. In distal radius fractures, this
has become by far the more common application,
and the external fixator remains in place until the
fracture is judged to be healed sufficiently.
Basic mechanics of an external fixator
Complexity of external fixator designs has
varied since initial descriptions of use of the
fixator in 1943 [4]. Initial fixator designs consisted
of transfixing pins passed through the extremity
with a frame on either side, the so-called ‘‘bilateral
frames.’’ By the late 1960s improved biomechan-
ical understanding and metallurgy led to the
development of sturdier but less complicated
frames applied on one side of the limb using
threaded Schanz screws: the unilateral frames [5].
With the introduction of newer concepts in limb
lengthening and three-dimensional deformity cor-
rection, the design has become complex once
again with ring fixators that encircle the extremity
and are anchored with thin transfixion K-wires.
Although described by Ilizarov in 1951, wide-
spread use of the ring fixator system only began in
the1990s. Most recently various hybrid fixators
consisting of combinations of distal transfixion
pins and proximal Schanz screws are being pro-
posed for use in distal radius fractures [6].
Components
An external fixator is a modular system that
requires assembly at the time of use to create
a stable construct. External fixators can be used
for the management of the injured extremity or
for reconstructive procedures, such as correction
BINDRA
of deformity and limb lengthening following
congenital or acquired problems. Fixator frames
vary considerably in their appearance, but all have
the same basic components: an external frame
consisting of longitudinal bars that are connected
by clamps to pins that are anchored into the bone.
Basically a fracture is immobilized by inserting
pins into each fragment and then in turn securing
the pins to a scaffold that is constructed outside
the extremity. The longitudinal bars provide the
stable frame and the pins, the bone fixation; both
play an important role in stability of the con-
struct.
Anchoring pins
Anchoring pins vary from 2.5–6.0 mm for use
with different bones. Because they are subjected to
bending forces, the pins should be sufficiently
large and strong but should not exceed a third of
the bone diameter to prevent secondary pinhole
fractures. Ring frames use small diameter (1.5–
2.0 mm) K wires placed under tension. Unilateral
frames use one half threaded pins that are
anchored into the bone from one side, whereas
bilateral frames and ring frames use transfixion
wires that pierce the extremity from one side to
the other.
Connecting rods and joints
The longitudinal connecting rods are the
strongest elements of the frame and may be
constructed of metal or lighter radiolucent mate-
rial, such as carbon fiber. The rods can be more
complex in design with a built-in articulation to
allow angular correction or they may have a com-
plex telescopic design that allows changes in
length for distraction or compression. The largest
design variation among fixators from different
manufacturers is in the way the clamps join
anchoring pins to the connecting rods. A simple
articulation or joint connects a single pin to
a longitudinal rod. A joint with multiple degrees
of freedom is referred to as a universal joint. Some
frames incorporate clamps for connecting multi-
ple anchoring pins to the longitudinal rods. These
clamps typically accommodate two or more pins
that must be inserted parallel and at a set distance
to each other to fit into the clamp. Rod–rod joints
allow longitudinal rods to be connected to each
other at varying angles to create more complex
frame configurations. A ring frame has ring–rod
joints to connect longitudinal rods across several
circular rings placed around the extremity.
 EXTERNAL FIXATION OF DISTAL RADIUS FRACTURES 365

Frame configurations combined to create a unilateral two-plane tri-

angular frame with significant increase in stability.
The modularity of most external fixation
The commonest application of external fixa-
systems allows the creation of several different
tion for distal radius fractures is across the wrist
constructs with varying stability. It is obvious that
joint or bridging fixator. In fractures with minimal
use of more pins and connecting rods provides
comminution and sufficiently large distal fragment
improved stability but potentially causes more
it may be possible to achieve fixation in the
soft tissue tethering and may increase difficulty of
proximal and distal fragments without immobiliz-
management of the pin tracks and open wounds.
ing the wrist; this is referred to commonly as the
It is thus important to achieve a balance between
nonbridging or radio–radial fixator [7]. The con-
the mechanics and biology to provide a frame that
cept of treating extra-articular distal radius frac-
is suitably strong but with minimal interference
tures using a fixator that does not span the wrist
with soft tissues. Most of the research in mechan-
joint was proposed first by Jenkins and later
ics of external fixation has examined its use in the
supported by Melendez et al [8,9]. Because there
tibia and the principles learned can be applied
is insufficient length of distal fragment to accom-
easily to the radius.
modate two parallel pins for a unilateral frame,
The basic unilateral and bilateral fixator place-
nonbridging frames usually are designed as a tri-
ment with one-plane and two-plane constructs is
angular construct with two unilateral two-pin
illustrated in Fig. 1. With the introduction of
frames connected to each other (Fig. 1).
threaded half-pins (Schanz pins) placed bicorti-
cally, adequate stability can be achieved with
Frame stability
unilateral frame configurations [5]. Most fixator
designs in use for distal radius fractures have Different fixator designs have differing degrees
a four-pin unilateral configuration. In situations of strength and stability based on the design of the
with extreme instability, such as in the presence of frame and connecting clamps. It is important,
significant bone loss, two unilateral frames may be however, to understand the basic factors that

1- plane 2- plane 1- plane 2- plane

Bridging fixator
Non bridging fixator

Fig. 1. Basic external fixator constructs and their application to the distal radius.
366
govern the stability of a generic external fixator.
Stability of a fixator construct is determined by
the following variables [5] (Fig. 2):
1. Frame configuration (unilateral, bilateral, or
triangular) and design
2. Pin size, number of pins, and pin spread along
bone
3. Pin–bone interface
4. Decreased frame–bone distance
5. Fixator placement along plane of major
displacement
6. Injury characteristics: anatomic reduction,
comminution of fracture, and use of bone
graft
7. Supplemental fixation with K-wires, augmen-
tation with graft
Several of these factors can be controlled by
the surgeon and hence it is of utmost importance
that surgical principles of pin insertion, clamp
application, and frame construction are followed
meticulously.
The strength of the fixator depends on the
rigidity of the connecting rods and the clamps.
Rod diameter and strength must be weighed
against their weight. The connecting rod must be
placed as close to the extremity as possible, and
additional rods may be added for increased
stability [10].
The pins that are part of the external fixator
construct are subjected to constant bending forces
and minimal pullout forces. Modern threaded
pins hence are designed with a larger core di-
ameter and less core-thread diameter difference to
allow the pin to withstand bending. Furthermore,
when the pin engages both cortices, it is mainly
the far cortex that is subjected to pullout forces,
whereas bending forces act on the pin fixation at
the near cortex. A pin with a short thread placed
bicortically such that the threads engage the far
Additional
connecting rod
Rod strength
Rod-bone distance
Fracture reduction
and stability
Fig. 2. Factors affecting fixator stability.
BINDRA
cortex and the thicker shaft engages the proximal
cortex thus provides the best pin–bone fixation.
The pins selected must be strong and as large as
possible proportionate to the bone in which they
are to be inserted [11,12]. In radius fixation
compared with 3-mm pins, 4-mm self-tapping
half-pins are 145% stronger in bending and have
significantly higher pull-out strength of 76% and
only 8% decrease in torsional load strength of the
bone [13]. Cylindric pins (also known as Schanz
screws) are preferable to tapered or triangular
pins. The latter were first designed to allow further
tightening by advancing a wider part of the screw
into the cortex at first signs of loosening. These
tapered screws, however, have the drawback that
once inserted too deep cannot be backed out,
because they will be loose.
Bone can tolerate compression better than
tension or shear forces. One way to reduce pullout
and increase compression forces at the pin–bone
interface is to preload or prestress the pins before
fixing to the external fixation system [10]. When
a fixator is applied to neutralize forces in an
unstable fracture configuration, the pins in the
two fracture fragments cannot be compressed
against each other. Compression at the pin–bone
interface can be generated by pre-stressing the
pins of each fragment against themselves as they
are attached to the frame. This is done by elastic
deformation of the pins as they are attached to the
frame by squeezing them together (compression)
or separating them (distraction). Although it is
a sound biomechanical principle, preloading a pin
can cause excessive unilateral cortical pressure
and subsequent necrosis and loosening, and its use
in the radius no longer is recommended [14].
Another method of applying compression at
the pin–bone interface is to create a tight-fit of the
pin in the bone, referred to as radial preload. Pre-
drilling the hole for pin insertion with a smaller
Pin spread
Clamp rigidity
Pin diameter
Pin-bone interface
Supplemental K-wire fixation
 EXTERNAL FIXATION OF DISTAL RADIUS FRACTURES
hole than the pin has been recommended for most
fixation systems. Drilling removes bone debris
from the hole and heat generation is minimal.
Animal studies have shown that bone resorption
occurs at areas of the bone that are not subjected
to compression, and radial preload is more
effective than bending preload in reducing this
resorption [15]. The optimum amount of radial
preload to be applied by pre-drilling is not clear.
Significant microstructural damage can occur with
excessive preloading that exceeds the elastic limit
of bone and has been shown experimentally to
occur after insertion of pins oversized by more
than 0.4 mm [16].
Stress concentration is another adverse factor
in stability of a construct that is subjected to
loading. It is advantageous to spread the force
evenly across the entire shaft of the bone by
creating a wide separation of the anchoring pins in
the shaft. To achieve stable fixation and reduce
the lever arm of displacing forces, however,
fixation also should be gained close to the fracture
site. It follows that the optimal and minimal pin
placement would be with at least two pins in each
fragment, one pin as close to the fracture as
possible and the second as far as feasible along
the shaft of the bone [5]. Some fixator designs
have multiple pin clamps in which the pins have to
be inserted at predetermined distances, limiting
the ability to create a good pin spread.
To increase fixation in the bone with a four-pin
frame, best fixation can be achieved with two pins
placed in the proximal radius. Distal metacarpal
fixation can be enhanced with a six cortical hold by
inserting the proximal metacarpal pin through the
base of the index and long metacarpals without
violating the interosseous musculature [17].
Augmentation of fixation
Augmentation of external fixation with percu-
taneously placed K-wires has been shown to
increase the stability of a distal radial fracture.
Augmentation of fixation also reduces the need
for excessive traction [18–20]. In addition, the
K-wire helps maintain palmar tilt that can be
difficult to restore with external fixation alone. A
single dorsal transfixion K-wire has been shown to
produce the greatest reduction in fragment mo-
tion in the flexion–extension plane [20]. The use of
an external fixator with two supplemental styloid
pins provides stability that approaches that
achieved with a 3.5-mm dorsal AO plate [21].
367
The additional stability of a single 0.065-in
(1.6-mm) K-wire passed from just Lister tubercle
in a proximal direction to exit from the volar
cortex at an angle of 45( in the sagittal plane
seems to outweigh the importance of fixator
design and inherent fixator rigidity [22].
Normal forces through radius and rehabilitation
It is important to take fracture stability into
account when planning rehabilitation. Force ap-
plied when mobilizing digits is magnified as it is
transmitted to the distal radius. A cadaveric study
has estimated that for each 10 N of grip force, 26–
52 N of force is transmitted through the distal
radius metaphysis, depending on the wrist posi-
tion [23]. The average male grip with a strength of
463 N can result in more than 2000 N force at the
distal radius, a much higher force than can be
tolerated in a fresh fracture that is internally or
externally fixed [24]. Wrist fixators have been
found to compress 3 mm with forces ranging
from 55–729 N. Assuming maximal force trans-
mission through the radius, the maximal safe
rehabilitation grip force in early phase of fracture
healing should not exceed 10–140 N to avoid
fixation failure [23].
Care also must be taken when initiating
mobilization of the forearm. By virtue of the
pull of the brachioradialis muscle and force trans-
mission through the distal radioulnar joint, fore-
arm rotation causes much larger magnitudes of
fragment motion than finger mobilization [21].
Static external fixation
The fundamental goal of external fixation is to
obtain and maintain an acceptable reduction until
the fracture has gained sufficient stability. The
fixator can be applied before or after reduction is
achieved. One method of application is closed
reduction by the time-tested maneuver of traction,
flexion, and pronation. The fracture then can be
stabilized by percutaneous pins, the wrist brought
to a neutral position without distraction, and
fixator applied as a neutralizing device. Another
method is to insert the anchoring Schanz pins and
use the fixator to achieve indirect reduction. The
ability to reduce the fracture after fixator appli-
cation varies with the fixator clamp and frame
design, because some fixator clamps do not have
sufficient degrees of freedom in all axes. In the
usual bridging construct, no mobilization of the
wrist is possible until after removal of the fixator.
368 BINDRA

Dynamic external fixation extraskeletal device anchored to the radius and

first metacarpal for the closed treatment of
Early motion of an intra-articular distal radius
comminuted distal radius fractures [34]. In a ca-
fracture not only minimizes stiffness of the wrist, it
daveric study DePalma demonstrated that the soft
also may facilitate articular cartilage repair [25].
tissue envelope around the radiocarpal and distal
Jones in 1977 was the first to suggest that it was
radioulnar joints was preserved in artificially
possible to move the wrist during bridging external
created comminuted fractures of the distal radius
fixation by placing a flexible tube between connect-
[35]. Straight traction of the hand with the wrist in
ing rods [26]. A decade later Clyburn designed
full supination was capable of anatomic reposi-
a fixator frame with a ball joint for the same
tioning of the fragments except for the volar tilt.
purpose [27]. Other similar dynamic external fix-
The popularization of articular fracture reduction
ators have been designed, all based on a frame that
by distraction is credited to Vidal et al, who
allows movement at a ball joint that is aligned with
demonstrated that ligamentotaxis could be used
the capitate [28,29]. For an external fixator to be
to reduce fractures around the wrist, ankle, hip,
truly dynamic and to allow joint movement during
and knee [36].
fracture healing, it should be kinematically com-
Radial length and inclination usually are re-
patible with the wrist joint to allow unconstrained
stored easily because of the pull on the radial
movement. Several of the commercially available
styloid by the attachments of the strong volar
dynamic external fixation devices for treatment of
ligaments. Several clinical series, however, have
distal radial fractures, however, do not replicate
shown that palmar tilt often is restored inade-
normal wrist kinematics that involves rotational
quately. Excessive application of a longitudinal
and sliding movements. Movement with these
distraction force with the wrist in palmar flexion
fixators in place thus risks forcing the carpal bones
causes tension in the extrinsic long extensor
into an abnormal pattern of movement or causing
muscles and produces a clinically evident clawing
displacement of fracture fragments [30]. A clinical
of the digits [4]. The inability to restore normal
comparative study has demonstrated poorer results
palmar tilt with ligamentotaxis also has been
with loss of reduction and increased complications
demonstrated experimentally in a cadaveric model
with the use of ball joint-type external fixator
[37]. Even 30 lb of traction with up to 30( of wrist
compared with static fixation [31].
flexion does not restore palmar tilt of the distal
A frame with a single ball joint can be aligned
radius fragment. This is because the palmar
with the center of rotation of the wrist only about
ligaments are short, thick, and more longitudi-
one axis. Only one type of movement (flexion–
nally aligned than the dorsal carpal ligaments,
extension or radioulnar deviation) thus can be
which are arranged in a dorsal V with the apex at
synchronous with the center of rotation of the
the triquetrum. When distraction is applied to the
wrist. A new fixator design has been proposed
wrist the palmar ligaments become taut and resist
(Flexafix fixator, AO Research Institute, Davos,
further distraction, leaving the dorsal ligaments
Switzerland) that uses two sliding discs connected
loose. Only if the palmar ligaments are released
with a screw. This creates a sliding mechanism
can tension be applied to the dorsal ligaments,
with a center of rotation that is projected 50 mm
resulting in distraction of the dorsal lip and return
away from the fixator over the capitate. Further-
of the palmar tilt with minimal traction and
more the sliding mechanism simultaneously al-
without the need for wrist flexion.
lows rotation about all three axes without
Agee has refined further the concepts of liga-
a change of the center of rotation [32,33]. Cadav-
mentotaxis as applied to the distal radius [4]. He has
eric studies with this fixator compared with
termed conventional ligamentotaxis that is applied
conventional ball joint designs have confirmed
in one plane as uniplanar ligamentotaxis. Unipla-
the kinematic similarity with the sliding disc
nar ligamentotaxis does not achieve restoration of
mechanism and absence of increased loads at the
the palmar tilt. Longitudinal traction can be
pins in all planes of wrist motion [33].
combined with radioulnar and dorsopalmar trans-
lation, however, to provide multiplanar ligamen-
Ligamentotaxis totaxis that is capable of restoration of normal
anatomy of the distal radius. For this purpose,
Principles and biomechanics
Agee has developed an external fixation system, the
In 1944 Anderson and O’Neil were the first to WristJack (Hand Biomechanics Lab Inc, Sacra-
describe the use of sustained traction by an mento, California), that has a gear mechanism
 EXTERNAL FIXATION OF DISTAL RADIUS FRACTURES
incorporated into the longitudinal supporting
frame to allow supplemental translational forces
after application of distraction. In this technique,
after longitudinal traction is applied the hand is
translated in a palmar direction, producing a pal-
mar vector at the midcarpal joint. The volar
displacement of the capitate creates a rotatory force
on the lunate; the distal radius fragment follows the
lunate and tilts palmar-ward, restoring the normal
palmar inclination (Fig. 3). Traction then is re-
duced until the fingers can be fully passively flexed
into the palm. The final maneuver consists of ulnar
translation of the carpus to create a radial soft
tissue hinge that helps restore radial inclination.
Clinical studies also have shown that distrac-
tion by ligamentotaxis alone is not capable of
reducing volar marginal intra-articular fractures
(AO type B or volar Barton pattern). These
fractures require an additional volar buttress plate
[38,39]. In addition, severely impacted fragments
may not reduce with traction and require percu-
taneous manipulation using supplementary K-
wires [17].
Biologic effects of distraction
Excessive prolonged distraction of the radio-
carpal ligaments may cause adverse effects on the
A regional pain syndrome. The development of
B
C It has been established that bone heals by
Fig. 3. Principle of ligamentotaxis. (A) Initial fracture
displacement. (B) Uniplanar traction restores length, but
as palmar ligaments are stretched fully, palmar tilt is not
restored. (C) Additional palmar displacement of the
capitate rotates the lunate that carries the distal
fragment into palmar tilt.
369
ligaments themselves and on the hand and wrist.
Increased distraction and duration of distraction
have been associated with adverse outcomes, with
a linear correlation with worse outcomes in
function, pain, motion, and grip strength [3].
Distraction of the wrist can result in strains as
high as 20% in the volar and dorsal ligaments
[40]. This may contribute to wrist stiffness by
ligament fibrosis from compromise of circulation
or micro-failure of the already injured ligaments.
Overdistraction of the wrist also has been associ-
ated with finger and wrist stiffness and with
adverse outcome with poorer scores for function,
pain, motion, and grip strength [3]. Clinically
overdistraction can be avoided by checking that
all fingers can be fully flexed into the palm after
application [4]. Alternatively, radiographs can be
used to determine carpal height ratio index [3] or
relative distraction of the radiocarpal joint in
comparison with the midcarpal space [17]. These
methods have been shown to be unreliable in an
experimental model, however [41]. The carpal
height ratio increases with distraction for the first
10–20 lb of traction, but then remains static
despite increasing tension. Similarly the ability
to passively flex fingers into the palm is not lost at
higher loads of distraction.
Fractures of the distal radius have a higher
incidence of carpal tunnel syndrome and complex
carpal tunnel syndrome may be related to in-
creased pressure within the carpal tunnel [42].
Distraction of the wrist has been shown to cause
a linear increase in carpal tunnel pressure, with
pressures exceeding 40 mm Hg over baseline after
2.72 kg of distraction force with the wrist in
neutral. Placing the wrist in extension further
magnifies this effect [43].
Bone healing with external fixation
direct Haversian remodeling and without callus
formation after rigid internal fixation. In less rigid
environments, the healing process includes an
intermediate fibrocartilaginous phase or callus
formation. The relative motion between the bone
fragments determines the morphologic features of
the repair tissue. The exact mechanism of this is
not known but may be related to the interfrag-
mentary strain [44].
Lewallen et al compared bone healing with the
application of a unilateral frame with that
370
achieved by dynamic compression plating in
a canine tibia model [45]. Both methods resulted
in healing of the tibial osteotomy when the
animals were sacrificed at 120 days. Internally
fixed osteotomies were significantly stronger and
healed with endosteal bone formation. The heal-
ing process in specimens treated with a fixator was
less mature, with a high bone turnover and less
direct healing. Experimental studies of bone heal-
ing after controlled osteotomies stabilized by
external fixation have suggested that healing is
a combination of different processes [46]. Bone
healing mechanisms are different and depend on
the rigidity of the device used. With more rigid
fixation achieved by six-pin bilateral frames, there
is early clinical union with similar appearance to
that of internal fixation. On the other hand, with
four-pin unilateral frames, periosteal callus for-
mation and local bone resorption is significantly
increased because of the less rigid fixation. The
distribution of callus is greater in the biomechan-
ically weaker plane—the anteroposterior plane if
a fixator is applied along the mediolateral plane
[47]. A longer period is required for fracture repair
and remodeling when external fixation with less
rigidity is used [48]. The abundance of callus
formation after external fixation allows the return
of sufficient stability to allow early removal of the
fixator in comparison with internal fixation [49].
When the fixator is used in distraction as in the
wrist, overdistraction or actual bone void from
impaction may result in secondary loss of reduction
in 10%–50% of cases after fixator removal [2,38]. A
significant void in subchondral bone must be filled
with bone graft or substitute to prevent this
problem [17]. Bone graft or substitute placed in
the subchondral defect provides additional stabil-
ity, allows the defect to fill in with bone, prevents
ingrowth of fibrous tissue, and has been shown to
reduce secondary collapse in clinical studies [50,51].
Biology of the pin–bone interface
The pin–bone interface is the link between the
patient and the fixator [17]. Failure of this link
affects not only the outcome of the fracture, but it
may result in serious additional complications,
such as osteomyelitis with additional morbidity
for the patient. Pin loosening leads to failure of
fixation and predisposes the pin track to infection
(Fig. 4). Pins holding an unstable fracture and
those subjected to static loading are more likely
to loosen. Histologically, loose pin tracks
BINDRA
Thermal Skin Uneven cortical Excessive
damage tension pressure loading
Local cortical resorption
Pin loosening
Bacterial
invasion
Sepsis
Fig. 4. Pathogenesis of pin track infection.
demonstrate inflammatory exudates and extensive
bone resorption [52]. Rehabilitation should take
into account the fracture stability to minimize
excessive pin loading and subsequent loosening.
Recent clinical and laboratory studies using an-
choring pins coated with hydroxyapatite suggest
that osseointegration of the pins can help prevent
the loss of pin–bone fixation over time. It is also
possible that the coating creates a roughness that
increases the initial interference fit of the pins [53–
55]. Such pins are certainly advantageous when
a fixator is to be placed for prolonged periods of
time, such as for bone lengthening applications,
but are of doubtful value in short-term applica-
tions, such as for wrist fractures.
Infection around anchoring pins is one of the
commonest complications of external fixation,
and the reported incidence ranges from 0.5%–
30%. The incidence of more serious infection
leading to osteomyelitis is much lower and ranges
from 0%–4%. External fixation wires and pins are
colonized with bacteria, usually Staphylococcus
aureus and Staphylococcus epidermidis [56]. As
much as 75% of screw tips have positive cultures
after external fixator removal with a higher rate of
gram-positive bacteria [57]. The incidence of pin
track infection in ring fixators may be lower than
that seen in hybrid or unilateral frames [58].
Recent measures to lower incidence of pin track
infection being studied are silver coatings [56],
hydroxyapatite and chlorhexidine coatings, and
antibiotic pin sleeves [59,60].
Thermal damage to local tissues at the time of
anchor pin insertion is believed to be one of the
important factors in pin loosening in cortical
bone. The damage is an effect of high temperatures
 EXTERNAL FIXATION OF DISTAL RADIUS FRACTURES
and the duration of exposure to high temper-
atures. Most animal studies indicate that temper-
atures of approximately 50(–55( C can cause
necrosis in skin and bone. Heat adversely affects
bone by weakening collagen inter-linking, inacti-
vation of alkaline phosphatase, and osteocyte
death [61,62]. Matthews et al examined the
thermal effects of pin insertion in cortical bone
[63]. The single highest temperature recorded was
185( C when a trocar-point pin was inserted at
700 revolutions per minute. Manual drilling
resulted in increased duration of exposure and
produced higher temperatures than drilling at
3000 revolutions per minute. Manual insertion
of pins into predrilled holes produced the least
increase in temperature, exceeding 55( C only in
the immediate vicinity of the pin. Thermal effects
may be magnified if surgery is performed under
tourniquet because of the lack of cooling effect of
the circulation. Other investigators also have
demonstrated significant heat generation with
pin insertion and stress the need for cooling with
saline irrigation at the time of pin insertion [64].
Pin care also may have a significant impact on
overall incidence of pin track sepsis. Opinions on
this vary widely and there is no universal consen-
sus on the best way to take care of the pin–skin
interface. At one extreme is the recommendation
for daily showers without any specific care of the
pins sites [65], and at the other is twice-daily pin
site cleansing with hydrogen peroxide and povi-
done-iodine [66]. Necrotic skin and bone at the
pin site interface also provide a medium for the
growth of bacteria, and it is important to ensure
that skin tension around the pin is relieved by an
adequate incision.
Additional other factors that may contribute
to pin tract infection include the thickness of the
soft tissue mantle between the skin and bone and
mobility at the pin–skin interface. Pin track
infection is more common because of early
mobilization of the wrist that is possible with
nonbridging fixators. Wrist immobilization in
a splint between periods of exercise has been
recommended to reduce this complication [7].
Summary
External fixation is a versatile and useful tool
for management of complex fractures. There is
little to choose between the various types of
commercially available fixators, and it is impor-
tant to use one that allows the surgeon adequate
371
versatility and follows sound biomechanical prin-
ciples. Ligamentotaxis can be used effectively to
reduce the most difficult fractures; however, over-
distraction and prolonged traction are harmful
and should be avoided. Certain types of fractures
do not respond to treatment with ligamentotaxis
alone and require adjunctive treatment, such as
limited internal fixation. A single K-wire signifi-
cantly adds to the stability of fixation and should
be considered in all cases. Understanding the basic
mechanical principles and respect for pin–bone
biology allow for successful use of external fixation
with minimal complications.
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 Hand Clin 21 (2005) 375–380
Non-spanning External Fixation of the Distal Radius
Margaret M. McQueen, MD, FRCSEd (Orth)
Edinburgh Orthopaedic Trauma Unit, Royal Infirmary of Edinburgh, Old Dalkeith Road,
Edinburgh EH16 4SU, UK
Non-spanning external fixation of the distal
radius employs pins in the distal fragment and
pins in the radius proximal to the fracture. It is
indicated in the treatment of minimal articular or
extra-articular fractures of the distal radius with
metaphyseal instability, and in distal radial os-
teotomy for malunion. This article describes the
technique, with emphasis on correct pin place-
ment in the distal radius. Results show that
anatomy is well-restored and maintained, and
that function is improved using non-spanning
external fixation in preference to spanning exter-
nal fixation.
Anatomy
Non-spanning external fixation for fractures of
the distal radius depends on placement of two pins
into the distal radial fragment. It is therefore
important to have a sound knowledge of the
anatomy of the distal radius.
The articular surface of the radius is triangular,
with the apex of the triangle at the radial styloid.
It slopes in a volar and ulnar direction, with the
average normal volar angle ranging from 7  12 
in a volar plane.
The dorsal surface of the distal radius is convex
and irregular. Lister’s tubercle acts as a fulcrum
for the tendon of extensor pollicis longus, which
lies in a groove on the ulnar side of the tubercle.
The extensor tendons lie in six dorsal compart-
ments, a knowledge of which is essential for
Funding support: Scottish Orthopaedic Research
Trust into Trauma.
E-mail address: mmcqueen@staffmail.ed.ac.uk
0749-0712/05/$ - see front matter Ó 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.hcl.2005.04.006
placement of fixator pins. The volar side of the
distal radius is flat and makes a smooth curve
concave from proximal to distal. It is covered by
the muscle belly of pronator quadratus.
Proximal pins for non-spanning external fixa-
tion are placed from dorsal to volar around the
area of the junction of the proximal and middle
thirds of the radius. At this level, the radius is
covered by the flat tendons of extensor carpi
radialis longus and extensor carpi radialis brevis
proximal to abductor pollicis longus, which
crosses over them at an angle of 45  . In this
area, about 5 cm proximal to the wrist the
superficial branch of the radial nerve descends
across abductor pollicis longus and extensor
pollicis brevis on its way into the hand.
Indications for non-spanning external fixation of
the distal radius
Non-spanning external fixation of the distal
radius is indicated for the management of un-
stable extra-articular or minimal articular frac-
tures. It can be used for more severe articular
fractures where there is space for the pins in the
distal fragment after reduction and fixation of the
articular component. Non-spanning external fix-
ation is also indicated for stabilization of the
distal radius after radial osteotomy for dorsal
malunion.
Non-spanning external fixation of the distal
radius is indicated in the independent adult
patient. There is no upper age range for the use
of this technique because it is effective in the
presence of osteopenia [1,2], although in the frail
elderly, malunion of the distal radius should be
accepted. The technique is not suitable for use in
hand.theclinics.com
376 MCQUEEN
younger patients who have open epiphyses, or in
volar displaced or partial articular fractures.
Non-spanning external fixation is best used
primarily in the unstable fracture if metaphyseal
instability can be predicted by a combination of
the patient’s age, initial fracture displacement, and
the presence of comminution [3,4]; however,
closed reduction can be performed up to 3 weeks
after fracture with this technique, because the
distal pins give direct control of the distal frag-
ment. Care must be taken in these circumstances
to use gentle pressure on the distal pins to achieve
a gradual reduction. Inappropriate force on the
distal pins can cause pin cut-out. At a later stage
after fracture, non-spanning external fixation
must be combined with radial osteotomy to
achieve a satisfactory reduction.
Contraindications
Non-spanning external fixation is contraindi-
cated when the distal fragment is too small for pin
placement; 1 cm of intact volar cortex is required
for pin purchase. Intact dorsal cortex is not
necessary for a successful result. The technique
is also contraindicated in volar displaced or
partial articular fractures and in children who
have open epiphyses.
Surgical technique
Unstable fracture
The patient is positioned on the operating table
in the supine position with the arm extended on
a hand table. Either general or regional anesthesia
may be used. A tourniquet is used on the upper
arm. The surgeon is seated on the cephalic side of
the hand table and the image intensifier positioned
distal to the hand.
Anteroposterior and lateral views of the wrist
are obtained by forearm rotation. Manipulative
or finger trap reduction of the fracture is not
required before insertion of the fixator pins. The
wrist is held in the lateral position by an assistant
during insertion of the distal pins.
The distal pins are inserted first using an open
technique to avoid damage to the extensor ten-
dons. In most cases, depending on the fixator used,
two parallel pins are inserted on either side of
Lister’s tubercle and the extensor pollicis longus
tendon (see Fig. 1) from dorsal to volar in the
distal fragment. The ideal position for the skin
incision is determined by placing a marker on the
skin and confirming on a lateral view, using the
image intensifier, that the marker overlies the ideal
entry point, halfway between the fracture site and
the joint. Two separate longitudinal incisions on
either side of Lister’s tubercle are made and
deepened down to the extensor retinaculum. Ex-
tensor pollicis longus can usually be seen moving
under the retinaculum if the interphalangeal joint
of the thumb is flexed and extended.
The first pin is placed on the ulnar side of
extensor pollicis longus between the third and
fourth extensor compartments. A short longitudi-
nal incision is made in the extensor retinaculum
and the pin is placed onto the dorsal surface of the
distal radius between extensor pollicis longus and
extensor digitorum communis. The starting posi-
tion of the pin should be approximately halfway
between the fracture and the radiocarpal joint
(Fig. 1). It is not necessary to check the antero-
posterior view, because the pin position is consis-
tently on the ulnar side of the radius if the correct
extensor compartments have been identified. With
the wrist in the lateral position, the pin is directed
parallel to the joint surface on the lateral view and
horizontally. The pin is inserted until it engages the
volar cortex (see Fig. 1). The pins must always be
inserted by hand and not with power, which may
cause a ring sequestrum from heat necrosis.
The second distal pin is inserted in a similar
manner, but between the second and third exten-
sor compartments and parallel to the first pin in
both planes. The clamp on the fixator may be used
as a pin guide if desired, to ensure correct spacing.
The proximal pins are also placed through an
open approach. A short longitudinal incision is
Fig. 1. A fluoroscope view of a pin in the distal fragment
of an instable fracture. Note that the pin is parallel to the
radiocarpal joint and it engages the volar cortex.
 NON-SPANNING EXTERNAL FIXATION OF THE DISTAL RADIUS
made on the dorsal radial aspect of the radius
approximately 5 cm proximal to the most proxi-
mal extent of the fracture. The incision is deep-
ened to the tendons of extensor carpi radialis
longus and extensor carpi radialis brevis, and the
interval between the two is opened. The radial
sensory nerve is protected by extensor carpi
radialis longus at this point as it emerges between
it and brachioradialis. Two parallel pins are then
inserted with or without predrilling, engaging the
opposite cortex.
The external fixator is then assembled. Re-
duction of the dorsal/volar angle is achieved by
gentle thumb pressure on the distal pins, using
them as a ‘‘joystick’’ to control the position of the
distal fragment. The correction obtained can be
viewed on the image intensifier (see Fig. 2). If the
radial angle requires correction, this can be done
by manipulation of the pin clamp. The fixator
components are then tightened and adequacy of
the reduction is assessed with the fluoroscope.
The range of movement possible in the wrist is
now confirmed by flexing, extending, and rotating
the wrist. The pin track incisions are released if
there is any obvious skin tension to prevent pin
track infection. They are normally left open with
light dressings around the pins.
Distal radial osteotomy
Patient positioning is identical to that for the
unstable fracture, but because iliac crest bone
Fig. 2. The fracture has been reduced and the fixator
assembled. A metaphyseal defect can be seen. This does
not require bone graft if the reduction is closed.
377
graft is used, this area must also be prepared and
draped.
A 4-to-5 cm transverse skin incision is first
made over the site of the deformity (Fig. 3). With
the skin edges retracted, a longitudinal incision is
made in the extensor retinaculum, taking care to
protect the extensor pollicis longus tendon. The
incision is deepened to bone, and subperiosteal
dissection to the radial and ulnar sides exposes the
distal radius. The site of the osteotomy cut is
determined, usually at the site of the deformity
and ensuring adequate space for pins in the distal
fragment.
The distal pins are then inserted. Two 1-cm
longitudinal incisions are made at a level between
the proposed osteotomy site and the joint surface
on either side of Lister’s tubercle. The distal skin
flap of the original transverse incision can be lifted
to visualize insertion of the pins, thereby avoiding
tendon damage. The distal pins followed by the
proximal pins are then inserted as described above
for an unstable fracture.
A transverse osteotomy cut is then made at the
site of the deformity with a small power saw
through the dorsal and lateral surfaces of the
radius, but leaving the volar cortex intact. An
osteotome is then placed into the osteotomy cut
and used as a lever to crack the remaining volar
cortex. This ensures relative stability of the distal
fragment. The osteotomy should not be com-
pleted using the distal pins because this may lead
to pin loosening.
When the osteotomy is complete, the distal
fragment can be placed in the desired position
Fig. 3. Corrective radial osteotomy using non-spanning
external fixation is possible through a small transverse
skin incision.
378 MCQUEEN
using the distal pins. The fixator is then assembled
(see Fig. 2).
A small amount of cancellous bone graft is
then harvested from the iliac crest and placed in
the wedge-shaped defect in the distal radius. The
extensor retinaculum and the skin are then closed,
but the pin tracks are left open. Light dressings
are required on the pins and on the osteotomy
incision.
Should it be necessary to treat a multiplanar
deformity of the distal radius by osteotomy, this is
best performed using the small semicircular ring
and independent pin placement. This allows pins
to be inserted, for example, more radially to
correct radial collapse. This technique also allows
the use of double bars, which can give extra
rigidity to the frame.
Potential pitfalls
Intraoperative complications are unusual pro-
vided the preoperative selection of fracture type
has been adequate. If the size of the distal
fragment is found to be too small to allow
insertion of the pins, then the technique can be
changed to using a bridging construct for the
external fixator.
Pin purchase is not usually a problem, despite
the osteoporotic nature of many of these frac-
tures. With the use of this technique in approxi-
mately 650 cases, only 2 cases of pin loosening
have occurred perioperatively, both because of
surgeon error with unnecessarily forcible fracture
reduction. If this occurs, the fixator can be
converted to a bridging construct. Neither of the
patients had any complications related to the pin
loosening.
Failure to reduce the fracture with the distal
pins is also unusual, but can occur if the fixator is
being applied late after fracture. Closed reduction
is usually possible with this technique up to 3
weeks after the fracture. If reduction is not
possible with the application of gentle and grad-
ual pressure on the distal pins, more forcible
reduction should not be used because this will
cause pin loosening. In this situation, a small
incision can be made over the fracture site to
allow insertion of a small lever, which is used to
achieve a reduction. Bone grafting is not used
unless a formal osteotomy has been performed.
The main iatrogenic complication is over-
reduction of the fracture. This can occur partic-
ularly when there is associated volar comminution
or bayoneting of the volar cortex, causing loss of
the volar cortex as a buttress. If this is not
appreciated during the procedure, then volar
malunion can result.
Postoperatively, wrist and finger movement is
encouraged immediately. There is no need to
immobilize the wrist after this technique. The
external fixator is retained for 4 to 6 weeks for
unstable fractures and 6 to 8 weeks for radial
osteotomy.
Results
Non-spanning external fixation of the distal
radius has several advantages over other techni-
ques for the management of metaphyseal insta-
bility. It is minimally invasive, allows reliable
restoration and maintenance of volar tilt and
carpal alignment, and allows both more rapid
and better long-term rehabilitation [1,2].
In a randomized study performed by the
author [1], non-spanning external fixation was
compared with spanning external fixation for the
treatment of extra-articular or minimal articular
metaphyseal unstable fractures of the distal ra-
dius. Instability was defined as redisplacement in
a cast after manipulative reduction. Radiological,
clinical, and functional review was performed at
regular intervals, with final review at 1 year after
fracture.
Patients treated with non-spanning external
fixation had statistically significant better radio-
logical results throughout the period of review
(Table 1). In particular, non-spanning external
fixation consistently restored the volar tilt and
carpal alignment, which has been shown to in-
fluence function [5]. Radiological improvement
was mirrored by functional improvement. Most
functional indices were statistically significantly
better at an early stage; wrist flexion and grip
strength remained significantly better at final
review in patients treated with non-spanning
external fixation. Complication rates were similar
between the two groups.
Critics of the technique list a number of
potential problems. Concern is expressed that
the technique is difficult for the ‘‘non-expert,’’
that pins will pull out from osteopenic bone, that
there will be an increased rate of tendon rupture,
and that there are a limited number of fractures
for which the technique can be used. To in-
vestigate these potential problems, a prospective
study of 641 patients who had unstable fractures
of the distal radius treated with external fixation
 NON-SPANNING EXTERNAL FIXATION OF THE DISTAL RADIUS 379

Table 1 Table 2
The radiological results of spanning and non-spanning The proportions of different AO types of fractures of the
external fixation distal radius treated by external fixation
Spanning Non-spanning Total Spanning Non-
group group P value (%) (%) spanning (%)
Mean dorsal angle (degrees) Fractures 641 (100) 265 (41) 376 (59)
After surgery 3.6 ÿ5.0 !0.001 AO classification
6 weeks 9.5 ÿ6.6 !0.001 AO A3.2 253 (40) 43 (17) 202 (57)
1 year 12.2 ÿ5.6 !0.001 AO C2.1 174 (27) 64 (25) 110 (31)
Mean radial shortening (mm) AO C3.2 119 (19) 107 (42) 12 (3)
After surgery 1.5 ÿ0.2 !0.001
6 weeks 2.8 0.2 !0.001
1 year 2.8 1.4 O0.05
The only complication that increases with non-
spanning external fixation is minor pin track
infection. This is because the patient moves the
has been performed in this unit. Fifty-nine percent wrist, allowing movement of the skin around the
of these cases were treated with non-spanning pins. These are easily treated with dressings and
external fixation. Of the non-spanning cases, 82% oral antibiotic therapy, and do not compromise
were performed by trainee surgeons with similar final outcome.
outcomes and complication rates to those in the The outcome of distal radial osteotomy for
randomized study [1] in which all surgery was dorsal malunion using non-spanning external fixa-
performed by a specialist in wrist fracture surgery. tion has also been examined in the author’s unit in
The fractures in which spanning or non-spanning a prospective study. Twenty-three patients had ra-
fixators were used are shown in Table 2. This diological, functional, and patient orientated out-
shows that the non-spanning technique is mainly come measures performed before and after surgery,
used in AO type A3.2 and C2.1 fractures, which with a final review at 6 months. This study showed
account for approximately 50% of all distal radius statistical improvement in all functional indices
fractures [6]. except wrist extension at final review (Table 3).
There was no pin pull-out in this series, and the
tendon rupture rate was the same for the two
Summary
techniques. Examination of the odds ratios for the
risk of complications revealed a seven times Non-spanning external fixation of the distal
increased risk of dorsal malunion with spanning radius is a simple, reliable, and noninvasive
external fixation. This study has therefore con- technique to restore the anatomy in unstable
firmed the advantages of non-spanning external extra-articular or minimal articular fractures of
fixation demonstrated in the randomized study, the distal radius. Rehabilitation is faster and more
and has refuted cited potential problems with the complete than with other comparable techniques.
technique. It is also a successful technique for stabilization of

Table 3
The functional results before radial osteotomy with non-spanning external fixation and 6 months postoperatively
Outcome measure Preoperative 26 weeks Difference in means (95% CI) P value
Pain 3.9 (2.6) 2.3 (2.4) 1.6 (0.5 to 2.7) 0.014
Pronation 77.5 (29.4) 88.9 (16.7) ÿ11.4 (ÿ20.2 to 0.4) 0.036
Supination 68.2 (30.1) 87.0 (18.5) ÿ18.8 (ÿ30.2 to ÿ7.2) 0.001
Flexion 46.7 (18.9) 81.6 (19.4) ÿ34.9 (ÿ43.3 to ÿ26.5) 0.000
Extension 77.5 (26.6) 83.5 (26.6) ÿ6.0 (ÿ23.5 to 11.6) 0.962NS
Radial deviation 74.8 (34.3) 99.7 (29.4) ÿ24.9 (ÿ44.6 to ÿ5.1) 0.020
Ulnar deviation 59.1 (23.4) 77.5 (20.1) ÿ18.4 (ÿ30.8 to ÿ6.1) 0.010
Functional score 73.5 (14.8) 93.1 (7.8) ÿ19.6 (ÿ26.0 to ÿ13.0) 0.000
Grip strength 29.2 (21.8) 56.3 (38.0) ÿ27.1 (ÿ47.6 to ÿ6.6) 0.012
Abbreviation: NS, not significant.
380 MCQUEEN
corrective osteotomy of the distal radius for
malunion.
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[6] McQueen MM. Epidemiology of fractures of the ra-
dius and ulna. In: McQueen MM, Jupiter JB, editors.
Radius and ulna. Oxford (UK): Butterworth Heine-
mann; 1999. p. 1–11.
 Hand Clin 21 (2005) 381–394
Nonbridging External Fixation
of Intra-Articular Distal Radius Fractures
David J. Slutsky, MD, FRCS(C)
3475 Torrance Blvd., Suite F, Torrance, CA 90503, USA
External fixation of distal radius fractures may
be used in a bridging or nonbridging manner.
Bridging external fixation of distal radius frac-
tures typically relies on ligamentotaxis to obtain
and maintain a reduction of the fracture frag-
ments. Superior motion can be achieved as
compared with plate fixation because of less
interference with the soft tissue envelope [1].
Ligamentotaxis has several shortcomings, how-
ever, when applied to the treatment of displaced
intra-articular fractures of the distal radius. First,
because ligaments exhibit viscoelastic behavior [2],
there is a gradual loss of the initial distraction
force applied to the fracture site through stress
relaxation [3]. The immediate improvement in
radial height, inclination, and volar tilt are de-
creased significantly by the time of fixator removal
[4]. Ligamentotaxis does not restore the normal
volar tilt of the articular surface, nor does it
reduce a depressed lunate fragment [5–8].
Bad outcomes associated with external fixation
are often related to overdistraction. The degree
and duration of distraction correlates with the
amount of subsequent wrist stiffness [9]. Distrac-
tion, flexion, and locked ulnar deviation of the
external fixator encourage pronation contrac-
tures. Distraction also increases the carpal canal
pressure [10], which may predispose to acute
carpal tunnel syndrome.
The author would like to acknowledge a debt of
gratitude to Qiang Guo Dai, PhD, Director of the
Biomechanics Laboratory at Loma Linda University
Medical Center, for his tireless efforts during this study
and for his generous donation of time away from his
family.
E-mail address: d-slutsky@msn.com
0749-0712/05/$ - see front matter Ó 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.hcl.2005.02.002
Bridging fixation does not lend itself to early
wrist motion. Efforts to dynamically mobilize the
wrist with joint spanning fixators have been
largely unsuccessful. This is related to the diffi-
culty in reproducing the complex kinematics of
the carpus and the inability of the fixator to
maintain ligamentotaxis throughout the entire
arc of motion [11,12]. Good results have been
achieved with nonbridging fixation of extra-
articular distal radius fractures, which does allow
early wrist motion. The final wrist range of
motion and grip strengths are superior to those
attained with bridging external fixators [13,14].
Reports of nonbridging external fixation (or
radio–radial external fixation) for the treatment of
intra-articular fractures are sparse and mostly
restricted to the European literature [15–20].
Some investigators believe that intra-articular
fractures are not suited for nonbridging external
fixation and advise a transarticular application
[21,22]. The use of currently available external
fixators applied in a nonbridging manner may
result in articular incongruity (Fig. 1A–G). This
was evident in one reported clinical trial of 30
patients with Frykman type 7 and 8 fractures who
were treated with the Delta frame nonbridging
external fixator (Mathys Medical, Ltd.; Bettlach,
Switzerland) [15]. Although favorable wrist motion
was reported, the median intra-articular step was
2.8 mm (range, 0–9.1 mm), with a median intra-
articular gap of 1.8 mm (range, 0–13.4 mm) [17].
Biomechanical considerations for external fixation
External fixation is considered flexible fixation
[23]. The biomechanical requirements of external
fixation for fractures of the distal radius are not
known, because the magnitude and direction of
hand.theclinics.com
382 SLUTSKY

Fig. 1. A 61-year-old male: right distal radius fracture with an unstable distal radioulnar joint. (A) PA view
demonstrating intra-articular extension plus an ulnar styloid fracture. (B) Lateral view demonstrating dorsal tilt and
metaphyseal comminution. (C) Initial reduction with metaphyseal bone grafting and limited internal fixation of the
volar-medial fragment. (D) Lateral view showing correction of dorsal tilt. (E) Clinical photo of nonbridging external
fixator (EBI; Parsippany, NJ). (F) Note supplementary radial pin fixation. (G) Nine-month follow-up showing late
collapse of radial styloid fragment.
 INTRA-ARTICULAR FRACTURES: NONBRIDGING EXTERNAL FIXATION
Fig. 1 (continued )
the physiologic loads on the distal radius are
dynamic and unknown, even for the normal wrist
[24]. Increasing the rigidity of the fixator does
not appreciably increase the rigidity of fixation of
the individual fracture fragments [25]. There are
several ways, however, in which to augment the
stability of the construct. After restoration of
radial length and alignment by the external
fixator, percutaneous pin fixation can lock in the
radial styloid buttress and support the lunate
fossa fragment [26]. A fifth radial styloid pin
attached to the frame of a spanning AO (Synthes;
Paoli, Pennsylvania) external fixator prevents
a loss of radial length that can occur secondary
to settling and leads to improved wrist range of
motion as compared with a four-pin external
fixator [27]. The addition of a dorsal pin attached
to a sidebar easily corrects the dorsal tilt found in
many distal radius fractures [28,29].
K-wire fixation enhances the stability of exter-
nal fixation. The combination of an external fixator
augmented with 0.62 K-wires approaches the
strength of a 3.5-mm dorsal AO plate (Synthes)
383
[30]. Supplemental K-wire fixation is more critical
to the fracture fixation than the mechanical rigidity
of the external fixator itself [25]. Stabilizing a frac-
ture fragment with a nontransfixing K-wire that is
attached to an outrigger is just as effective as a K-
wire that transfixes the fracture fragments [31].
These observations were incorporated into the
design of a biomechanical study to examine the
feasibility of nonbridging external fixation of
simulated three- and four-part intra-articular frac-
tures [32]. The goal of the study was to determine
whether fragment specific external fixation could
provide sufficient stability to allow immediate wrist
motion. A secondary goal was to define safe limits
for the rehabilitation forces during passive assisted
wrist motion and simulated gripping.
Materials and methods
The study was performed in three phases. In
the first phase, the feasibility of this approach was
tested in a three-part intra-articular fracture
model using one or two external fixators applied
384
in a nonbridging fashion. Safe anatomic intervals
for pin placement of the proximal and distal
radius were established by pre-dissection of the
specimens. In one specimen the distal ulna was
excised to remove any load sharing. In another
specimen a section of bone was removed from the
metaphyseal/diaphyseal region to simulate a seg-
mental fracture with bone loss. The fracture
fragments were held in a reduced position by
two radial styloid pins and two dorsal pins (see
section on pin configuration). The specimens
underwent biomechanical testing with single and
double nonbridging fixator configurations.
The second phase examined the maximum
static force that could be withstood during simu-
lated passive assisted wrist extension and simulated
gripping without causing articular displacement in
a four-part fracture model. All of the fractures
were stabilized using a single custom nonbridging
external fixator that incorporated a dorsal side-
arm (the Fragment Specific Fixator, South Bay
Hand Surgery Center, Torrance, California)
(Fig. 2).
Fig. 2. (A,B) The fragment specific fixator demonstrating pin configuration in an intra-articular fracture.
SLUTSKY
In the third phase the effects of cyclic loading
were examined on a three-part intra-articular
fracture model with dorsal comminution as de-
scribed by Dodds et al [33]. All of the frac-
tures were stabilized with the Fragment Specific
Fixator.
Specimen preparation
Seventeen nonmatched fresh frozen above-
elbow specimens were disarticulated at the elbow.
All the soft tissues were removed except for the
tendons of the primary wrist motors: the con-
joined extensor carpi radialis longus and brevis
(ECRL/B), the extensor carpi ulnaris (ECU), the
flexor carpi ulnaris (FCU), and the flexor carpi
radialis (FCR). A #0 braided polyester suture
then was placed in a Bunnell fashion in each of the
tendons. The volar wrist capsule and the volar
ligaments, the pronator quadratus, and the inter-
osseous membrane were left intact. In phase I
and II, the dorsal capsule was excised to facilitate
the creation of the intra-articular fractures and to
 INTRA-ARTICULAR FRACTURES: NONBRIDGING EXTERNAL FIXATION
assess the articular displacement after biomechan-
ical testing. In phase III the dorsal radiocarpal
ligament was elevated as described by Berger et al
[34], and then repaired with the #0 braided nylon
suture before testing. The below-elbow specimens
were fixed in midrotation with three 0.062-mm
crossed K-wires and potted vertically in cement.
The specimens were refrigerated overnight to
allow cement hardening and then were allowed
to warm to room temperature for testing.
Osteotomy
In phase I a three-part fracture was outlined
using drill holes that then were connected with an
osteotome to create separate radial styloid and
lunate fragments. In phase II the lunate fragment
was osteotomized to create a dorsomedial and
volar-medial fragment. The dorsal radioulnar
ligament and the triangular fibrocartilage (TFC)
insertion into the radius were cut arbitrarily in 4/8
specimens, to simulate a disrupted TFC. In phase
III a three-part fracture was created, followed by
excision of a 2-cm dorsal wedge to simulate
metaphyseal comminution.
Pin configurations
The radial styloid fragment was stabilized by
drilling a 3.0-mm threaded cortical pin from the
tip of the radial styloid at an approximate 45(
angle through the fracture site to engage the ulnar
cortex of the proximal fragment. A second more
proximal 3.0-mm pin was inserted horizontally
into the medial fragment to provide subchondral
support. Two 3.0-mm threaded pins were inserted
dorsally into the lunate fragments. The available
portals for distal pin placement corresponded to
the standard intertendinous interval for wrist
arthroscopy portal [35]. Radial sided pins could
be inserted safely on either side of the first
extensor compartment. Dorsal pins could be
inserted between the extensor pollicis longus
(3/-,4 portal), between the extensor digitorum
and the extensor digiti minimi (4/-,5 portal) and
between the extensor digiti minimi and the exten-
sor carpi ulnaris (6R portal). The proximal pins
could be inserted in the standard dorsoradial
position or dorsally between the ECRB and
extensor digitorum, which carries less risk for
injury to the superficial radial nerve [36].
In phase I a modified Stableloc external fixator
(Acumed, LLC; Hillsboro, Oregon) was applied
dorsally and attached to the dorsal pins to
385
maintain the height of the lunate fragment and
to restore the normal volar tilt of the joint surface.
In the two-fixator configuration, an AO fixator
(Synthes) also was applied along the radial mid-
axial line and fastened to the radial styloid pins.
Specimens #4 and #5 were tested only with the
two-fixator configuration (Fig. 3).
In phase II and III the fragment specific fixator
was applied along the radial midaxial line and
clamped to the two radial styloid pins (Fig.
4A–D). The two dorsal 3.0-mm pins were attached
to separate locking clamps on the dorsal sidearm.
Reduction of the intra-articular gap between the
radial styloid and lunate fragments was facilitated
by sliding the dorsal pin clamps in a radial
direction. Anatomic fixation of the joint surface
was confirmed by direct visual inspection. The
proximal fixator clamp then was attached to
parallel 3.0-mm pins that were drilled into the
proximal radial shaft.
Biomechanical testing
All of the specimens were mounted vertically
with an 89-N preload (20 lb) [37] applied by way
of gravity traction by hanging 5-lb metal plates
from the wrist tendons. Active wrist motion was
simulated by manually moving the wrist through
a complete flexion and extension arc. Passive
assisted wrist motion was simulated by applying
an additional load to the carpus with a servohy-
draulic materials testing machine (Instron 1321
Biaxial Hydraulic System; Instron Corporation,
Canton, Massachusetts). Gripping was simulated
by direct axial loading of the lunate fossa [24].
Fig. 3. Two-fixator configuration stabilizing a three-
part fracture.
386 SLUTSKY

Fig. 4. (A) Fragment specific fixator in a three-part fracture with dorsal wedge osteotomy. (B) Demonstration of
unrestricted wrist flexion. (C) Demonstration of unrestricted wrist extension. (D) AP radiograph showing pin fixation of
a four-part fracture seen through the radiolucent dorsal sidearm of the custom fixator.

In phase I the specimens were tested twice,
with the testing performed in two series. In each
series, the testing commenced with the two-fixator
configuration. The AO fixator was removed
without disturbing the radial styloid pins and
the testing was repeated. The constructs were
initially loaded in extension, with the force applied
to the palm of the hand at the level of the distal
palmar crease. Testing in flexion was not possible
because of the dorsal capsulotomy. The load was
applied at a constant rate of 25 mm/min. Each
specimen was loaded up to a maximum of 20 cm
of displacement (from compression of the soft
tissue) or to a maximum load of 100 N, whichever
came first. The articular surface was inspected and
any step-off between the scaphoid and lunate
fossae was measured with calipers. In the second
series, the preload was removed and the carpus
was disarticulated. An axial load was applied
directly to the lunate fossa at the same loading
rate up to a maximum of 400 N. The articular
surface was inspected again for any displacement.
 INTRA-ARTICULAR FRACTURES: NONBRIDGING EXTERNAL FIXATION 387

Fig. 5. (A) Biomechanical testing setup simulating passive assisted wrist flexion. Note the 20-lb preload. (B)
Demonstration of a congruent articular surface after testing.

In phase II a four-part intra-articular fracture mm, because higher amounts led to impingement
was created in eight arms and stabilized with the of the back of the carpus on the dorsal sidearm of
fragment specific fixator. In the first series an the fixator in some specimens. The combination of
identical loading protocol was used, but the the 89 N physiologic load and the additional
maximum load was increased to 400 N. In series applied load thus ranged from 135–145 N.
two, the carpus was disarticulated and the preload
was removed. The maximum axial load was Loading data
increased to 600 N.
Data acquisition was made by the Instron Series
In phase III a three-part intra-articular frac-
IX software program (Instron Corporation, Can-
ture with a dorsal wedge osteotomy was per-
ton, Massachusetts), which generated a force/dis-
formed in four arms and stabilized with the
placement curve. Stiffness was defined as the slope
fragment specific fixator. Each specimen was
of the straight-line region of the load-displacement
tested twice. The wrist was taken through 100
curve. The secant of the slope, ie, the average line,
cycles of flexion and extension with just the 89 N
was drawn through the slope, and the stiffness (Y/
preload. The hanging weights were kept in place
X) was calculated. Statistic analysis of the results
while additional load was applied directly to the
was performed using a two-tailed student’s t-test.
carpus through the force plate of the Instron
machine (Fig. 5A,B). The added load was applied
for 100 cycles at a rate of one cycle every 2 Results
seconds up to 20 mm of displacement. The
Phase 1
constructs had disparate loading requirements
due to the variable stiffness of the individual In three constructs the mean stiffness of the
specimens. This difference resulted in loads of one-fixator configuration in extension loading was
45–55 N. The displacement was restricted to 20 42.2 N/mm and was 75.8 N/mm with two fixators.

Table 1
Stiffness data for phase I
Stiffness of extension (N/mm) Stiffness of axial loading (N/mm)
Specimen 1 fixator 2 fixators 1 fixator 2 fixators Joint displacement
1 76.5 100.9 152.5 122.5 None
2 15.4 25.2 143.4 125.6 None
3 34.8 101.4 150.0 143.9 None
4 — 100.0 — 114.0 None
5 8.3 — 17.5 — Yield point 40 N
388 SLUTSKY

Table 2
Stiffness data for Phase II
Extension Axial loading
stiffness Max. stiffness Max.
Specimen (N/mm) Comment load (N) (N/mm) Comment TFC/DRUL load (N)
1 16.2 1 mm sagittal 330 110.8 Cut 600
split at 330 N
(sidearm
impingement)
2 12.6 400 195.0 Intact 600
3 23.2 361 178.1 Intact 600
4 28.5 200 89.9 2-mm gap at 500 N Cut 600
5 16.5 200 133.5 Intact 600
6 10.8 300 123.1 1-mm depression Cut 600
at 200 N
7 10.6 250 219.0 Intact 600
8 18.2 350 145.2 Cut 600
Mean 17.07 149.32

The mean stiffness in axial loading was 148.6
N/mm with one fixator and was130.7 N/mm with
two fixators (Table 1). These differences were not
statistically significant. Despite the variation in
stiffness, however, no joint displacement was
observed. In the remaining two constructs, it
was observed that removal of the distal ulna did
not affect the stiffness significantly, although
meaningful results cannot be drawn from only
one specimen. Removal of a 4-cm segment of
radius dramatically affected the stability of the
construct. Fracture angulation could not be
controlled, even with two fixators at low load
levels (40 N); hence, the construct was not tested
in axial loading.
Phase II
In the second study, the stiffness ranged from
10.6–28.5 N/mm in extension loading, with
a mean of 17.1 N/mm, and ranged from 89.9–
219.0 N/mm in axial loading, with a mean of 149.3
N/mm (Table 2). The mean stiffness of specimens in
extension loading was 18.4 with an intact TFC and
15.7 N/mm with a cut TFC. This difference was not
statistically significant. The mean stiffness of speci-
mens in axial loading was 117.25 N/mm with an
intact TFC and 181.4 N/mm with a cut TFC, which
was statistically significant (P=0.039).
During extension loading, there was gapping
of the articular surface in 1/8 specimens caused by
leverage on the dorsal sidearm by the carpus. In
axial loading, there was a 2-mm gap in specimen
#4 at 500 N, and a 1-mm lunate fossa depression
in specimen #5 at 200 N.
Phase III
In the third study there was no observable
articular displacement in any of the wrists after
200 cycles of wrist flexion and extension with
loads of up to 145 N (Table 3).
Conclusions
There was a wide variation in the stiffness of the
constructs during phases I, II, and III. Despite this
variation, fragment specific external fixation was
able to maintain articular congruity with forces
that exceed physiologic loading. The stiffness of
the construct stabilized with the fragment specific

Table 3
Data for phase 3
Articular
Specimen Gender Side Physiologic load (N) Applied load (N) Combined load (N) displacement
1 M R 89 N 55 N 144 None
2 F L 89 N 40 N 129 None
3 F L 89 N 45 N 134 None
4 F R 89 N 55 N 144 None
 INTRA-ARTICULAR FRACTURES: NONBRIDGING EXTERNAL FIXATION 389

Fig. 6. Comminuted intra-articular left distal radius fracture. (A) AP radiographic view of distal radius. (B) Sagittal CT
view reveals multiple free articular fragments. C, capitate. (C) Coronal CT view highlighting the central comminution.
U, ulna. (D) AP radiographic view demonstrating a congruent joint surface after limited internal fixation, bone grafting,
and nonbridging external fixation. (E) Clinical photograph of nonbridging fixator at 6 weeks. (F) Lateral view of fixator.
390
Fig. 6 (continued )
fixator averaged 149 N in axial loading with an
intact TFC and 117 N with a cut TFC. These
values compared favorably with the stiffness data
of five commercially available distal radius plates,
which ranged from 95.5–136.0 N [38].
In fragment specific external fixation, the
fixator pins are used in place of K-wires. The
fixator pins have dual roles. They provide inter-
fragmentary fixation, but when attached to the
fixator, they also act like blade plates to resist
bending moments and buttress the fracture frag-
ments. The immediate subchondral position of the
pins supports the joint surface and is critical in
maintaining articular congruity during fracture
healing. Ligamentotaxis through joint bridging
can be avoided to allow early wrist motion.
Similar to a fixed-angle plate, the biomechanical
rationale for the fragment specific fixator is to
transfer load from the fixed support of the
articular surface to the intact radial shaft, bypass-
ing any metaphyseal comminution. Unlike a
fixed-angle blade plate, the fixator pin angle is
freely adjustable so that it can be adapted to the
fracture site plane, which may diminish fracture
malalignment.
Discussion
Early wrist motion following intra-articular
fractures provides several possible benefits, in-
cluding diminished stiffness, stimulation of carti-
lage repair [39], and decreased osteopenia of the
distal fragments [17]. To accomplish this with
nonbridging external fixation, the construct must
be able to withstand the forces generated during
active and passive wrist motion.
The physiologic forces across the wrist are not
known and only can be estimated. Previous
cadaver investigations have used a load of 88–
135 N applied with weights or springs to the wrist
tendons to simulate muscle forces [37,40–43].
SLUTSKY
Wolfe et al [31] and Osada et al [38] used
a maximum load of 100 N to simulate the muscle
forces exerted during active wrist joint motion as
well as light activities of daily living (ADL) [31].
Other investigators have estimated that a 250-N
load compares with the physiologic loads that
occur during active digit flexion [38,44].
In phase I it was demonstrated that fragment
specific nonbridging external fixation for intra-
articular fractures was feasible. In phase II the use
of the fragment specific external fixator controlled
articular displacement under static forces that
exceeded physiologic levels. In phase III there
were no failures with loads of up to 145 N after
200 cycles of simulated active and passive assisted
wrist motion. These observations therefore pro-
vide confidence for allowing active and passive
wrist motion during the healing phase.
Whereas for every 10 N of grip force, 26 N is
transmitted through the distal radius metaphysis,
it has been recommended that the rehabilitation
grip forces should be kept at less than 140 N with
external fixation to prevent or minimize fixation
failure [45]. The author therefore agrees that this
is a safe limit as it pertains to nonbridging external
fixation also. Although this study demonstrated
the ability of the fragment specific fixator to
withstand loads in excess of this, the author did
observe 1 mm of articular depression in one
specimen with a cut TFC at a 200-N axial load.
The author recommends limiting aggressive pas-
sive assisted wrist exercise, gripping, and dynamic
wrist splinting until there is some fracture site
healing, because articular displacement of even
1–2 mm has been shown to lead to osteoarthritis
[46–48].
Case report
A 49-year-old anesthesiologist presented with
a 2-week-old distal radius fracture. A CT scan
 INTRA-ARTICULAR FRACTURES: NONBRIDGING EXTERNAL FIXATION 391

Fig. 7. Follow-up at 15 months. (A) AP radiographic view showing maintenance of radial height and length but
early radiocarpal narrowing. (B) Lateral view demonstrating neutral tilt. (C) Range of wrist flexion. (D) Wrist extension.
(E) Pronation arc. (F) Supination arc.

revealed the true extent of the intra-articular
comminution (Fig. 6A–C). He underwent an ar-
throscopic aided reduction of the fracture together
with limited internal fixation of the volar-medial
fragment and percutaneous bone grafting. Two
radial and two dorsal pins were inserted and
buttressed by the custom nonbridging fixator
(Fig. 6D–F). He was allowed unrestricted wrist
motion and he continued to work in his pain
management practice. The pins and the fixator
were removed at 6 weeks. Long-term follow-up
demonstrated maintenance of the initial reduc-
tion. He had a functional arc of motion and
minimal pain despite early radiocarpal arthrosis
(Fig. 7A–F).
Caveats
Nonbridging external fixation of intra-articular
distal radius fractures should be reserved for
392 SLUTSKY
Fig. 7 (continued )
manually active patients with good bone quality
without evidence of prior wrist arthritis. Any
metaphyseal defects should be bone-grafted to
minimize bending loads on the fixator. It is impor-
tant to engage the palmar lip of the distal radius
(where the bone density is highest) when inserting
the dorsal pins, especially in osteopenic bone [22].
In four-part fractures, palmar translation and
rotation of the volar-medial fragment should be
treated with limited internal fixation [8,49,50].
Contraindications
Volar and dorsal marginal fractures (Barton’s
and reverse Barton’s) are excluded and should be
treated with internal fixation. Fractures with
extensive metaphyseal/diaphyseal comminution
and articular fractures in elderly inactive patients
should be approached cautiously.
Summary
New solutions to difficult problems are always
welcome, but nonbridging external fixation of
intra-articular fractures is still in its infancy.
Multicenter clinical trials are necessary to deter-
mine whether the superior results obtained with
nonbridging fixation of extra-articular fractures
can be duplicated. With further study and new
fixator designs, it is anticipated that nonbridging
external fixation of intra-articular distal radius
fractures will become another viable treatment
option.
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 Hand Clin 21 (2005) 395–406
Combined Internal and External Fixation
of Distal Radius Fractures
John A. McAuliffe, MD
Cleveland Clinic Florida, 2950 Cleveland Clinic Boulevard, Weston, FL 33331, USA
The treatment of distal radius fractures has
changed over the last several decades as under-
standing of these common injuries has grown
[1–4]. We have come to appreciate that pain and
dysfunction following distal radius fracture are
not as uncommon as was once believed [5–7]. We
have recognized that the degree to which preinjury
anatomy is restored has a real bearing on the
outcome of treatment [8–12]. At the same time,
our patients, particularly those in the sixth decade
and beyond, have grown more active and have
developed higher expectations regarding their
recovery.
One need only look at the number of new
devices marketed for the treatment of distal radius
fractures over the last decade to realize the
obvious change in attitude that has occurred
concerning the treatment of these injuries. Al-
though internal fixation devices have dominated
the marketplace recently, advances also have been
made in the technology of external fixation. As we
consider the treatment of these injuries, we must
remember that the specific device or surgical
technique is, after all, only a means to an end.
The continuing challenge remains the selection of
the most appropriate method of treatment for
a given fracture.
External fixation
Surgeons often have strong feelings about the
use of external fixation in the treatment of distal
radius fractures; the author believes it is fair to say
E-mail address: mcaulij@ccf.org
0749-0712/05/$ - see front matter Ó 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.hcl.2005.03.003
that many practitioners are fond of external
fixators and many others generally dislike them.
For some, external fixation is the treatment of
choice for simple unstable fractures confined to
the radial metaphysis, whereas others only con-
sider external fixation in cases of complex and
often open injury. These beliefs often are based on
variations in training and the experience and
preferences of the individual surgeon. Although
each of these factors is important in the choice of
treatment methodology, a more dispassionate
look at the advantages and disadvantages of
external fixation of distal radius fractures seems
warranted.
There are studies on the use of external fixation
for fracture of the distal radius that have reported
complications in up to 60% of cases [13–16].
These reports would certainly make one carefully
consider the role of external fixation in the
treatment of these injuries. Fortunately, increas-
ing knowledge of the biology and biomechanics of
external fixation has helped to make many of
these complications avoidable.
Pin track problems associated with external
fixation generally fall into one of four categories:
loosening and infection (the former often predis-
posing to the latter), damage to adjacent soft
tissues, and fracture through the site of pin
placement [17,18]. These complications may result
in the need for pin removal and revision of the
fixation, potentially prolonging treatment. Deep
infection (osteomyelitis), injury to the radial
sensory nerve, or secondary fracture may lead to
permanent undesirable sequelae.
Open pin placement technique in which the bone
is visualized, soft tissue structures (tendons and
sensory nerves) are retracted out of harm’s way,
hand.theclinics.com
396 MCAULIFFE

and central pin placement is assured, obviates many

of these problems [17–20]. Pre-drilling of the bone
before placement of the external fixation pins
decreases thermal injury, further lessening the risk
for pin loosening and thereby also decreasing
infection rates [21,22]. Three-millimeter diameter
pins seem to offer the best combination of rigidity
to guard against micromotion that promotes loos-
ening over time, while not creating a substantial
risk for subsequent fracture [23]. Four-millimeter
pins advocated by some investigators do provide
greater rigidity [24] but often are not suitable for
placement in the metacarpal and may increase the
risk for fracture through the pin site [23]. Experi- Fig. 1. This patient has been immobilized in an external
mental data indicate that hydroxyapatite-coated fixator with the wrist in 40  of flexion for approximately
pins have significantly lower rates of loosening and 6 weeks. Note that the metacarpophalangeal joints are in
infection, although such pins are not available for a nearly neutral position at rest. Complete digital flexion
general use at this time [25,26]. Despite the most never was regained following fixator removal and several
meticulous technique, there are a certain number of months of therapy.
superficial pin track infections that are probably
unavoidable whenever pins remain exposed to the probably the clearest indication that additional
environment for many weeks. Careful patient combined forms of fixation are necessary.
follow-up allows these superficial infections to be Centers with substantial experience in the
recognized early and treated simply without jeop- treatment of distal radius fractures with external
ardizing the ultimate outcome. fixation report overall complication rates of 14%
In times past, closed reduction of distal radius
fractures sometimes was followed by cast immo-
bilization in positions of extreme wrist flexion and
ulnar deviation (the Cotton–Loder position).
These awkward and dysfunctional wrist postures
also have been used to obtain and maintain
reduction of distal radius fractures following
external fixation. Such unacceptable positions
have been shown to cause potentially uncorrect-
able wrist stiffness caused by capsular contracture,
digital stiffness caused by long extensor tightness
inhibiting flexion (Fig. 1), and also are associated
with an increased risk for median nerve compres-
sion resulting in carpal tunnel syndrome [1,27].
Even with the wrist in neutral position, over-
distraction in the fixator can result in similar
untoward effects, including wrist and digital
stiffness, median neuropathy, and possibly even
delayed union or nonunion. Overdistraction also
has been implicated as a possible risk factor in the
production of complex regional pain syndrome,
although this simply may represent another ex-
pression of distraction neuropathy [28].
Extreme wrist flexion and ulnar deviation or
Fig. 2. Lateral radiograph of the wrist following exter-
overdistraction may be helpful temporarily in the nal fixation. The fracture is adequately reduced; how-
operating room to achieve fracture reduction, but ever, the wrist was immobilized in this position of flexion
fixators should never immobilize the wrist in these to maintain the reduction. Internal fixation should have
positions (Fig. 2). Inability to maintain reduction been performed to maintain the reduction and to allow
with the wrist in a neutral or functional position is the wrist to be placed in a functional position.
 COMBINED FIXATION OF DISTAL RADIUS FRACTURES
or less, with superficial pin track infections in 4%–
10% of cases and no instances of deep infection
[29]. Major complications, such as loss of fixation
and fractures through pin sites, occurred in
approximately 1% of cases, whereas the possibil-
ity of nerve and tendon injury is virtually elimi-
nated by the open technique of pin placement
[23,30].
In their simplest form, external fixators act as
neutralization devices, helping to prevent the
compressive force of the carpus from displacing
the fracture into its pre-reduction position. In this
circumstance, the reduction must be stable by
virtue of bony contact, or such stability must be
achieved with the use of additional fixation at the
fracture site [3]. Dynamic fixators that allow
motion at the wrist joint have been largely
abandoned because of difficulties with loss of
fracture reduction over time and an unacceptable
risk for pin track complications [31,32].
External fixation also can be used to reduce
fractures of the distal radius using the principle of
ligamentotaxis [33,34]. Traction force applied to
the hand or carpus is transmitted to the fracture
fragments of the distal radius by way of intact
capsuloligamentous structures, allowing the frag-
ments to be reduced indirectly [35]. The intra-
articular vacuum effect created by such traction
also may help to reduce central articular frag-
ments devoid of soft tissue attachments, although
this reduction is seldom complete or anatomic
[36]. Limitations of ligamentotaxis have been
recognized clinically and experimentally; it is
essentially impossible to restore palmar tilt of
the distal radius with traction and flexion of the
wrist [37]. The tendency to ‘‘pull harder’’ in this
circumstance often produces an effect opposite
that desired, because the stouter and straighter
palmar ligaments exert greater influence on the
anterior lip of the radius and rotate the fragments
to which they are attached into extension. Agee
has pointed out that palmar translation of the
carpus, not flexion, produces palmar tilt of the
distal radial articular surface [34,38].
The potential biologic advantage of external
fixation is that it allows treatment of the fracture
with minimal manipulation and devascularization
of the bone and adjacent soft tissue supporting
structures, including tendons and joint capsule
[17,18]. It is almost impossible to determine if this
provides a true advantage for fracture healing,
because nonunions of distal radius fractures are
decidedly rare no matter how they are treated.
Unfortunately there is little objective evidence to
397
decide the question of whether external fixation
does in fact produce more favorable outcomes
with respect to other variables, such as range of
motion or recovery of function.
Kapoor et al compared 33 patients treated with
closed reduction and cast immobilization to 29
patients treated with open reduction and internal
fixation and 28 patients treated with external
fixation [39]. They provide few details about
surgical technique or hardware used in cases of
internal fixation, and apparently did not supple-
ment external fixation in any way. Their results
favor operative treatment of some kind over
closed reduction and cast immobilization and
suggest that slightly greater range of motion is
recovered following external fixation, but details
are few and statistic significance of this finding is
not addressed.
Kreder et al compared 88 patients treated with
indirect reduction and percutaneous fixation to 91
patients treated with open reduction and internal
fixation in a multicenter, prospective, randomized,
controlled trial [40]. The goals of surgery in all
patients were to restore radial length and palmar
tilt to neutral, radial inclination to at least 7  –10  ,
and to leave no articular gaps or step-offs greater
than 2 mm. External fixators were used in both
groups at the discretion of the treating surgeon.
There was no significant difference in radiologic
outcome, range of motion, or grip strength
between the two groups. At 6 months, patients
treated with indirect reduction had better overall
scores on the Musculoskeletal Function Assess-
ment; however, this difference was not seen at 12
or 24 months following treatment.
Internal fixation
Accurate open reduction and stable internal
fixation followed by early functional rehabilita-
tion is the generally accepted objective in the
treatment of articular or periarticular fractures
[3]. The goal of stable internal fixation has been
difficult to achieve in the case of distal radius
fractures, particularly those with comminution of
the metaphysis or articular surface, given the
limitations of previously available fixation devices
[1,41]. Many factors contribute to the difficulties
in the treatment of distal radius fractures with
internal fixation, including the normal morphol-
ogy of the bone, small fragment size, and the
plethora of immediately adjacent soft tissue struc-
tures, particularly the extensor tendons. Only
398 MCAULIFFE
fairly recently, with the availability of fixation
hardware designed specifically for this purpose,
have efforts at attempting stable internal fixation
been made in cases of more complex injury to the
distal radius. The radiocarpal joint is, in fact, the
last remaining large joint in the body for which
such routine attempts at definitive internal fixa-
tion have been made.
Earlier hardware designed expressly for the
distal radius attempted to provide support and
a means of fixation along the dorsal rim while
decreasing the bulk of the device to avoid soft
tissue, particularly extensor tendon, injury [42,43].
Plates designed for the palmar surface of the distal
radius have become increasingly sophisticated,
and many surgeons now advocate this type of
fixation even when comminution and displace-
ment occurs, as it does most commonly, on the
dorsal side [44]. Recognizing the frequency of
three part fractures of the articular surface,
fragment or column specific fixation devices are
being used more frequently [45,46]. The value of
locking pins or screws that integrate the important
features of fixed angle devices and provide strong
structural support to the subchondral bone in-
creasingly is being increasingly recognized and
incorporated into new designs.
Good results have been reported using several
of these internal fixation devices, although device-
specific randomized comparisons with other forms
of fixation are not available [42–45]. Complication
rates using these new devices are not unreason-
able, although extensor tendonitis and rupture
remain a concern with devices applied to the
dorsal surface of the radius [47]. Many of these
devices do not yet have long enough track records
on which to judge their individual merits.
The mainstay of internal fixation for fractures
of the distal radius for many years, and probably
still today, has been the Kirschner wire. K-wire
fixation seldom provides sufficient stability to
allow for early motion and often necessitates use
of a cast or splint, but these devices are simple to
insert, inexpensive, and almost universally avail-
able. The same caveats regarding risk for adjacent
soft tissue structures apply as in the case of
external fixation pins, and similar precautions
must be taken to avoid risk for tendons and
nerves [19]. Fixation is limited in osteoporotic
bone, but there are limits to all fixation devices
and techniques in this setting that must be
recognized and respected. K-wires can be placed
in an almost limitless number of configurations
with minimal soft tissue dissection or disruption
[48,49]. Introduction of the wire into the fracture
site (intrafocal pinning) may help reduce the
fracture and buttress unstable fragments during
healing [50,51]. Wires usually can be withdrawn in
the office setting with relative ease when healing is
sufficient. Although not as sophisticated as other
devices, K-wires continue to play an important
role in the internal fixation of the most complex
and comminuted distal radius fractures (Fig. 3).
Combined fixation
Combined internal and external fixation is
a technique that attempts to maximize the advan-
tageous features of each of its two components
while minimizing their disadvantages. The inter-
nal fixation element of the technique may vary
from percutaneous techniques of reduction and
pin placement [52], to arthroscopically assisted
reduction and fixation [3,53,54], to formal open
reduction and plate application in instances of
high energy injury or severe comminution [55,56].
Often the magnitude of open reduction or internal
fixation required is not apparent until the external
fixator is applied and provisional reduction is
achieved.
The external fixator initially may be over-
distracted to allow better visualization of the joint
surface fluoroscopically or by open means. It also
may place the wrist in flexion and ulnar deviation
temporarily to allow fixation of fragments in
anatomic position. As mentioned, palmar flexion
of the distal radial articular surface can be difficult
to restore by ligamentotaxis alone; this position
can be achieved and maintained by the addition of
internal fixation as required [28]. Studies have
shown that the addition of K-wires to a fracture
treated by external fixation significantly increases
the stability of the fracture fragments [57–59].
Certain fixator designs allow wires or additional
pins in the distal fragments to be fixed to the
frame with outriggers, further enhancing fracture
stability [60,61]. Once adequate internal fixation
has achieved anatomic reduction, distraction can
be reduced and the wrist placed in a neutral or
slightly extended position in the fixator, which
now acts as a neutralization device.
The author considers bone grafting to be an
integral part of the technique of combined fixa-
tion. Elevation of depressed articular fragments
and metaphyseal comminution often results in
substantial bone defects. The addition of bone
graft not only provides some element of structural
 COMBINED FIXATION OF DISTAL RADIUS FRACTURES 399

Fig. 3. (A) Anteroposterior radiograph of the wrist following combined fixation. The Kirschner wires maintain joint
surface contour and angulation. Coralline hydroxyapatite bone graft substitute material has been place in the
metaphyseal defect following reduction. (B) Anteroposterior radiograph shows excellent maintenance of reduction at
6 months from injury.

support, but also may influence healing advanta-
geously. Fixation of any fracture is always a race
between osseous union and device failure, and this
is especially true when fractures are complex and
comminuted. Earlier healing not only decreases
the biomechanical demands on the chosen fixa-
tion, it also promotes return of function. In cases
with severe metaphyseal comminution, primary
bone grafting may allow earlier removal of the
fixator and may help to prevent late collapse and
shortening [62–64]. Bone graft substitutes are
being used with increasing regularity and seem
to hold great promise in the treatment of distal
radius fractures [65–68].
Patient selection
Combined fixation can be used for almost any
distal radius fracture, although there are certain
injuries for which it is particularly well suited.
General indications include comminuted fractures
for which stable cortical contact cannot be estab-
lished, fractures with severe soft tissue injury or
those that are open, and fractures in multiply
traumatized patients in whom rapid provisional
fixation is required.
Some surgeons elect to use combined fixation
for AO type A2 and A3 fractures (metaphyseal
bending fractures with an intact articular surface),
whereas others choose open reduction and in-
ternal fixation. There are no randomized con-
trolled studies to guide this decision, and both
techniques are acceptable. The author believes
that AO type B injuries (partial articular shear
fractures in which a portion of the articular
surface remains attached to the metaphysis) are
clear indications for open reduction and internal
fixation. These fractures almost always require
open reduction to restore joint surface anatomy
accurately; stable internal fixation at that time
often allows for early motion and rapid recovery.
The most generally accepted indication for the
technique of combined fixation is an AO type C
fracture, particularly type C2 (articular involve-
ment with metaphyseal comminution) and type
C3 (articular surface comminution). Again, sur-
geon preferences vary, and there are minimal
comparative data on which to base these deci-
sions. Contemporary fixation hardware that al-
lows internal fixation of two or three articular
400 MCAULIFFE
surface fragments (as seen in type C1 and C2
fractures) is preferred by some surgeons. The
likelihood of using combined fixation techniques
generally increases with the degree of comminu-
tion, particularly for type C3 fractures [55,56,69].
There are occasional fractures with such mas-
sive comminution or articular cartilage loss that
primary arthrodesis must be considered [70]. De-
pending on the nature of the injury, partial fusion,
such as radius–scaphoid–lunate arthrodesis, may
be possible. The decision to proceed with such
a salvage procedure in the acute setting requires
mature surgical judgment and should always be
discussed with the patient preoperatively.
Technique
The following description is not meant to be
exhaustive, but is provided to highlight certain
elements of technique that facilitate the process of
combined fixation.
The choice of external fixation device is not
critical. Virtually all modern fixators offer ade-
quate rigidity and are biomechanically acceptable
[71,72]. Some devices allow for simple adjustment
of length, biplanar translation, and rotation using
gear drive mechanisms, and these features can be
helpful [34]. Many fixators have proximal and
distal mechanisms into which the pins are
mounted. These designs require a specified and
unalterable distance between the pins. The author
prefers designs such as the small AO fixator that
allow pin placement in any position and at any
distance, because they allow for variations in
anatomy and the placement of additional pins if
this is desired [73]. Additional pins can improve
the rigidity of the fixator in osteoporotic bone
significantly and can be used for fragment specific
fixation [18,60,61].
Pins are placed by open technique to avoid soft
tissue injury and assure central placement in the
bone [19,20,41]. If arthroscopically assisted re-
duction is to be performed, it is best not to
assemble the fixator until the conclusion of the
procedure. The ability to move the wrist in the
traction device greatly facilitates arthroscopic re-
duction and fixation, and the fixator frame
impedes this process. The fixator can be applied
to the previously placed pins at the conclusion of
the arthroscopic procedure. When using percuta-
neous or open reduction techniques, the fixator is
assembled immediately after the pins are inserted
to allow provisional reduction and assistance in
maintaining distraction and wrist position while
internal fixation proceeds. At the conclusion of
the procedure, the fixator must be left in neutral
position or slight wrist extension, with a physio-
logic amount of distraction. Radiographic meth-
ods to evaluate distraction have been described,
and some of them discounted [1,74]. If the fingers
can be passively flexed into the palm without
resistance, distraction is not excessive [33].
Palmar translation of the distal fragments and
rotation of the palmar medial fragment may be
difficult to control by closed means. A palmar
buttress or fixation plate may help provide a stable
base onto which the dorsal articular fragments
can be assembled (Fig. 4). Detailed techniques for
the percutaneous manipulation and reduction of
fragments have been described elsewhere (Fig. 5)
[75]. Blunt dissection down to bone through
limited incisions and use of a tissue protector are
required when placing K-wires percutaneously.
Packing the metaphyseal defect with bone graft
before fixation is completed sometimes can pro-
vide additional structural support to articular
fragments and facilitate definitive reduction and
fixation.
Initial overdistraction in the fixator can draw
attention to carpal ligament injuries by distally
translating the scaphoid or triquetrum on the
lunate (Fig. 6). These findings and other conven-
tional radiographic evidence of such injury (in-
creased interosseous gapping and flexion of the
scaphoid) should be sought and consideration
given to primary treatment of these injuries by
arthrotomy and repair or percutaneous pinning
[36,76–78]. Following fixation of the radius frac-
ture and adjustment of the fixator to a physiologic
position, integrity of the distal radioulnar joint
must be assessed. Clinical instability should be
addressed by repair of destabilizing injury to the
ulnar styloid or triangular fibrocartilage [36,79].
Studies concerning the use of internal fixation
in the treatment of distal radius fractures not
infrequently mention that supplementary external
fixation was necessary in some cases, because
adequate stability of the fracture could not be
achieved by internal fixation alone [10,53,80,81].
Similarly, reports on the use of external fixa-
tion sometimes mention that additional internal
fixation is performed when reduction following
application of the fixator is unacceptable
[20,27,69,82]. The results in these subsets of
patients usually cannot be separated from the
remainder of the group and are difficult to assess.
Seitz et al reported on the results of 51 patients
treated with augmented external fixation using
 COMBINED FIXATION OF DISTAL RADIUS FRACTURES 401

Fig. 4. (A) Anteroposterior and (B) lateral radiographs of a displaced articular fracture of the distal radius. The arrow
on the lateral view highlights the articular fracture in the frontal plane. (C) Anteroposterior and (D) lateral radiographs
following combined fixation using a volar plate and cannulated screw fixation show near anatomic reduction.
(Photographs courtesy of David J. Slutsky, MD.)

K-wires to reduce and fix unstable fragments [30].
Forty-seven patients (92%) had satisfactory re-
sults, defined as anatomic restoration of the radius,
grip strength and range of motion at least 80% of
the uninjured wrist, and freedom from pain. The
four unacceptable results included one instance of
loss of reduction, one case of reflex sympathetic
dystrophy, and two patients with decreased grip
strength and ulnar-sided pain.
Doi et al reported on 34 patients treated with
combined fixation techniques at the time of arthro-
scopically assisted reduction of intra-articular
402 MCAULIFFE

Fig. 5. (A) Anteroposterior radiograph of a severely comminuted and displaced articular fracture of the distal radius.
(B) Anteroposterior image obtained intraoperatively shows a Freer elevator introduced through a small incision being
used to reduce the ulnar-sided articular fragments while Kirschner wire fixation is being performed. (C) Anteroposterior
radiograph following combined fixation demonstrates the reduction obtained. (D) Anteroposterior and (E) lateral
radiographs at 4 months from injury show good maintenance of reduction. Slight radial shortening has occurred in this
comminuted fracture despite coralline hydroxyapatite grafting and 8 weeks of external fixation.

fractures [53]. Eighty-two percent of patients
achieved good or excellent results by the criteria
of Gartland and Werley and those of Green and
O’Brien. These patients exhibited significantly
greater range of motion and grip strength when
compared with 48 patients treated with open
reduction and internal or external fixation.
Bass et al reported on 13 severely comminuted
AO type C3 fractures treated with combined fix-
ation that necessitated dorsal and palmar open
 COMBINED FIXATION OF DISTAL RADIUS FRACTURES
Fig. 5 (continued )
approaches [55]. Motion at 27 months following
injury averaged 60  of flexion and 45  of exten-
sion; grip strength was 83% of the uninjured side.
Using the Green and O’Brien [83] rating scale, 10
of the 13 wrists achieved good or excellent status.
Rogachefsky et al reported on a similar cohort of
17 severe AO type C3 fractures treated with
combined internal and external fixation [56]. At
30 months postoperatively, motion averaged 72%
and grip strength 73% of the uninjured side. One
fracture collapsed, necessitating wrist fusion.
Only 5 patients merited good or excellent results
using the Green and O’Brien [83] rating system,
whereas the Gartland and Werley [84] scale rated
10 patients as good or excellent.
It must be recognized that these studies,
particularly those of Bass and Rogachefsky, de-
scribe treatment of the most severe articular
fractures of the distal radius. Despite this caveat,
they are comparable with results reported by
other investigators who included less severe frac-
tures treated by a variety of techniques [9,10,
85,86]. The only alternative for treatment of some
of these fractures would have been primary
arthrodesis. Long-term follow-up of these patients
is not available, and the need for secondary
salvage is unknown. At least in the short term,
the technique of combined fixation seems capable
of restoring reasonable joint function following
severe articular fracture of the distal radius.
403
Fig. 6. Anteroposterior traction radiograph of the wrist
following perilunate dislocation shows marked distal
translation of the scaphoid with respect to the lunate,
indicating complete scapholunate ligament disruption.
Summary
Combined internal and external fixation of
distal radius fractures is used most commonly to
treat injuries with joint surface or metaphyseal
comminution. External fixation aids reduction
intraoperatively and facilitates arthroscopic, per-
cutaneous, or open manipulation of the fracture.
Internal fixation maintains precise reduction of
critical anatomy, principally the contour and
orientation of the articular surface. Postopera-
tively the fixator functions as a neutralization
device, preventing fracture collapse and decreas-
ing the biomechanical demands on the internal
fixation hardware. The combined technique ex-
ploits the benefits of both forms of fixation,
allowing each to be used to full advantage in the
treatment of complex distal radius fractures.
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 Hand Clin 21 (2005) 407–416

Intra-articular Distal Radius Fractures:

The Role of Arthroscopy?
William B. Geissler, MD
Arthroscopic Surgery and Sports Medicine, Division of Hand and Upper Extremity Surgery,
Ole Miss University of Mississippi Medical Center, Department of Orthopaedic Surgery and Rehabilitation,
2500 North State Street, Jackson, MS 39216-5144, USA

Arthroscopy has revolutionized the practice of
orthopedics by providing the technical capability
to examine and treat intra-articular abnormalities.
The development of wrist arthroscopy was a nat-
ural evolutionary progression from the successful
application of arthroscopy to other larger joints,
such as the knee and shoulder. Wrist arthroscopy
has seen considerable growth since Whipple et al
reported their original description of the techni-
ques they developed for viewing the anatomy of
the wrist [1]. Wrist arthroscopy allows direct
visualization of the articular surface, interosseous
ligaments, and components of the triangular
fibrocartilage complex under bright light and
magnification.
The application of wrist arthroscopy in the
management of displaced intra-articular fractures
of the distal radius takes advantage of its ability to
view the articular surface reduction, remove
fracture debris, and detect and manage associated
soft tissue injuries that occur with these fractures
through minimally invasive techniques [2–7]. The
purpose of this article is to discuss the rationale
and technique in the application of wrist arthros-
copy as a useful adjunct in the management of
fractures of the distal radius.
Displaced intra-articular fractures are a unique
subset of distal radius fractures. These fractures
are less amenable to the traditional methods of
closed manipulation and casting [8–11]. These
fractures are usually the result of a high-energy
injury and can be associated with soft tissue
injuries. The prognosis for these injuries has
E-mail address: sfleming@orthopedics.umsmed.edu
0749-0712/05/$ - see front matter Ó 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.hcl.2005.02.009
been shown to depend on radial shortening,
residual extra-articular angulation, radiocarpal
and radioulnar articular congruity, and associated
soft tissue injuries [12–22]. It is the last two factors
in particular, articular reduction and detection
and management of the associated soft tissue
injuries, in which wrist arthroscopy can be a valu-
able adjunct in the management of these difficult
fractures.
Over the years 2 mm of articular displacement
has become a well established critical threshold
tolerance for incongruity of the articular surface
of the distal radius. Knirk and Jupiter in their
classic article demonstrated the importance of
articular reduction within 2 mm or less [12].
Patients whose articular reduction was greater
than 2 mm at final follow-up had a higher instance
of degenerative changes in the wrist. This was
substantiated further in the study by Bradway and
Amadio [13].
More recent investigations have indicated the
critical threshold may be as low as 1 mm less,
however, as demonstrated by Fernandez and
Geissler in their series of 40 patients [21]. They
showed the instance of complication was sub-
stantially lower when the articular reduction was
within 1 mm or less. Trumble and Schmidt had
similar results in their published study [14].
Edwards et al noted the advantage of wrist
arthroscopy in monitoring the articular reduction
as compared with monitoring the reduction by
fluoroscopy alone. In that series, 15 patients
underwent arthroscopic evaluation of the articu-
lar reduction after reduction and stabilization
under fluoroscopy [23]. They found that 33% of
the patients had an articular step-off of 1 mm or
hand.theclinics.com
408 GEISSLER

more as viewed arthroscopically. They concluded
that adjunctive arthroscopy may detect residual
gapping not seen under fluoroscopy.
It has been shown that intra-articular fractures
of the distal radius have a high prevalence of
associated soft tissue injuries of the interosseous
ligaments and the triangular fibrocartilage com-
plex [24–28]. The real question is whether these
associated tissue injuries truly affect the final
prognosis in these fractures. Mohanti and Fontes,
in two separate wrist arthrographic studies, noted
a high instance of triangular fibrocartilage complex
tears associated with the fractures of distal radius
[26,28]. Fontes noted a 66% instance of tears of
the triangular fibrocartilage complex in 58 patients
with distal radius fractures [28]. Similarly, Mohanti
in a series of 60 patients found a 45% instance of
triangular fibrocartilage complex tears [26].
There have been several arthroscopic studies
documenting the incidence of associated soft tissue
lesions with fractures of the distal radius
[24,25,29]. A triangular fibrocartilage complex
tear seems to be the soft tissue injury associated
most frequently with fractures of the distal radius.
Geissler et al reported their experience with 60
patients with intra-articular fractures of the distal
radius undergoing arthroscopic evaluation. In
their series, 49% of patients had a tear of the
triangular fibrocartilage complex [24]. Injuries to
the scapholunate and lunotriquetral interosseous
ligaments also were present but were less common.
Tears of the scapholunate interosseous ligament
were present in 32% of their patients and injury to
the lunotriquetral interosseous ligament was noted
in 15%. In a similar arthroscopic study of 50 pa-
tients by Lindau, 78% of patients had a tear of the
triangular fibrocartilage complex with 54% of the
patients having an injury to the scapholunate
interosseous ligament, and 16% had an injury to
the lunotriquetral interosseous ligament [29]. Han-
ker, in a series of 65 patients, noted that the
triangular fibrocartilage complex was torn in 55%,
and an injury to the scapholunate interosseous
ligament occurred in 75% [2].
Geissler et al noted a spectrum of injury that
may occur to the interosseous ligaments in asso-
ciation with fractures of the distal radius [24]. An
arthroscopic classification of interosseous liga-
ment tears was developed (Table 1). The normal
scapholunate and lunotriquetral ligaments should
have a concave appearance between the carpal
bones as seen from the radiocarpal space. In the
midcarpal space, the scapholunate interval should
be tight and congruent without a step-off. Simi-
larly, the lunotriquetral interval should be con-
gruent, but occasionally a 1-mm step-off is seen
from the midcarpal space, which is normal. Using
Geissler’s classification, in a grade 1 injury, there
is loss of the normal concave appearance between
the carpal bones, and the ligament bulges and
becomes convex. Hemorrhage may be seen within
the ligament itself. Evaluation of the midcarpal
space still shows the carpal bones to be congruent.
In Geissler grade 2 injuries, the interosseous
ligament becomes convex between the carpal
bones as seen in grade 1 injuries, but the involved
carpal bones are no longer congruent, as seen
from the midcarpal space. There is a slight palmar
flexion of the dorsal edge of the scaphoid as
compared with that of the lunate. In injuries of the
lunotriquetral interosseous ligament, increased
motion is seen between the lunate and triquetrum.

Table 1
Geissler arthroscopic classification of carpal instability
Grade Description Management
I Attenuation/hemorrhage of interosseous ligament as seen from Immobilization
the radiocarpal joint. No incongruency of carpal alignment in
the midcarpal space.
II Attenuation/hemorrhage of interosseous ligament as seen from Arthroscopic reduction and pinning
the radiocarpal joint. Incongruency/step-off as seen from
midcarpal space. A slight gap (less than width of a probe)
between the carpal bone may be present.
III Incongruency/step-off of carpal alignment is seen in the Arthroscopic/open reduction and pinning
radiocarpal and midcarpal space. The probe may be passed
through the gap between the carpal bones.
IV Incongruency/step-off of carpal alignment is seen in the Open reduction and repair
radiocarpal and midcarpal space. Gross instability with
manipulation is noted. A 2.7-mm arthroscope may be passed
through the gap between the carpal bones.
 INTRA-ARTICULAR DISTAL RADIUS FRACTURES: ARTHROSCOPY
In Geissler grade 3 injuries, the interosseous
ligaments start to tear and separate from volar
to dorsal, as seen from the radiocarpal space. In
the midcarpal space, a 1-mm probe may be passed
between the carpal bones and twisted. The dorsal
portion of the interosseous ligament is still
attached. In Geissler grade 4 injuries, the inteross-
eous ligament is detached completely and a 2.7-
mm arthroscope may be passed freely from the
radiocarpal space to the midcarpal space through
the tear. This is the so called ‘‘drive-through sign.’’
Fractures without extensive metaphyseal com-
minution are ideal for arthroscopic assisted fixa-
tion [7]. Radial styloid fractures, die punch
fractures, three-part T fractures, and four-part
fractures are all ideal fracture patterns for arthro-
scopic assisted reduction and internal fixation.
Four-part fractures generally are managed through
a combination of open reduction combined with
arthroscopic assisted reduction of the articular
fragments where the joint capsule is not opened.
Small joint arthroscopic instrumentation is
required for arthroscopic reduction of distal
radius fractures. A large joint 4.5-mm arthroscope
is not indicated in wrist arthroscopy. The small
joint arthroscope measures 2.7 mm, and smaller
arthroscopes may be used if desired. A small joint
motorized shaver, 3.5 mm or less, is necessary to
débride out fibrin clot and debris to obtain good
visualization of the fracture fragments.
A traction tower is useful in the management
of these fractures. A traction tower allows the
surgeon to flex, extend, and radial and ulnar
deviate the wrist while retaining constant traction
to reduce the fractured fragments. A new traction
tower was designed to allow the surgeon to
simultaneously evaluate arthroscopically the ar-
ticular reduction and to monitor the reduction
fluoroscopically (Fig. 1). The traction bar is
placed at the side of the wrist rather than in the
center of the wrist so it does not block fluoro-
scopic visualization. This also allows the surgeon
to arthroscope the wrist and simultaneously
allows volar access to the wrist because the
traction bar is not in the way. The surgeon may
arthroscope the wrist in a vertical position, or the
new tower may be adjusted to maintain traction in
the horizontal position if the surgeon is more
comfortable with wrist arthroscopy in the hori-
zontal position (Fig. 2).
Irrigation of the joint is provided through
a separate inflow 6-U portal. Inflow is provided
through a 14-gauge needle that initially distends
the wrist. The traditional viewing portal is the 3-4
409
Fig. 1. A new traction tower (Arc Medical, Hillsboro,
Oregon) was developed so the traction bar is off to the
side. This allows for simultaneous arthroscopic evalua-
tion and assessment of the fracture through the volar
incision. The side traction bar also allows for simulta-
neous fluoroscopic evaluation of the fracture reduction
and position of the implants used to stabilize the fracture.
portal. This portal is made between the third and
fourth dorsal extensor compartments. These
wrists frequently are swollen, and it is hard to
palpate the extensor tendon landmarks. Usually
the bony landmarks can still be palpated. This
includes the bases of the metacarpals, the dorsal
lip of the radius, and the ulnar head. Remember
the 3-4 portal is made in line with the radial
border of the long finger. It is helpful to place an
18-gauge needle into the joint before making the
skin incision to locate the ideal location of the
viewing portal. In this way, the arthroscope will
not be placed mistakenly into the fracture site too
proximally or into the carpus too distally. After
the ideal location of the 3-4 viewing portal is
identified by an 18-gauge needle, the portal is
made by pulling the skin against the tip of a #11
scalpel blade. The tissue is spread with a hemostat
and the arthroscope with a blunt trocar is in-
troduced through the 3-4 portal. At this point it is
helpful to wash out the fracture hematoma and
debris to improve visualization. This also may
potentially improve the final range of motion.
Outflow is through the arthroscope cannula,
which decreases fluid extravasation into the soft
tissues. Additionally, the forearm may be
410
Fig. 2. The tower also may be placed in the horizontal
position for arthroscopic and fluoroscopic evaluation.
wrapped with a compressive dressing if the
surgeon is concerned about fluid extravasation
into the soft tissues. A motorized shaver may be
brought in to further improve visualization of the
joint.
The ideal timing of arthroscopic assisted re-
duction seems to be 3–7 days. Earlier attempts of
arthroscopic fixation may result in troublesome
bleeding. The fracture’s fragments start to heal in
a mal-reduced position and it becomes difficult to
elevate and reduce the articular fragments at more
than 7–10 days postinjury.
Radial styloid fractures
Radial styloid fractures are an ideal fracture
pattern to attempt to reduce arthroscopically,
particularly if one is just beginning to gain
experience in arthroscopic reduction of distal
radius fractures. A closed reduction and percuta-
neous fixation of the radial styloid fragment may
be attempted under fluoroscopy and then fracture
reduction evaluated arthroscopically. Frequently
what is found is that, although the reduction
looked anatomic under fluoroscopy, the radial
styloid fragment may be rotated, as seen arthro-
scopically. The best portal to view rotation of
a fracture fragment is by looking across the wrist.
It is therefore best to place the arthroscope in the
4-5 or 6-R portal to view the rotation of the radial
GEISSLER
styloid fragment. The 4-5 portal is made between
the fourth and fifth dorsal compartments, and the
6-R portal is just radial to the extensor carpi
ulnaris tendon. If the radial styloid fragment is
mal-rotated, it is easy to back the guide wire or
Kirschner wire out of the radial shaft, leaving the
guide wire in the radial styloid fragment only and
using the guide wire as a joystick to control
rotation and reduce the fragment, then advance
the guide wire across the fracture site. A trocar
may be inserted through the 3-4 portal to provide
additional control of the radial styloid fragment.
An alternative technique is to advance the guide
wire or Kirschner wire under fluoroscopy into just
the radial styloid fragment alone to act as a joystick.
The wrist then is suspended in traction and the
arthroscope is placed in the 4-5 or 6- R portal. The
joysticks are used to manipulate and control
rotation of the radial styloid fragment to the
remainder of the articular surface and are advanced
into the radial shaft. It is important to remember to
make a small incision and insert the wires through
a 14-gauge needle or consider using an oscillating
drill to prevent injury to the dorsal sensory branch
of the radial nerve. The radial styloid fragment may
be stabilized by multiple Kirschner wires or poten-
tially by a cannulated or a headless cannulated
screw (Figs. 3–6). Patients seem to recover quicker
with cannulated screws as compared with Kirsch-
ner wires, which hamper rehabilitation because
they protrude from the skin.
Radial styloid fractures also are associated
highly with injury to the scapholunate inteross-
eous ligament [2,24,27,29]. Following completion
of the articular reduction, the arthroscope is
placed in the 3-4 portal to evaluate the integrity
of the scapholunate interosseous ligament. The
midcarpal space also should be evaluated arthro-
scopically. It is more accurate to evaluate carpal
instability from the midcarpal space rather than
the radiocarpal space; occasionally loose bodies
also may be found there.
Three-part fractures
Three-part fractures are more difficult to treat
than radial styloid fractures. The radial styloid
fragment may be closed reduced and percutane-
ously pinned under fluoroscopic visualization.
The radial styloid then may be used as a landmark
to elevate arthroscopically the depressed lunate
facet fragment [16,21]. After the radial styloid
fragment has been reduced closed and stabilized,
 INTRA-ARTICULAR DISTAL RADIUS FRACTURES: ARTHROSCOPY
Fig. 3. Anteroposterior view of a radial styloid fracture
in a 45-year-old man.
the wrist is suspended in the traction tower.
Fracture debris is lavaged out and the arthroscope
is placed in the 3-4 portal. The depressed lunate
facet is visualized arthroscopically. An 18-gauge
needle may be placed percutaneously through the
wrist directly over the depressed fracture frag-
ment. This can be used as a landmark so
a Steinman pin can be placed approximately 2
cm proximal to the 18-gauge needle onto the
depressed fracture fragment. The depressed artic-
ular fragment then is elevated percutaneously with
the Steinman pin. A bone tenaculum can be useful
to further reduce any sagittal gap that exists
between the radial styloid and the depressed
lunate facet fragment. One point of the tenaculum
is placed on the radial styloid and the second tip is
placed on the lunate facet fragment to close the
sagittal gap. Once the fracture reduction is judged
to be anatomic under arthroscopy, it is pinned
transversely. It is important to aim the pins
Fig. 4. Lateral radiograph of the same patient reveals
a fracture dislocation of the carpus.
411
Fig. 5. The fracture was reduced under fluoroscopic
guidance. Two joysticks were placed in the radial styloid
fragment and the fracture was reduced with the
arthroscope in the 6-R portal. The patient had a dorsal
lip fragment that was observed and reduced with the
arthroscope in the volar radial portal as described by
Slutsky (From Slutsky DJ. Wrist arthroscopy through
a volar radial portal. Arthroscopy. J Arthrosc Rel Surg
2002;18(6):624–30; with permission).
dorsally to capture a dorsal die punch fragment;
otherwise it will not be stabilized. It is also
important to pronate and supinate the wrist to
insure that the pins have not violated the distal
radial ulnar joint. Headless cannulated screws are
helpful to stabilize the fragment if metaphyseal
comminution is not present. One headless cannu-
lated screw may be placed down the radial styloid
fragment. A second cannulated screw is inserted
transversely over the guide wire to support and
compress the medial fragment (Figs. 7 and 8).
Additional support may be provided by placing
bone graft through a small dorsal incision be-
tween the fourth and fifth dorsal compartments to
avoid late settling of the fracture.
Fig. 6. Lateral radiograph showing reduction of the
fracture and the carpus.
412 GEISSLER

Four-part fractures
Four-part fractures are managed through
a combination of open reduction and arthroscopic
assisted fixation. The volar–ulnar fragment fre-
quently is unable to be reduced by closed manip-
ulation (Figs. 9 and 10). The volar–ulnar fragment
rotates with traction on the volar wrist capsule
[30]. The radial styloid fragment again is reduced
by closed manipulation under fluoroscopy. Two
Kirschner wires are put in place to stabilize the
radial styloid fragment. A 6-cm skin incision is
made, starting at the distal wrist crease and
extending proximally over the flexor carpi radialis
tendon. The tendon sheath is opened and the
Fig. 8. These impacted fragments are ideal for arthro-
tendon may be retracted radially to protect the
scopic assisted reduction. They are difficult to visualize
radial artery. The flexor pollicis longus tendon is
through an arthrotomy but are easily seen and elevated
identified and retracted ulnarly to protect the arthroscopically. The headless cannulated screws allow
median nerve. The pronator quadratus is released for early rehabilitation.
from its radial border to expose the fracture site.
The radial styloid fragment may be adjusted
further by direct observation of the fracture Frequently there is a dorsal rim fragment. It is
fragment in relation to the shaft of the radius. helpful to leave the dorsal rim fragment unre-
The volar–ulnar fragment then is reduced under duced initially and work through this fragment to
direct observation by reducing it to the shaft and be able to get to the depressed central fragments.
styloid fragments and then is provisionally pinned Once these are elevated, Kirschner wire pins are
transversely. A volar radius plate then is placed to placed through the plate to stabilize the elevated
stabilize the volar bone fragments (Figs. 11 and fragments or transversely through the radial
12). The initial screws are placed in the proximal styloid fragment (Fig. 14). The dorsal lip fragment
screw holes only, and not distally to prevent then is elevated and closed like a book to support
blocking the reduction of the articular fragments. the depressed facet fractures. Once the articular
The wrist then is suspended in the traction reduction has been judged anatomic as viewed
tower and the arthroscope is placed in the 3-4 arthroscopically, the distal screws may be placed
portal. Now the depressed dorsal fragments can in the plate (Figs. 15–17). One advantage of the
be elevated to the radial styloid and volar–ulnar new tower is that it allows simultaneous access to
fragments that act as landmarks (Fig. 13). the volar aspect of the wrist to place the screws
through the plate, while maintaining traction to

Fig. 7. Anteroposterior radiograph of a depressed

impacted articular fragment with a radial styloid Fig. 9. Anteroposterior radiograph of a four-part intra-
fracture. articular distal radius fracture.
 INTRA-ARTICULAR DISTAL RADIUS FRACTURES: ARTHROSCOPY
Fig. 10. Lateral radiograph of the same patient with
a four-part intra-articular fracture. The volar ulnar
fragment cannot be reduced closed.
review the reduction arthroscopically. The dorsal
rim fragments may be visualized by placing an
arthroscope in the 6-R portal and looking across
the wrist or may be placed through the volar
radial portal as popularized by Slutsky [31]. If
a volar incision is used, the arthroscope is placed
through the incision between the radioscaphoca-
pitate ligament and the long radiolunate ligament
to assess the reduction of the dorsal lip fragment
and to evaluate the volar portion of the scapho-
lunate interosseous ligament (Fig. 18).
Ulnar styloid fracture
Wrist arthroscopy provides some rationale as
to when to stabilize an associated ulnar styloid
Fig. 11. The radial styloid fragment is pinned pro-
visionally. The volar ulnar fragment is reduced through
an open incision and is stabilized by a volar buttress
plate. Screws are placed in the shaft only so as not to
block the arthroscopic intra-articular reduction.
413
Fig. 12. Anteroposterior radiograph showing the pro-
visional reduction. Note the gap between the radial
styloid fragment and the remaining articular surface.
fragment with fractures of the distal radius, which
is often a perplexing question. Following anatom-
ic reduction of the distal radius fracture, the
tension of the triangular fibrocartilage complex
articular disk is evaluated arthroscopically with
a probe inserted through the 6-R portal. If there is
good tension (trampoline effect) of the articular
disk, then most of the fibers are attached to the
Fig. 13. The wrist is suspended in the traction tower and
the joint reduction visualized arthroscopically. A bone
fragment was blocking reduction of the radial styloid
fragment. The amount of displacement is seen on the
arthroscopic monitor in the background. Joysticks were
placed in the radial styloid fragment and the loose bone
fragment was removed.
414
Fig. 14. Anteroposterior radiograph showing provisional
fixation and reduction of the radial styloid fragment.
base of the ulna, and the ulnar styloid fragment is
not stabilized. If the articular disk is lax by
palpation, a peripheral tear of the triangular
fibrocartilage complex is suspected. If a peripheral
tear is identified, it is sutured and repaired
arthroscopically. Consideration to stabilization
of a large ulnar styloid fragment is given when
there is laxity of the articular disk and a peripheral
tear of the triangular fibrocartilage complex is not
identified arthroscopically. The ulnar styloid frag-
ment may be stabilized by tension band wire,
Kirschner wire, or a small headless cannulated
screw.
The literature concerning arthroscopic reduc-
tion and internal fixation of intra-articular frac-
tures of distal radius is sparse [1–3,5–7,30,32].
Stewart et al presented results in a comparison
Fig. 15. Distal screws then are placed through the plate
to stabilize the articular surface once an anatomic reduc-
tion has been confirmed arthroscopically. The Acu-lock
plate (Acumed, Hillsboro, Oregon) has two screws spe-
cifically designed to stabilize the radial styloid fragment.
GEISSLER
Fig. 16. Anteroposterior radiograph showing the re-
duction. Note the two screws supporting the radial
styloid fragment.
study of 12 open and 12 arthroscopic assisted
reductions of comminuted fractures of the distal
radius [32]. These fractures were classified as
Frykman type VII and VIII. In their study they
had five excellent, six good, and one fair result in
comparison with the other group in which there
were no excellent results. They also found the
arthroscopic reduction group had a statistically
increased range of motion when compared with
the open group.
Doi et al recently presented results in a similar
comparison study of 38 patients who underwent
arthroscopic assisted fixation as compared with 48
patients who underwent open reduction and in-
ternal fixation [33]. Similarly, in their review, the
arthroscopic group had increased range of motion
as compared with the open group.
Ruch recently presented results for 15 patients
who underwent arthroscopic assisted reduction in
Fig. 17. Lateral radiograph showing the reduction of
the fracture.
 INTRA-ARTICULAR DISTAL RADIUS FRACTURES: ARTHROSCOPY
Fig. 18. The dorsal rim and volar aspect of the
scapholunate interosseous ligament are evaluated with
the arthroscope placed through the volar incision between
the radioscaphocapitate ligament and long radiolunate
ligament.
comparison with 15 patients who underwent
closed reduction and external fixation under fluo-
roscopic guidance [34]. In the 15 patients who
underwent arthroscopic reduction, there were 10
tears of the triangular fibrocartilage complex, of
which 7 were peripheral. All seven peripheral tears
underwent arthroscopic fixation. In the arthro-
scopic group, no patients had instability of the
distal radioulnar joint at final follow-up. In the 15
patients who underwent closed reduction and
external fixation, there were 4 patients with con-
tinued complaints of distal radioulnar joint in-
stability. Those four patients potentially may have
had a peripheral tear of the triangular fibrocarti-
lage complex that could have been repaired
arthroscopically if detected at the same time of
the fracture stabilization.
Geissler and Freeland reviewed results of 33
patients who underwent arthroscopic assisted re-
duction of a comminuted distal radius fracture [6].
In their series, at final follow-up 25 patients had an
anatomic reduction and 8 patients had a 1-mm step-
off. Using the Mayo Modified wrist score there
were 20 excellent, 10 good, and 3 fair results. Simple
articular fractures had better results than complex
fracture patterns, which is to be expected.
This was also the first series to analyze results
based on the associated soft tissue injuries. The
415
investigators found that when a grade 2 injury to
the scapholunate interosseous ligament was pres-
ent, it did not affect the final prognosis. Grade 2
injuries were distributed evenly between AO-type B
and type C fracture patterns and did not affect the
final results. When a Geissler grade 3 or 4 tear was
present in an AO-type C fracture, however, it
significantly affected the final result. In the five
patients with an AO-type C fracture without
interosseous ligament tear, all five patients had an
excellent result. In the five patients with an AO-
type C fracture with a Geissler grade 3 or 4
interosseous ligament tear, there were four good
results and one fair result. In this study the presence
of a Geissler grade 3 or 4 interosseous ligament tear
significantly affected the final prognosis.
Summary
Arthroscopic assisted fixation of distal radius
fractures offers several advantages. It allows for the
evaluation of the articular reduction under a bright
light and magnification. Particularly, rotation of
the fracture fragments, which is difficult to judge
under fluoroscopy, may be detected arthroscopi-
cally and corrected. Washing out fracture hema-
toma and debris potentially allows for improved
range of motion, as shown by the studies of Doi and
Stewart [32,33]. Wrist arthroscopy also allows for
detection and management of associated soft tissue
injuries, which has been shown to occur with distal
radius fractures [2,24–26,28]. Some of the more
severe interosseous ligament injuries can be di-
agnosed on plain or traction radiographs. Arthros-
copy performed at the same time as fracture
reduction, however, substantially increases the
recognition of these injuries. In addition, it is well
known that the management of acute interosseous
ligament tears has a better prognosis when com-
pared with chronic lesions.
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 Hand Clin 21 (2005) 417–425

Treatment of Injuries to the Ulnar Side of the Wrist

Occuring with Distal Radial Fractures
Tommy Lindau, MD, PhDa,b,*
a
Department of Orthopedics, Hospital of Ängelholm, S-26281 Ängelholm, Sweden
b
The Pulvertaft Centre Derbyshire Royal Infirmary, London Road, Derby, DE1 2QY, UK

Frykman first emphasized in 1967 [1] the Functional anatomydligaments are important
importance of the disturbance of the distal radio- stabilizers
ulnar joint. This article is not remembered for its
The radius rotates around the ulnar head during
important emphasis on methods for the prevention
pronation and supination of the forearm through
of reflex sympathetic dystrophy, but rather for its
the DRUJ (Fig. 1) [25,26]. This joint is also
classification, which implied an increased severity
connected to the carpus with a ligament apparatus
if the ulnar styloid was fractured. Frykman, as well
(see Fig. 1) and thus transmits forces to and from
as many other authors, recognized that the most
the hand [26]. The stability of the DRUJ is achieved
frequent complaint after distal radial fractures was
by bony congruity between the sigmoid notch of
ulnar-sided wrist pain [1–5]. It is present in every
the radius and the ulnar head, which are held
fifth patient after distal radius fracture [1] and
together by ligaments (see Fig. 1) [15,26,27]. The
affects the end result adversely [1,6,7]. Ulnar-sided
bony stability can easily deteriorate after trauma
wrist pain has mainly been attributed to malunion
as only approximately 60% of the joint surfaces
of the distal radius [1,6,8–14], creating an imbal-
are in contact in neutral forearm position and
ance distally, which might lead to ulno-carpal
10% in full pronation and supination [27–30].
abutment [15], incongruency [16], and osteoarth-
The major stabilizer of the DRUJ are the ulno-
rosis of the distal radio-ulnar joint (DRUJ) [17].
radial ligaments, which represent the transverse,
Wrist arthroscopy has revealed that the com-
peripheral part of the triangular fibro-cartilage
mon distal radial fracture often is complicated by
complex (TFCC) [15,26,27,31–34]. The ligaments
ligamentous injuries [18–20]. These injuries can
run from the fovea of the ulnar head and the base
lead to laxity of the DRUJ and subsequent worse
of the ulnar styloid to the dorsal and palmar edges
outcome [21], so that if we want to better un-
of the distal radius [31–35]. The periphery is well-
derstand the fracture and its sequel, we must have
vascularized [35,36], which implies that peripheral
a complete diagnosis that includes ligament inju-
tears might heal. The TFCC also includes a central
ries. This may partly explain way the Frykman
articular disc and the ulno-carpal ligament (see
classification does not correlate with the outcome
Fig. 1). Secondary stability is achieved through
[22] and why there is still insufficient knowledge
different degrees of contribution from the exten-
regarding treatment of the fracture and its associ-
sor carpi ulnaris tendon [27], the pronator quad-
ated ligament injuries [23]. However, by analyzing
ratus muscle [29], and the radio-ulnar interosseous
recent literature [24], we can recognize the different
membrane [37].
problems and plan a strategy to address the acute
fracture and ligament injuries and later secondary
problems related to malunion, instability, and pain.
The fracture must be congruently fixed

* The Pulvertaft Centre Derbyshire Royal Infirmary, Ulnar fragments of the distal radius create
London Road, Derby, DE1 2QY, UK. a problem, because they represent a possible risk
E-mail address: tommy.lindau@telia.com of a ‘‘double joint incongruency’’ [38]; ie, in both
0749-0712/05/$ - see front matter Ó 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.hcl.2005.04.002 hand.theclinics.com
418 LINDAU

Fig. 1. Ligaments are important stabilizers. (A) Schematic drawing showing the triangular fibrocartilage complex
(TFCC), which is the major stabilizer of the DRUJ. (B) The TFCC is cut open to show that the central disc is
membranous and adds no stability between ulna and radius. A = the ulno-carpal ligament, which is the palmar, distal
part of the TFCC arising from the fovea of the ulna and inserting at the palmar aspect of triquetrum. B = the central
articular disc. C = the dorsal and palmar ulno-radial ligaments, which stabilize the DRUJ.

the obvious radio-carpal and the DRUJ. There are congruity with complete diagnosis and treatment
several options, decisions, and questions that must of ulnar-sided and intercarpal-associated injuries
be addressed in treating these fractures, and every [38,48].
surgeon has a preference of addressing such an
incongruency by means of closed, minimally in- Arthroscopic reduction and percutaneous pinning
vasive, or open reduction techniques. It is com-
Arthroscopy is performed under upright
forting to know that ‘‘only a few and provisional
[38,48] or horizontal [49] traction, which can
conclusions relating to clinical management can be
help reduce some fragments by way of ligamento-
drawn from the available randomized trials, which
taxis. Most often, however, the fragments have to
do not provide robust nor sufficient evidence for
be mobilized before reduction, which is done
most of the decisions necessary in the management
either with a probe within the joint or with an
of these fractures’’ [23]. Careful analysis has not
elevator through a separate skin incision over the
demonstrated differences of outcome results from
fracture. This is well described in the article by
treatment of intra-articular incongruencies when
Geissler elsewhere in this issue.
comparing medullary pinning with external fixa-
However, in the specific treatment of ulnar-
tion [39] or percutaneous pinning with external
sided fragments, I prefer to start the realignment
fixation [40,41]. However, it has been shown that
at the ulnar border of the radius, thereby reducing
a 1⁄4 tubular plate may be somewhat better than
the double joint incongruency of both the radio-
a pi-plate [42] and that arthroscopy-assisted re-
carpal joint and the DRUJ (Fig. 2), then add
duction with pinning supported by an external
further fragments to the ulnar platform. Finally,
fixator is superior to open reduction and plate
the extra-articular fracture component, the can-
fixation [43]. These results agree with nonrandom-
cellous defect, and associated injuries have to be
ized studies in which arthroscopy-assisted reduc-
evaluated, and additional procedures have to be
tion has been found to realign pre-operative
considered.
incongruity with good accuracy and give an
excellent or good outcome in about 90% of
Ligamentous (triangular fibro-cartilage complex)
patients [44–47]. Bearing this in mind, there is
injuries are underestimated
evidence that arthroscopy should be considered
when addressing ulnar-sided injuries, because it The TFCC is the most involved associated
combines the possibility of securing the bony injury with distal radial fractures (80%) [19].
 INJURIES TO THE ULNAR SIDE OF THE WRIST 419

This laxity was not correlated to malunion

Fig. 2. Realignment of the incongruency from the ulnar
side. Fragment reduction with arthroscopy-assisted
technique should reconstruct the ‘‘double incongruency’’
of both the DRUJ and the radio-carpal joints, hereby
minimizing the risk for instability as well as post-
traumatic secondary osteoarthritis. The next step is to
realign the other fragments (3) to the ‘‘ulnar platform.’’
[21,51], but instead correlated to these peripheral
tears of the TFCC.
Only a few uncontrolled studies have reported
results after acute management of DRUJ injuries;
in these studies, reasonably good results have been
reported with both open and arthroscopic treat-
ment in selected patients [45,52]. On the other
hand, the natural course of untreated peripheral
TFCC tears has been found by some authors to
end with fairly good results [21]. Hence, the
recommendations given here are based upon the
authors’ opinions from what is currently known
about these conditions. Keep in mind, though,
that there are still no randomized studies that
merit surgical treatment regarding these associ-
ated injuries, and that surgery itself adds trauma
and possible morbidity.

Because the TFCC is a combination of structures

that make up the ligamentous support of the
DRUJ and the ulno-carpal joint, I prefer to
describe these injuries not entirely according to
Palmer’s classification [34], but rather as either
central perforation tears, tears of the ulno-radial
ligament (ie, peripheral tears), or tears of the ulno-
carpal ligament [50]. This facilitates the functional
understanding and importance of the different
tears, namely as representing possibly destabiliz-
ing tears of the DRUJ or not [50], as we have
found that tears to the ulno-radial ligament
caused laxity and a subsequent worse outcome
[21].
Arthroscopic management
Central perforation tears are located parallel to
the sigmoid notch of the radius with a 2-mm rim
of membranous substance left between the sig-
moid notch and the perforation (Fig. 3A). These
tears are stable and can be debrided with a suction
punch (Fig. 3B). Care should be taken not to be
too aggressive, thus jeopardizing the stability by
debriding the important palmar and dorsal ulno-
radial ligaments. The edges are then smoothened
with a motorized shaver or vaporizer.
Tears of the ulno-radial ligament can be either
avulsion tears from the insertion of the dorsal and

Fig. 3. Central perforations in the articular disc are stable. (A) Radio-carpal arthroscopy shows a stable central
perforation tear in the central articular disc of the TFCC (dorsum of the wrist to the right). The lunate facet of the radius
(R) is in the foreground with the probe (1 mm thick) lifting the torn ligament about 2 mm from its insertion in the
sigmoid notch of the radius. (B) The tear without healing capacity is best treated with debridement (eg, with a suction
punch).
420 LINDAU

palmar edge of the sigmoid notch of the radius or
ulnar avulsion tears (Fig. 4). They can sometimes
be hidden behind a capsular blood clot. Hence,
debride the area with the shaver to fully examine
the ulno-radial ligament. As previously stated,
these tears are associated with late clinical in-
stability of the DRUJ [21] and worse outcome
[21,51]. Consequently, they probably have to be
repaired.
Radial avulsion tears are often caused by
dorso-ulnar fracture fragments, but may be true
avulsions from the insertion site of the ulno-radial
ligament. Fragments should be anatomically re-
duced to both give bony congruity of the sigmoid
notch as well as fixate the ligament insertion. A
true avulsion at the insertion probably has to be
reinserted, either with drill holes through the
radius [52,53] or with a suture anchor.
An ulnar avulsion tear (Fig. 4A) is preferably
repaired with two or three 2-0 absorbable (PDS)
sutures through a drill hole of the fovea in the
distal ulna (Fig. 4B–D) rather than the previously
recommended technique through the dorsoulnar
capsule and extensor carpi ulnaris tendon sheath.
The repair is protected from supination and
pronation for 4 weeks, followed by 2 to 4 weeks
in a short arm cast or splint.
Tears of the ulno-carpal ligament are rare [19].
Treatment may be considered with a palmar open
reinsertion technique.
Degenerative tears with secondary cartilage
changes on the ulnar head and the lunate may
be found, en passent, together with the fracture.
Sometimes there may be acute tears superimposed
on the degenerative tears [19]. The degenerative
changes are probably best left alone, as they most

Fig. 4. Peripheral TFCC tears cause laxity of the DRUJ. (A) An arthroscopic view of a dorsal ulnar avulsion tear of the
ulno-radial ligament of the TFCC (right wrist with dorsal to the right). The lunate is on top with a chondral flake
hanging down. The dorso-ulnar peripheral tear (arrows) creates a rough longitudinal line from the lunate facet of the
radius in the bottom going all the way toward the ulnar styloid, which is not visible arthroscopically. There is synovium
with hematoma to the right and a cloud of blood over the central disc. (B) A drill hole is made to the fovea of the ulnar
head. (C) The suture is retrieved after it has been inserted through the extensor carpi ulnaris subsheath with the
instrument. (D) The suture is tied after the arm is taken from the traction and with the forearm in neutral.
 INJURIES TO THE ULNAR SIDE OF THE WRIST
often have been asymptomatic before the fracture.
However, an acute component may need treat-
ment as recommended above.
The ulnar styloid fracture is ‘‘unimportant’’
Ulnar styloid fractures have been associated
with worse outcome [1,7,10,54], which was part of
the reason for Frykman’s classification [1]. This
classification pointed out that each fracture type
(extra-articular = I, radio-carpal = III, radio-
ulnar = V, radio-carpal and radio-ulnar = VII)
had a worse counterpart when the ulnar styloid
was fractured (type II, IV, VI, and VIII) [1].
However, the usefulness of his classification has
been questioned [55], because others have not
found a correlation between this classification and
outcome [22]. Furthermore, several studies have
not found any correlation between ulnar styloid
fractures and end result [14,21,51,56–58]. This
controversy might be explained by the previously
stated findings of acute TFCC tears without ulnar
styloid fractures [38,48]. Furthermore, there has
been no correlation between ulnar styloid frac-
tures at the time of trauma and development of
late DRUJ instability [21,51]. Consequently, the
outcome is more correlated with the other ulnar-
sided injuries than the fracture of the ulnar styloid
itself. This is probably the reason why no studies
have shown any benefits with repair of ulnar
styloid fractures [38,57].
Even if operative treatment cannot be advo-
cated, I strongly recommend arthroscopic evalua-
tion if a subluxation or dislocation is present on
normal radiography. After complete diagnosis, I
then recommend a combined repair of both the
TFCC tear (as described above) and the styloid
fracture, preferably with a tension band wiring
technique.
Late DRUJ-related problems are often
misunderstood
There are many possible causes of ulnar-sided
wrist pain after distal radial fractures (Box 1) [24].
Patients who have symptomatic malunion of the
distal radius mainly have symptoms secondary to
the relatively longer ulna, causing an ulna abut-
ment syndrome. By performing a radial osteot-
omy with bone graft [17,28,59], the distal radius
can be realigned regarding both axial shortening
as well as radial and dorsal angulation. The
lengthening osteotomy rebalances the load distri-
bution in the wrist, thereby decompressing the
421
Box 1. Verified and suggested causes
of distal radio-ulnar joint–related
symptoms after distal radial fractures
Verified causes
Ulno-carpal abutment
DRUJ laxity
Tears of the TFCC
Radiographic osteoarthrosis of the
DRUJ
Incongruency of the sigmoid notch
Nonunion of hypertrophic ulnar styloid
Arthrofibrosis
Suggested causes
Tenosynovitis of the extensor carpi
ulnaris
Adapted from Lindau T, Aspenberg P. The
radioulnar joint in distal radial fractures. A
review. Acta Orthop Scand 2002;73:583.
ulna abutment. The techniques of this are ad-
dressed in Stevanovic’s article on extra-articular
distal radial fracture malunion. The ulna abut-
ment might also be decompressed with ulnar
shortening osteotomies [15,60], with Sauvé-
Kapandji arthrodesis of the DRUJ [61–64], or
with an ulnar head resection arthroplasty [65].
The arthroplasty might in turn be performed as an
arthroscopic [60,66] or open [60] procedure.
The radial osteotomy for malunion also alters
the sigmoid notch, which might give both better
range of pro-supination motion and create bony
stability of the DRUJ [17,59]. However, this
osteotomy alone does not yield stability in all
cases. Some authors have considered additional
ligament stabilizing procedures to be necessary in
almost half the patients [17,67,68], while af Eken-
stam and colleagues [28] did not find this advan-
tageous. Because ulnar styloid fixation was seen as
a ligament-stabilizing procedure, these contradic-
tory results might be explained by the findings that
the stabilizing ulno-radial ligaments might be torn
without an ulnar styloid fracture [19]. Further-
more, ligament rupture alone can give laxity of the
DRUJ even without malunion [21]. Consequently,
we should not only reinsert the ulnar styloid when
we attempt to stabilize the DRUJ in conjunction
with a radial osteotomy, but also need to address
the soft-tissue problem completely.
422
Fig. 5. Ligament reconstruction is sometimes the final solution. (A) The most appealing reconstruction technique uses
a tendon graft (most often palmaris longus), which is passed in a tunnel parallel to the sigmoid notch of the radius and
reinserted in the fovea [1]. (B) After reconstruction, the graft is pulled firmly and tied with the forearm in neutral
rotation. Thereafter, the capsule is closed.
Authors preferred assessment of posttraumatic
ulnar wrist pain
Every patient with ulnar sided wrist pain after
distal radial fractures should be examined with
a stability test of the DRUJ [50], including ulno-
carpal stress test, and assessment of radiographic
signs of malunion. In cases with obviuos axial,
radial and dorsal malunion, I do a straightforward
lengthening osteotomy of the radius with bone
graft. If congruity and stability of the DRUJ is
not achieved, there is a clear indication to add
arthroscopy to evaluate the status of the TFCC
and continue with a reattachment of its ulnar
insertion in the fovea of the ulnar head, sometimes
combined with reinsertion of the ulnar styloid.
In cases with only axial shortening malunion, I
always start with an arthroscopic evaluation of
the ulno-carpal complex and grade the findings
according to Palmer [34] (as opposed to the acute
tears were I follow my previous recommendations
for classification). A shortening osteotomy of the
ulna is done if there is an ulnar variance of 1 to 2
mm or more, while I do an arthroscopic partial
ulnar head resection (wafer) if the ulnar variance
is less than 1 to 2 mm, bearing in mind that the
full circumference of the ulnar head must be
resected. However, in cases with additional wear
of the luno-triquetral ligament [34], I always do an
ulnar shortening osteotomy to stabilize the entire
ulno-carpal complex.
In cases with laxity of the DRUJ without
malunion of the radius, I perform an arthroscopy
to see if there is an option to arthroscopically
reinsert the ligament to the fovea, as previously
described. However, in many cases it is necessary
LINDAU
to do a reconstruction procedure, where a tendon
graft I used to constrain the joint by passing the
graft in a tunnel parallel to the sigmoid notch of
the radius and reinserting both ends in the fovea
through a tunnel of the ulnar head [69] (Fig. 5).
This pulls the radius toward the ulna like the
reigns of a horse.
Summary
We still do not know how to best treat the
DRUJ condition that was recognized 200 years
ago by Abraham Colles and later addressed in
Frykman’s classic thesis [18]. To improve the
outcome, we must recognize the differences be-
tween osteoporotic and other fractures and un-
derstand the importance of ligament injuries,
especially in patients under the osteoporotic age
[39]. However, our current problem is that neither
the initial ligament injury nor the posttraumatic
laxity is detectable with radiographic methods,
which creates future challenges regarding diagno-
sis and treatment. We therefore have to critically
analyze each fracture in each patient and be aware
of the complexity of the entire injury to the wrist.
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 Hand Clin 21 (2005) 427–441

Combined Fractures of the Scaphoid and Distal

Radius: A Revised Treatment Rationale Using
Percutaneous and Arthroscopic Techniques
Joseph F. Slade III, MDa,*, Sudeep Taksali, MDb, John Safanda, MDb
a
Hand and Upper Extremity Service, Department of Orthopaedics and Rehabilitation,
Yale University School of Medicine, 73 Faulkner Drive, Guilford, CT 06437, USA
b
Department of Orthopaedics and Rehabilitation, Yale University School of Medicine,
800 Howard Avenue, New Haven, CT 06520, USA

The revised treatment protocol for the treat-
ment of combined scaphoid and distal radius
fractures involves a three-step process. The first
step involves reduction and percutaneous K-wire
fixation of the scaphoid. The second step is the
reduction and rigid fixation of the distal radius.
The third step is the rigid fixation of the scaphoid.
This step is performed last because distraction and
reduction maneuvers to treat the distal radius
fracture may result in loss of reduction, loss of
fixation of the scaphoid fracture, or both.
Combined fractures of the distal radius and
scaphoid are uncommon but present a challenging
treatment dilemma (Fig. 1) [1]. Distal radius
fractures, when poorly managed, result in defor-
mity and impaired function. Scaphoid fractures are
commonly unrecognized and can result in carpal
collapse, cystic degeneration, and eventual carpal
degenerative arthritis when untreated [2,3]. This
destructive process remains hidden until the patient
presents with chronic pain and stiffness, typically
after the original injury has been forgotten.
Historically, care of distal radius injury has
evolved from benign neglect (with protective
splinting) to aggressive efforts to anatomically
restore the distal radius bony platform to permit
full recovery of hand and wrist function [4]. With
the focus evolving toward more aggressive treat-
ment of distal radius fractures, the treatment of
* Corresponding author.
E-mail address: joseph.slade@yale.edu (J.F. Slade).
0749-0712/05/$ - see front matter Ó 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.hcl.2005.03.004
scaphoid fractures has, at best, been relegated to
an afterthought in the overall management of
these combined injuries [5].
The distal radius functions as a platform that
positions the wrist and hand through its articula-
tion with the carpus and the distal radioulnar joint.
As a scaffold, it suspends tendons and transfer
forces to the hand. An improvement in the bio-
mechanical understanding of the wrist has led to
a change in the management of these injuries. The
goal now is the restoration of the distal radius to
permit early aggressive therapy to recover hand
and wrist function [6]. Isolated stable scaphoid
fractures might be managed safely with plaster
immobilization for periods of 3 to 4 months. This
period of immobilization, however, is not suitable
for the treatment of distal radius fractures and
results in arthrofibrosis and atrophy of the distal
radius and hand, making the recovery of full hand
function unlikely.
A review of the relatively few published reports
on combined scaphoid and distal radius fractures
demonstrates that treatments have evolved over the
past decade. This transformation appears to have
paralleled our growing understanding of scaphoid
[7] and distal radius fractures. The arthroscopic
care of distal radius and scaphoid fractures and the
use of percutaneous techniques has permitted the
rigid fixation of these fractures while preserving
uninjured tissues [8–11]. This approach has allowed
for the early recovery of hand function with
minimal complications. The purpose of this article
is to present an approach for the care of combined
hand.theclinics.com
428 SLADE
Fig. 1. Combined fractures of the distal radius and
scaphoid present a challenging treatment dilemma.
Conventional wisdom states that the goal of treatment
should allow an early recovery of hand function, which
requires rigid fixation of the scaphoid and radius
fractures.
scaphoid and wrist fractures using arthroscopic
and percutaneous techniques. This article details
the authors’ technique for the management of these
fractures and reviews their results [12].
Materials and methods
The authors reviewed scaphoid fractures trea-
ted with percutaneous repair by a single surgeon
(J.F. Slade III) at the Yale Hand and Upper
Extremity Service between 1998 and 2002. Seven
ipsilateral fractures of the scaphoid and distal
radius were identified in adults. The average age
was 30 years (range, 18–58 years) and there was
a bimodal distribution, with men having an
average age of 22 years and women 49 years.
The injuries were three right and four left. Five of
the seven patients were men. In all male cases, the
injury involved a fall from a substantial height or
a motor vehicle accident. The two female patients
were injured in falls.
All scaphoid fractures were displaced greater
than 1 mm. Six of the scaphoid fractures were
located at the waist, and one involved the prox-
imal pole of scaphoid. An additional carpal
fracture was identified on arthroscopic examina-
tion that involved a coronal split of the lunate
(and was also percutaneously repaired). The distal
radius fractures included two displaced radial
styloid fractures and one volar shearing fracture.
The remaining distal radius fractures were Colles’
fractures with dorsal comminution, and two
fractures were intra-articular.
All fractures were operatively treated within 2
weeks of injury. All scaphoid fractures were
et al
treated with arthroscopic-assisted reduction and
dorsal percutaneous fixation with a standard Acu-
trak screw (Acumed, Beaverton, Oregon), a head-
less cannulated compression screw. All radius
fractures were treated with arthroscopic-assisted
fracture reduction and rigid fixation, which was
accomplished by using percutaneous screws or
open repair with a dorsal or a volar plate system.
No external fixation was used, and allograft was
used in all radius fractures requiring bone grafting
for structural support. No scaphoid fractures
required bone grafting.
Overview of surgical technique
The treatment of combined fractures of the
scaphoid and distal radius includes the arthro-
scopic-assisted reduction of both fractures and
their percutaneous or miniopen rigid fixation
[13]. The key to success is the following three-
step process (Fig. 2):
1. Percutaneous/arthroscopic reduction of the
scaphoid fracture and provisional stabilization
with a guidewire placed along its central axis
2. Percutaneous/arthroscopic reduction and rigid
fixation of the distal radius fracture to permit
early motion
3. Fixation of the scaphoid fracture by dorsal
percutaneous implantation of a cannulated
headless compression screw along the central
scaphoid axis
This surgical staging permits reduction of both
fractures without compromising the final rigid
fixation of either fracture, which is required to
initiate an aggressive hand therapy program to
recover function.
It has been shown that screws placed along the
central scaphoid axis increase the rate of healing
[12,14,15] and increase the stiffness of fixation
(Fig. 3) [6]. An additional benefit is that screws
placed in this position reduce the risk of thread
penetration and cartilage injury [7].
Arthroscopy is used to confirm fracture re-
duction and identify occult injuries. Joint surface
incongruities that are detected are addressed by
placing K-wires percutaneously as joysticks and
adjusting the fracture under direct vision. After
reduction is achieved, provisional fixation is
achieved by K-wires. After provisional fixation,
the authors’ preferred fixation of the radius is
a volar locking plate applied to the aligned distal
radius. Imaging is used to confirm the plate
position and to assist in minor adjustments to the
 PERCUTANEOUS AND ARTHROSCOPIC TECHNIQUES
Fig. 2. Treatment of combined fractures of the scaphoid
and radius is a three-step process. Step 1 is the
percutaneous reduction of the scaphoid fracture and
provisional stabilization with a guidewire placed along
its central axis. The scaphoid is not rigidly fixed now
because reduction of the radius fracture may require
significant bending forces to be applied to the fixated
scaphoid, which might lead to a loss in compression at
the fracture site and an eventual nonunion, particularly
with early motion. Step 2 is the percutaneous/arthro-
scopic reduction and rigid fixation of the distal radius
fracture to permit early motion. Step 3, the fixation of
the scaphoid fracture, is accomplished by the dorsal
percutaneous implantation of a cannulated headless
compression screw along the central scaphoid axis.
Scaphoid fixation is accomplished with minimal stress
on the radius fixation.
fracture. Bony defects in the metaphysis are
addressed with allograft. The use of a volar plate
with a targeting guide permits the placement of
subchondral locking screws. Finally, a headless
cannulated compression screw is percutaneously
introduced using the scaphoid guidewire to com-
plete the rigid fixation.
Equipment required includes the headless,
standard Acutrak cannulated compression screw
and the ACU-LOC Targeted Distal Radius Sys-
tem (Acumed). The authors prefer screws of
standard size because the larger core shaft in-
creases the ability to resist lateral displacement
forces [16]. The ACU-LOC Targeted Distal
429
Fig. 3. Clinically, screws placed along the central
scaphoid axis have an increased rate of healing and
have been shown biomechanically to have increased
stiffness. The central axis is the position that permits the
placement of the longest screw. Placement of a long
screw allows reduction of the forces acting on the screw
that cause loosening.
Radius System is a volar plating system with a drill
and screw guide jig that allows for the correct
placement of locking subchondral screws in the
distal radius. Additional equipment includes a fluo-
roscopy unit (preferably a mini-imaging unit),
0.045-in and 0.062-in double-cut K-wires, a wire
driver, and a small-joint arthroscopy setup in-
cluding a traction tower.
Surgical technique in detail
Step 1: imaging
The patient is supine, with the upper extremity
extended on a hand table [13]. A fluoroscopic
survey of the wrist and carpus is performed to
evaluate the personality of the fractures, including
the direction of displacement, the presence and
degree of comminution, and associated ligamen-
tous injuries. Radiographic views of the distal
radius to account for the palmar tilt and ulnar
inclination are useful in evaluating fracture dis-
placement of the articular surface. Longitudinal
traction is applied to the wrist and a second
fluoroscopic survey is conducted through a 90
arc. This survey helps to determine the reduction
achieved by ligamentotaxis and whether there is
any remaining displacement (Fig. 4).
On completion of this study, the central axis of
a reduced scaphoid is located by pronating and
flexing the wrist until the scaphoid poles are
430 SLADE
Fig. 4. Longitudinal traction is applied to the wrist and
a fluoroscopic survey (inset) is conducted to determine
the reduction achieved by ligamentotaxis and any
remaining displacement. The distal radius and carpus
fractures are evaluated, including the direction of
fracture displacement, the presence and degree of
comminution, and associated ligamentous injuries. Tilted
radiographic views of the distal radius joint are useful in
evaluating fracture displacement of the articular surface.
aligned in the radiographic beam as a cylinder
viewed along its axis. The scaphoid assumes
a ‘‘ring’’ shape, and the center of the circle is the
central axis of the scaphoid. This is the precise
location for placement of the guidewire (Fig. 5).
Fig. 5. (Left panel) The central axis of the scaphoid is the longest straight path in a scaphoid. This position permits the
placement of the longest screw. The central axis is obtained by pronating and flexing the wirst (right panel) until the
scaphoid poles are aligned in the radiographic beam as cylinder viewed along its axis. The scaphoid assumes a ‘‘ring’’
shape, and the center of the circle is the central axis of the scaphoid and the precise location for placement of the guide-
wire.
et al
Step 2: scaphoid fracture reduction and dorsal
guidewire placement along the scaphoid central axis
The starting position for the guidewire is the
proximal pole of the scaphoid (Fig. 6). The base
of the scaphoid is covered only by soft tissue [13].
This dorsal percutaneous approach permits easy
access to the central scaphoid axis. The distal
scaphoid, which is covered by the trapezium,
obstructs direct line of sight. Using minifluoro-
scopy, the guidewire is driven dorsally along the
central axis of scaphoid passing through the
trapezium. The wrist is maintained in a flexed
position to avoid bending the guidewire. As the
wire is advanced, its position is checked using
fluoroscopy. The wire is advanced from a dorsal
to volar position until the dorsal trailing end of
the wire clears the radiocarpal joint, permitting
full extension of the wrist (Fig. 7). The volar end
of the wire exits from the radial base of the
thumb, a safe zone devoid of tendons and neuro-
vascular structures. After the dorsal trailing end
of the guidewire has been buried into the proximal
scaphoid pole, the wrist can be extended for
imaging to confirm scaphoid fracture alignment
and correct positioning of the guidewire.
If the scaphoid is displaced, then the proximal
pole is ignored and the guidewire is placed
through the distal scaphoid fragment along its
central axis and withdrawn volarly beyond the
fracture site. With the wrist extended, the scaph-
oid fracture is reduced percutaneously using
dorsally placed 0.062-in K-wires as joysticks in
each fracture fragment. When the dorsal joysticks
are brought together, the flexion deformity of the
scaphoid is corrected. This reduction is best
confirmed on lateral fluoroscopy.
 PERCUTANEOUS AND ARTHROSCOPIC TECHNIQUES
Fig. 6. The starting position for the guidewire is the
proximal pole of the scaphoid.
With acute fractures, there is usually no loss of
volar cortex because the volar scaphoid fails in
tension in a hyperextension injury. Older or im-
pacted displaced fractures may require the direct
introduction of a small hemostat at the fracture site
to achieve reduction. The hemostat is introduced
through a midcarpal or accessory portal.
After reduction is achieved, the previously
placed wire in the distal fragment is driven from
its volar position into the proximal fragment to
capture and secure reduction. These fractures are
often unstable and require the placement of a
second parallel antiglide wire during reaming and
screw implantation.
Fig. 7. The wrist is maintained in a flexed position as the
wire is advanced from dorsal to volar to avoid bending
the guidewire. As the wire is advanced, its position can
be checked using fluoroscopy. The wire is advanced until
the dorsal trailing end of the wire clears the radiocarpal
joint, permitting full extension of the wrist.
431
Step 3: distal radius fracture reduction
After the scaphoid fracture is reduced and
provisionally stabilized, attention is turned to the
distal radius fracture. With the exception of radial
styloid fractures, which can be rigidly secured with
a percutaneous headless compression screw, the
distal radius is approached from a volar incision
and selected dorsal portal incisions. The wrist is
placed over a roll-towel and approached through
an incision centered over the flexor carpi radialis
tendon. The FCR tendon is retracted ulnarly and
the floor is incised (Fig. 8). The radial artery is
exposed and retracted radially. The flexor pollicis
longus muscle origin is identified and incised off
the radial distal radius and retracted ulnarly,
exposing the pronator quadratus over the volar
distal radius (Fig. 9). The pronator quadratus is
incised off the radial distal radius, and a Cobb
elevator is used to elevate the muscle ulnarly,
exposing the fracture site. The brachioradialis
tendon’s insertion on the radial styloid is identified
and Z-plastied (Fig. 10) [17]. Ethibond (Ethicon,
Inc., Somerville, New Jersey) sutures are placed at
both ends as markers. The floor of the first dorsal
extensor compartment is identified and incised.
This exposure is often sufficient to achieve an
anatomic reduction for acute extra-articular frac-
tures. Early malunions and intra-articular frac-
tures require greater exposure. In these cases, the
dorsal periosteum of the distal radius is incised, the
fracture callus is excised, and the proximal radius is
delivered from the wound (Fig. 11).
Using imaging, the distal articular surface can
be directly assembled and provisionally reduced
using multiple K-wires. This technique effectively
transforms an intra-articular fracture into an
extra-articular fracture. With longitudinal trac-
tion applied to the distal radius, the proximal
radius bone fragment is reduced.
Fig. 8. The distal radius is approached from a volar
incision centered over the flexor carpi radialis tendon.
432 SLADE
Fig. 9. The radial artery is exposed and retracted
radially. The flexor pollicis longus is retracted ulnarly,
exposing the pronator quadratus.
Step 4: arthroscopy and soft tissue injuries
After fluoroscopy confirms fracture reduction
of the scaphoid and the radius, arthroscopy can be
used as a valuable tool to provide direct confir-
mation of articular fracture reduction of the
scaphoid and the radius (Fig. 12) [9–11,18].
Longitudinal traction is applied through all
fingers to allow for safe entry of the small-joint
arthroscope and instruments. Using minifluoro-
scopy, the midcarpal and radiocarpal portals are
located and 19-gauge needles are used to mark
these portal sites. After a small longitudinal
incision is made, a small hemostat is used to
bluntly dissect the soft tissue down to the joint
capsule. A blunt trochar is used to enter the joint.
An angled, small-joint arthroscope is placed in the
radial midcarpal portal to confirm scaphoid
fracture reduction.
The arthroscope is placed in the radiocarpal
joint through the 3,4 portal to confirm reduction
of the distal radius chondral surface. The integrity
of the scapholunate and lunotriquetral interossei
Fig. 10. The brachioradialis tendon’s insertion on the
radial styloid is identified and Z-plastied.
et al
Fig. 11. Early malunions and intra-articular fractures
require greater exposure to obtain fracture reduction.
The Brachial Radialis is Z-plasty and dorsal periosteum
of the distal radius is incised and elevated. The fracture
callus is excised and the proximal radius is delivered
from the wound and curretted.
ligaments is assessed from the radiocarpal and the
midcarpal joints.
These joints are explored with a probe. Partial
tears can be treated with simple debridement.
Complete carpal ligament disruptions require
ligament repair.
Step 5: rigid fixation of the distal radius
Commonly, a distal radius metaphyseal defect
is visible on imaging and bone grafting is required
(Fig. 13). Although radial height is restored with
bone grafting, volar tilt still requires some coaxing.
This correction is achieved by molding the radius
to the volar locking plate. Biomechanical studies
suggest that the volar implantation of a locked
fixed-angled plate provides the strongest fixation
for comminuted fractures of the distal radius
[19,20]. A congruent plate is selected and fitted to
the volar distal radius surface. Its position is
checked using imaging. Care is taken to position
the plate on the distal volar lip of the radius and
ulna to capture the medial facet. After a plate is
selected, the screw jig is secured to the plate.
K-wires are placed through K-wire holes in the
plate, and the plate is provisionally secured to the
distal radius (Fig. 14). The construct is imaged in
the posteroanterior plane to confirm its position on
the volar surface of the distal radius. Next, a lateral
radiograph is obtained and the distal radius is
molded to the volar plate with the drill guide jig in
place (Fig. 15). Distal K-wires are used to secure
this position.
When satisfied with the fracture reduction and
plate fixation, the proximal plate is secured to the
radial diaphyseal shaft by placement of a 3.5-mm
 PERCUTANEOUS AND ARTHROSCOPIC TECHNIQUES 433

Fig. 12. (Left panel) Arthroscopy is used to provide direct confirmation of articular fracture reduction of the scaphoid
and the radius. Longitudinal traction is applied through all fingers. (Center panel) Minifluoroscopy permits the quick
identification of the midcarpal and radiocarpal portals. (Right panel) An angled, small-joint arthroscope is placed in the
radial midcarpal portal to confirm scaphoid fracture reduction. It is then placed in the radiocarpal joint through the 3,4
portal to confirm reduction of the distal radius chondral surface.

unicortical screw in a slotted screw hole. This screw
hole permits final adjustment of plate position by
the distal or proximal advancement of the plate on
the volar distal radius. The unicortical screw
prevents extensor tendon abrasion by exposed
leading screw tips. The key element to the partic-
ular wrist fracture system that the authors use is
the drill and screw jig, which positions and directs
drilling and placement of subchondral supporting
screws. These locking screws are fully threaded to
lock and secure a dorsal bone fragment or are
smooth to provide subchondral support to the
distal radius. The screw jig permits the securing of
the lunate facet and sigmoid notch with locking
screws. In addition, it allows the targeted place-
ment of locking radial styloid fixation.
The wrist is imaged through this process to
confirm correct plate and screw placement. When
this is accomplished, the jig is removed (Fig. 16).
Additional bone graft is applied radially as
needed. The brachioradialis tendon is repaired in
a lengthened position. The pronator quadratus is
advanced, providing plate coverage to the radial
styloid, and secured to the brachioradialis tendon
in a manner similar to hanging a sheet on
a clothesline (Fig. 17).
Step 6: scaphoid length and screw size
After distal radius fixation, the scaphoid frac-
ture can now be rigidly fixed. Earlier fixation of
the scaphoid can result in displacement during
distal radius fracture reduction and fixation. The
central axis scaphoid guidewire position is again
confirmed using imaging. The scaphoid length

Fig. 14. The volar tilt is restored by molding the distal

Fig. 13. The distal radius metaphyseal defect is sup-
ported by allograft and restores the radial height.
radius to the volar congruent plate. A plate is selected
and fitted to the volar distal radius surface. The position
of the plate is carefully checked so that it captures the
distal volar lip of the radius and the ulna media facet of
the radius. The volar drill guide permits exact placement
of subchondral and radial styloid screws.
434 SLADE
Fig. 15. Imaging is used to confirm the plate position in
the posteroanterior and lateral planes.
must now be determined [18]. The guidewire is
adjusted until the distal end is in contact with the
distal cortex of the scaphoid. A second wire of
equal length is placed at the tip of the cortex of the
proximal pole. The difference in length between
these two wires is the exact length of the scaphoid
(Fig. 18).
The most common complication of percutane-
ous screw implantation is implantation of a screw
that is too long. In the authors’ experience, to
avoid this complication, the screw should provide
for 2-mm clearance between the end of the screw
and the scaphoid cortex. The screw length should
be 4 mm shorter than the scaphoid length. This
length permits the complete implantation of
Fig. 16. The plate is first secured by a proximal screw in
the sliding slot. Next, the distal radius is secured with
subchondral pegs using the volar drill guide. When this
is accomplished, the plate is secured to the proximal
radius with 3.5-mm screws.
et al
Fig. 17. After securing the plate, the drilling jig is
removed. The brachioradialis tendon is repaired in a
lengthened position and the pronator quadratus is ad-
vanced and secured to the brachioradialis tendon.
a headless compression screw in bone without
exposure.
After the length of the screw has been de-
termined, the appropriate width must be selected.
Biomechanical studies suggest that the widest
screws provide the strongest fixation [16]. One
concern about introducing larger screws dorsally
is the consequences of the resulting cartilage
defect, but such defects have been shown to heal
over with cartilage in time without degenerative
changes [21].
Fig. 18. The scaphoid length is determined by using two
K-wires of equal length. The first K-wire, the central
guidewire, is adjusted until the advancing end is in
contact with the distal cortex of the scaphoid (see inset).
A second wire of equal length is placed at the tip the
cortex of the proximal pole. The difference in length
between these two wires is the exact length of the
scaphoid.
 PERCUTANEOUS AND ARTHROSCOPIC TECHNIQUES
With extremely small proximal pole fractures
or avulsions, there is a possible risk of fragmen-
tation with implantation of a large screw. Under
these circumstances, a smaller screw is inserted to
decrease the risk of fracture fragmentation. This
smaller-screw insertion is performed with the
understanding that the trade-off is a decrease in
the rigidity of the fixation.
Step 7: screw implantation
Dorsal implantation of a headless compression
screw is recommended for scaphoid fractures of
the proximal pole and volar implantation for
distal pole fractures because this permits maxi-
mum fracture compression [18]. Fractures of the
waist may be fixed from a dorsal or volar
approach so long as the screw is implanted along
the central scaphoid axis. Blunt dissection along
the guidewire exposes a tract to the dorsal wrist
capsule and scaphoid base. Before drilling, the
guidewire should be advanced so that both ends
are exposed equally, which will permit the wire
from becoming dislodged during reaming. The
scaphoid is prepared by hand drilling the scaphoid
cortex with a cannulated hand drill (Fig. 19),
which will permit the implantation of a headless
compression screw completely within the scaph-
oid. It is critical to use fluoroscopy to check the
position and depth of the drill. Overdrilling the
scaphoid reduces fracture compression and in-
creases the risk of motion at the fracture site.
A standard Acutrak screw, 4 mm shorter than
the scaphoid length, is selected. The screw is
Fig. 19. The scaphoid is prepared by drilling the
proximal pole of the scaphoid cortex with a cannulated
hand drill. It is critical to use fluoroscopy to check the
position, depth, and direction of the drill.
435
advanced under fluoroscopic guidance to within
1 to 2 mm of the opposite cortex with excellent
compression (Fig. 20). If the screw is advanced to
the distal cortex, attempts to advance the screw
further will displace the distal fragment. With
unstable fractures, a joystick is left in the distal
scaphoid fragment for reaming and screw implan-
tation. As the screw is implanted, a counterforce is
exerted through the joystick, compressing both
fracture fragments and insuring rigid fixation.
After screw placement, the guidewire is re-
moved, and wrist fluoroscopy is performed to
confirm screw position, fracture reduction, and
rigid fixation. Arthroscopy can also confirm re-
duction and complete seating of the screw.
Postoperative care
Postoperative care is directed at recovery of
hand function. A bulky hand dressing is applied
and elevation of the limb enforced to control early
swelling. A digital exercise program is initiated
immediately. Commercially available cooling pads
are valuable in helping to control pain. If significant
swelling is present intra-operatively, then consid-
eration is given to the release of the median nerve in
the carpal tunnel and placement of an indwelling
catheter for continuous infusion of marcaine. The
control of postoperative pain is critical for the
successful recovery of hand function.
At the first office visit, the surgical dressing is
removed and a volar splint is applied. A vigorous
hand and wrist therapy program is initiated to
recover a full arc of motion of the digits and
forearm. Patients with fractures of the scaphoid
waist are started on an immediate wrist range-
of-motion protocol. Patients with proximal pole
fractures are protected for 1 month before the
initiation of therapy. All patients are started on an
immediate strengthening program. The purpose of
this is to axially load the fracture site now secured
with an intramedullary screw to stimulate healing.
Heavy lifting and contact sports are restricted
until the patients are nontender and CT confirms
healing by bridging callous.
Clinical results: combined distal radius and
scaphoid fractures using a percutaneous technique
The average follow-up was 24 months (range,
12–42 months). All scaphoid fractures healed and
demonstrated complete bridging bone on CT at an
average of 14 weeks (range, 8–16 weeks). No
scaphoid developed avascular necrosis, as
436 SLADE et al

Fig. 20. Rigid fixation of scaphoid fractures is accomplished with the dorsal implantation of a headless cannulated
compression screw. (A) Counterpressure can be applied through the distal scaphoid fragment to ensure that bone-
to-bone contact is maintained during screw implantation. (B) The guidewire is advanced after the screw has been seated
to confirm scaphoid fracture reduction and rigid fixation. Any adjustments can be easily made with the guidewire in
place.

determined by CT scan. All radius fractures clini-
cally and radiographically healed within 6 weeks.
At final follow-up, all radii had maintained height
within 2 mm of opposite normal wrist and at least
neutral volar tilt. All intra-articular fractures main-
tained a congruent surface without displacement or
gapping. Radial styloid fractures were treated with
a percutaneous headless cannulated compression
screw and healed without displacement.
The patients’ wrist motion at follow-up aver-
aged 65 extension, 50 flexion, 15 radial devia-
tion, 26 ulnar deviation, 75 pronation, and 60
supination. The grip strength averaged 90 lb for the
injured hand and 110 lb in the opposite hand.
There was one complication: a rupture of the
extensor pollicis longus (EPL) tendon that was the
result of a radial styloid and dorsal plate (see case
3). The plate was removed at time of tendon
rupture, which occurred at 6 months postopera-
tively. The tendon was repaired with a tendon
graft/splint, and the patient made a full recovery.
Clinical cases
Case 1: radial styloid and scaphoid fracture
A 26-year-old man sustained a displaced com-
minuted waist fracture of the scaphoid and a radial
styloid fracture of the distal radius in a motorcycle
accident. Five days after injury, the patient un-
derwent arthroscopic-assisted fracture reduction
of the scaphoid and radial styloid fractures and
(using minifluroscopy) percutaneous fixation of
the scaphoid fracture with a dorsal implantation
of a headless compression screw. The radial
styloid fracture was performed in a similar man-
ner (Fig. 21A). CT scan at 8 weeks documented
a healed radius fracture and bridging bone of the
scaphoid, confirming partial osseous union (see
Fig. 21B). A CT scan confirmed solid healing by 6
months. At 8 months, the patient’s left wrist
extended 60 , flexed 50 , radial deviated 10 , and
ulnar deviated 25 (see Fig. 21C). His uninjured
right wrist extended 70 , flexed 65 , radial de-
viated 20 , and ulnar deviated 35 . He had full
supination and pronation of both wrists. The
patient returned to work as a health care
professional.
Case 2: Colles’ fracture and scaphoid fracture
A 30-year-old man fell on his outstretched
wrist while snowboarding and was diagnosed with
an undisplaced fracture of the scaphoid and distal
radius fracture with dorsal comminution (Fig. 22).
Two weeks after injury, the patient was treated
 PERCUTANEOUS AND ARTHROSCOPIC TECHNIQUES 437

Fig. 21. Case 1: radial styloid and scaphoid fracture. A 26-year-old male in a motorcycle accident sustained an
hyperextension injury to his wrist. Radiographic examination identified a displaced communited waist fracture of the
scaphoid and a radial styloid fracture of the distal radius. (A) Five days after his injury, the patient was taken to the
operating room. Using mini-fluroscopy, joysticks are placed percutaneously into the fracture fragments and the scaphoid
is aligned. A central axis guide-wire is placed from dorsal to volar along the scaphoid central axis. This accomplished,
a second guidewire is placed in the radial styloid, securing it the distal radius. The hand is placed in longitudinal traction
and an arthroscopic exam of the radiocarpal and midcarpal joint is performed cofirming fracture reduction. Carpal
ligaments are examined for tears. Headless compression screws are implanted to secure rigid fixation of the scaphoid and
the radial styloid. The radial styloid fracture was performed in a similar manner. (Left panel) posteroanterior view.
(Right panel) lateral view of the reduced fractures with internal fixation. (B) CT scan at 8 weeks documented a healed
radius fracture and bridging bone of the scaphoid confirming partial osseous union. (Left panel) coronal view. (Right
panel) Sagittal view. (C) At 8 months his wrist extended 60 (Upper panel), flexed 50 (Lower panel), radial deviated 10 ,
ulnar deviated 25 . CT scan confirmed solid healing by 6 months.

with an arthroscopic-assisted reduction of the
scaphoid and distal radius fractures. Fixation
was achieved by dorsal percutaneous repair of
the scaphoid with a headless compression screw
and volar open reduction of the distal radius
fracture with volar congruent plate. At the first
postoperative office visit, the wrist was placed in
a volar splint and an active strengthening program
was started. CT scan documented a healed radius
fracture at 7 weeks and bridging bone of the
scaphoid at 12 weeks, confirming osseous union.
At 9 months, the patient’s left wrist extended 65 ,
flexed 55 , radial deviated 20 , and ulnar deviated
30 . He supinated 60 , pronated 75 , and had 80
lb of grip strength for his nondominant wrist. For
his right-dominant, uninjured wrist, he had 95 lb
438 SLADE et al

Fig. 22. Case 2: Colles’ type fracture and scaphoid fracture. A 36-year-old male fell on an outstretched wrist while
snowboarding. He was splinted and told to seek care by an orthopaedic surgeon. Radiographs diagnosed an undisplaced
scaphoid fracture of the waist and a displaced distal radius fracture with dorsal communition. The patient was taken to
the operating room two weeks after injury. Mini-fluroscopy was used to place a dorsal central axis guidewire down the
scaphoid and withdrawn until the trailing end of the wire has cleared the radiocarpal joint. This accomplished, the distal
radius he was treated with an arthroscopic assisted fracture reduction and cofirmation of scaphoid reduction (A,B) The
wrist is taken out of traction and inclined over a roll. Fixation was achieved by dorsal percutaneous repair of the
scaphoid with a headless compression screw and volar open reduction of the distal radius fracture with volar congruent
plate. CT scan at 7 week documented a healed radius fracture and at 12 weeks bridging bone of the scaphoid confirming
osseous union. At 9 months, his left wrist extends to 65 , flexes to 55 , radial deviates 20 , ulnar deviates 30 . He
supinates 60 and pronates 75 . He has 80 lb for his nondominant wrist.

of grip strength. His right wrist extended 75 ,
flexed 65 , radial deviated 20 , ulnar deviated 40 ,
and supinated 70 and pronated 75 .
Case three: EPL tendon rupture
A 29-year-old male laborer fell off the tail of
a truck at work. Radiographs identified a left
displaced intra-articular distal radius fracture
and a displaced fracture of the scaphoid waist.
Twenty-two days after injury, the patient was
treated with an arthroscopic-assisted reduction of
the scaphoid and distal radius fractures (Fig. 23).
Rigid fixation of the scaphoid was accomplished
using a headless compression screw implanted
through a dorsal percutaneous approach. Using
a fragment-specific plate system, rigid fixation of
the distal radius fracture was accomplished
through a dorsal and volar radial incision. At
the first postoperative office visit, the wrist was
placed in a volar splint and an active strengthen-
ing program was started. The wrist was protected
for 5 weeks. CT scan at 10 weeks confirmed
a healed scaphoid by bridging bone at the
scaphoid fracture site.
Six months after injury, the patient’s EPL
tendon ruptured and was explored. On explora-
tion, the tendon path was found to glide over
a plate. The tendon was repaired and transposed.
A tendon graft was used as a splint to bridge the
repair, which permitted an immediate active mo-
tion protocol for restoration of hand function
while the tendon healed. At 9 months, the patient’s
left wrist extended 50 , flexed 40 , radial deviated
10 , and ulnar deviated 25 . He supinated 65 ,
pronated 75 and had 80 lb of grip strength for his
nondominant wrist. For his right-dominant, un-
injured wrist, he had 95 lb of grip strength. His
 PERCUTANEOUS AND ARTHROSCOPIC TECHNIQUES 439

Fig. 23. Case 3: EPL tendon rupture. A 29-year-old male laborer fell off the tail of a truck at work. Radiographs
identified a left displaced intra-articular distal radius fracture and a displaced fracture of the scaphoid waist. Twenty-two
days after injury, the patient was treated with an arthroscopic-assisted reduction of the scaphoid and the distal radius
fractures. (A) Rigid fixation of the scaphoid was accomplished using a headless compression screw implanted through
a dorsal percutaneous approach. Using a fragment-specific plate system, rigid fixation of the distal radius fracture was
accomplished through a dorsal and volar radial incision. (Right panel) posteroanterior radiograph of the internal fixation
construct. (Left panel) Lateral radiograph of the internal fixation construct. CT scan at 10 weeks confirmed a healed
scaphoid by bridging bone at the scaphoid fracture site. Six months after injury, the patient’s EPL tendon ruptured. The
tendon was repaired and transposed. (B) At 9 months, the patient’s left wrist extends 50 (upper panel), flexes 40 , radial
deviates 10 , ulnar deviates 25 . He supinates 65 and pronates 75 (lower panel), and has 80 lb for his nondominant
wrist.

right wrist extended 65 , flexed 55 , radial deviated
20 , ulnar deviated 35 , and supinated 80 and
pronated 85 . He returned full-time to his former
job in heavy labor without restriction.
Discussion
Simultaneous fractures of the distal radius and
ipsilateral scaphoid represent a relatively small
subset of upper-extremity injuries. The choice of
treatment for the distal radius or the scaphoid
fracture may significantly impact successful heal-
ing of the other fracture.
Published reports of these combined injuries
are sparse but reflect a change in treatment
protocols over the past decade. This transforma-
tion appears to have paralleled our evolving
understanding of scaphoid fractures themselves.
Due to the relative infrequency of this injury
combination, the actual incidence is difficult to
determine with precision; reports vary from 0.7%
to 6.5% of all distal radius fractures [22]. In 1983,
Osterman et al [23] noted that concurrent distal
radius and scaphoid fractures constituted 1.9% of
all distal radius fractures treated at their institu-
tion. This number differs significantly from Vukov
et al, who reviewed 650 patients with fractures of
the distal radius and noted that concomitant
scaphoid fractures occurred in 4% of patients
[24]. Due to the conflicting reports, Hove [1]
attempted to specifically address this question by
performing a prospective 3-year study that en-
rolled all distal radius fractures and scaphoid
fractures seen at his institution. During that 3-
year period, 2330 adults with distal radius frac-
tures and 390 adults with scaphoid fractures were
treated. Hove [1] noted only 12 combined injuries:
0.05% of all distal radius fractures and 3% of all
scaphoid fractures were combined injuries.
These concurrent fractures are a result of high-
energy injuries, most commonly a fall from signif-
icant height or a motor vehicle accident. The
mechanism of injury is rapid forced loading of an
outstretched radial deviated dorsi-flexed wrist
[1,6,22,25]. These injuries are often associated
with a displaced and angulated scaphoid fracture.
440 SLADE
Much of the early literature addressing these
combined injuries focused on defining the ‘‘pri-
mary fracture,’’ usually the distal radius. Treat-
ment algorithms focus on the primary fracture.
Smith et al [25] expressed concern that traction
placed across the wrist in the reduction of the
distal radius leads to displacement of the scaph-
oid. These investigators retrospectively reviewed
nine patients with concurrent distal radius and
scaphoid fractures and concluded that the re-
duction maneuvers used for the displaced distal
radius fractures had no adverse affect on scaphoid
healing. Although they used pins and plaster in
their series, they advocated the use of external
fixation placed across the wrist [25].
Proubasta and Lluch [26] presented two pa-
tients with displaced intra-articular fractures of the
distal radius and nondisplaced scaphoid fractures
who were treated by closed reduction and external
fixation. They noted dorsal comminution of the
distal radius and suggested that placing the wrist in
a flexed position would adversely affect healing of
the scaphoid. Their solution was to hold the wrist
in neutral with an external fixator. They reported
that the distal radius and scaphoid fractures healed
uneventfully in this fashion. The use of external
fixation has been associated with injuries to the
superficial branch of the radial nerve [27].
Tountas and Waddell [22] suggested that
treatment is dictated by the radius fracture alone.
In their series, all scaphoid injuries were typically
nondisplaced stable fractures, and treatment of
radius fracture took precedence. These observa-
tions were based on the mistaken belief that
standard radiographs could confirm scaphoid
healing at 12 weeks [28].
Richards et al [29] expressed renewed concern
about placing traction across a carpus that con-
tained a scaphoid fracture and presented two
patients who had combined scaphoid and distal
radius fractures. In both cases, the scaphoid was
treated with Herbert screw internal fixation before
placing traction across the wrist to avoid distrac-
tion across the scaphoid fracture.
Trumble et al [14] recognized that the closed
treatment of the scaphoid often requires extended
periods of immobilization and expressed concern
that this would adversely affect the outcome of the
distal radial fracture. These investigators also
recognized that placing traction across the wrist
would create a distraction force across the scaph-
oid and cautioned that this may decrease union
rates. They recommended internal fixation of the
scaphoid before reducing or fixing the radius with
et al
distractive forces. The force that is required to
reduce a radius fracture after scaphoid fixation,
however, could lead to scaphoid fracture displace-
ment or a reduction in the compressive effects of
the screw at the fracture site. Because the most
significant forces used in scaphoid fracture fixa-
tion are generated during the actual reduction and
alignment of the fracture itself, the introduction of
a percutaneous screw is a relatively simple matter.
It seems logical to address the reduction and
fixation of the distal radius fracture separately
from that of the scaphoid fracture, therefore
allowing rigid fixation of both fractures. These
observations are supported by the authors’ small
clinical series that permitted the initiation of an
immediate rehabilitation program without loss of
reduction or motion at either fracture site.
Summary
Revision of the treatment rationale for com-
bined fractures of the scaphoid and distal radius is
based on evolution of treatment goals. The trend
toward early recovery of hand function requires
rigid fixation of both fractures before the start of
a hand therapy program. It is clear that prolonged
immobilization of the scaphoid fracture jeopard-
izes early motion protocols for the distal radius.
The fixation of unstable distal radius fractures
with volar locking plates appears to offer the most
stable construct to permit early motion [19,20].
Evaluation, reduction, and fixation should be
accomplished without disruption of the uninjured
ligaments required for stable motion or the soft
tissue envelope required for healing. Minimally
invasive or percutaneous techniques are the meth-
ods required. The tools needed are a clear un-
derstanding of anatomy, minifluoroscopic
imaging units, and small-joint arthroscopy instru-
ments. Many investigators advocate these techni-
ques for scaphoid [7] and distal radius [9,10]
fractures. It is only natural that these techniques
should be used for these combined injuries.
The key to success is a three-step process: (1)
percutaneous reduction of the scaphoid fracture
and provisional stabilization with a guidewire
placed along its central axis, (2) percutaneous/
arthroscopic reduction and rigid fixation of the
distal radius fracture to permit early motion, and
(3) fixation of the scaphoid fracture. This final
step is accomplished by dorsal percutaneous
implantation of a cannulated headless compres-
sion screw along the central scaphoid axis. Dorsal
 PERCUTANEOUS AND ARTHROSCOPIC TECHNIQUES
percutaneous fixation of scaphoid fractures with
headless compression screws and rigid fixation of
unstable distal radius fractures with a volar lock-
ing plate system offer the most secure fixation.
This small series suggests that the goals of early
recovery of hand function can be accomplished
using percutaneous/miniopen techniques for frac-
ture reduction with rigid fixation and minimal risks.
References
[1] Hove LM. Simultaneous scaphoid and distal radius
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[2] Ruby LK, Stinson J, Belsky MR. The natural his-
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[3] Lindstrom G, Nystrom A. Natural history of scaph-
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[4] Bronstein AJ, Trumble TE, Tencer AF. The effects
of distal radius fracture malalignment on forearm
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1997;22(2):258–62.
[5] Oskam J, De Graaf JS, Klasen HJ. Fractures of the
distal radius and scaphoid. J Hand Surg [Br] 1996;
21(6):772–4.
[6] Trumble TE, Schmitt SR, Vedder NB. Factors af-
fecting functional outcome of displaced intra-
articular distal radius fractures. J Hand Surg [Am]
1994;19:325–40.
[7] Slade JF III, Jaskwhich D. Percutaneous fixation of
scaphoid fractures. Hand Clin 2001;17(4):553–74.
[8] Slade JF III, Grauer JN, Mahoney JD. Arthroscopic
reduction and percutaneous fixation of scaphoid
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[9] Geissler WB, Freeland AE. Arthroscopically assis-
ted reduction of intraarticular distal radial fractures.
Clin Orthop 1996;327:125–34.
[10] Geissler WB, Freeland AE. Intercarpal soft-tissue
lesions associated with an intra-articular fracture
of the distal end of the radius. J Bone Joint Surg
Am 1996;78(3):257–365.
[11] Doi K, Hattori Y, Otsuka K, et al. Intra-articular
fractures of the distal aspect of the radius: arthro-
scopically assisted reduction compared with open re-
duction and internal fixation. J Bone Joint Surg Am
1999;81(8):1093–110.
[12] Adams BD, Blair WF, Reagan DS, et al. Technical
factors related to Herbert screw fixation. J Hand
Surg [Am] 1988;13(6):893–9.
[13] Slade JF III, Grauer JN. Dorsal percutaneous repair
of scaphoid fractures with arthroscopic guidance.
Atlas Hand Clin 2001;6(2):307–23.
[14] Trumble TE, Clarke T, Kreder HJ. Non-union of
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[15] Pring DJ, Hartley EB, Williams DJ. Scaphoid osteo-
synthesis: early experience with the Herbert bone
screw. Hand Surg J [Br] 1987;12(1):46–9.
[16] Toby EB, Butler TE, McCormack TJ, et al. A com-
parison of fication screws for the scaphoid during
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[17] Orbay JL, Fernandez DL. Volar fixation for dor-
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[18] Slade JF III, Gutow AP, Geissler WB. Percutaneous
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[19] Osada D, Viegas SF, Shah MA, et al. Comparison of
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[20] Leung F, Zhu L, Ho H, et al. Palmar plate fixa-
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[21] Slade JF III, Moore AE. Dorsal percutaneous fixa-
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[22] Tountas AA, Waddell JP. Simultaneous fractures of
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[23] Osterman AL, Bora FW, Dalinka MK. Simulta-
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[24] Vukov V, Ristic K, Stevanovic M, et al. Simulta-
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[25] Smith T, Keeve JP, Bertin KC, et al. Simultaneous
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[26] Proubasta IR, Lluch A. Concomitant fractures of
the scaphoid and distal radius: treatment by external
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[27] Chang CH, Tsai YS, Sun JS, et al. Ipsilateral distal
radius and scaphoid fractures. J Formos Med Assoc
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[28] Dias JJ. Definition of union after acute fracture and
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[29] Richards RR, Ghose T, McBroom RJ. Ipsilateral
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 Hand Clin 21 (2005) 443–447

Nonunion of the Distal Radius

David Ring, MD
Hand and Upper Extremity Service, Department of Orthopaedic Surgery, Massachusetts General Hospital,
Yawkee Center, Suite 2100, 55 Fruit Street, Boston, MA 02114, USA
Harvard Medical School, Yawkee Center, Suite 2100, 55 Fruit Street, Boston, MA 02114, USA

Nonunion of the distal radius—long consid-
ered to be extremely rare [1,2]—has been noted
more frequently in recent years [3–7]. Although
some investigators have speculated that the ad-
vent of external fixation and other techniques for
maintaining the length of the radius has created
bony defects that can lead to nonunion [7], non-
union also is seen after internal fixation or non-
operative treatment [3–7] (Figs. 1–3). There seems
to be an association with concomitant fracture or
dislocation of the distal ulna [3,5] (see Fig. 2).
Although the cause and incidence of nonunion
of the distal radius are uncertain, the need for
operative treatment is clear. Most nonunions are
synovial [3,5–7]. The wrist usually is deformed,
unstable, and painful. Some patients have a severe
radial deviation deformity reminiscent of congen-
ital club hand, which has been referred to as
acquired or post-traumatic club hand [8,9] (Fig. 4).
Operative treatment can improve upper limb
function in patients with nonunion of the distal
radius by fusing the wrist or healing the fracture.
Improved implants and operative techniques have
improved the ability to gain healing of the frac-
ture, thereby preserving some wrist motion [3,6].
Even small amounts of wrist motion can enhance
upper limb function [10].
Treatment options
The most common treatment of ununited
fractures of the distal radius has been wrist ar-
throdesis [5,7], probably because attempts at
internal fixation of the small, metaphyseal distal
E-mail address: dring@partners.org
0749-0712/05/$ - see front matter Ó 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.hcl.2005.01.005
radius fragment seem risky. The appeal of retain-
ing some wrist motion together with the develop-
ment of better implants and techniques for the
fixation of small articular fractures has influenced
the author to offer patients an attempt to heal the
fracture with internal fixation and autogenous
cancellous bone grafting [3,6].
Two principals have proved useful. First, the
concept of applying two plates in orthogonal
planes (as practiced at other anatomic sites such
as the distal humerus [11] and as supported by
mechanical principals) is particularly useful in the
distal radius, in which the distal fragment can be
small [3]. A second, orthogonal plate provides
a greater number of fixation points in the distal
fragment. Second, the use of fixed-angle devices
instead of standard screws for osteoporotic
bone—also used in the humerus [12]—can provide
more secure fixation of bone in which pre-existing
osteoporosis often has been exacerbated by disuse
of the limb [13].
Wrist arthrodesis may be optimal in infirm
patients and patients with limited functional de-
mands for whom pain relief is the primary goal, and
as a salvage of failed attempts to gain union. Some
nonunions, particularly complex articular nonun-
ions, are not amenable to operative fixation, and
wrist fusion is the only option (see Fig. 3). Some
investigators have suggested that when there are
fewer than 6 mm of bone between the lunate facet of
the distal radius articular surface and the fracture
site, there is insufficient bone to support internal
fixation [7]. The author believes that, although this
certainly increases the challenge of internal fixa-
tion, there is usually a larger amount of bone in the
radial styloid portion of the distal fragment that can
accept internal fixation (see Fig. 2).
hand.theclinics.com
444 RING

Fig. 1. A 42-year-old man was injured in a race car accident. (A) His comminuted fracture of the distal radius was
stabilized and distracted with an external fixator. (B) The fracture failed to heal, his hand became stiff, and there was
osteopenia related to disuse. (C ) After removing the external fixator and rehabilitating his hand, the fracture remained
ununited. (D) Debridement of the nonunion, autogenous cancellous bone grafting, and internal fixation achieved union.
(E ) The use of a plate with fixed-angle metaphyseal screws enhanced the security of the fixation.

Operative techniques
Wrist arthrodesis
Standard wrist arthrodesis techniques using
specific wrist fusion plates [14] have proved
adequate for ununited fractures of the distal
radius [5,7]. In this situation the nonunion repre-
sents another articulation that must be débrided,
bone grafted, and stabilized with the plate. Bone
graft can be obtained from the resected ulna when
a concomitant Darrach procedure is performed,
from the radial styloid, or from the iliac crest (see
Fig. 2).
Open reduction and internal fixation
A volar Henry [15] exposure provides access to
the volar and radial aspects of the distal radius.
The fracture site is identified and fibrous or syno-
vial tissues are removed. The sclerotic fracture
ends are opened with rongeurs and curettes and
then drilled repeatedly with a small bit to open the
 NONUNION OF THE DISTAL RADIUS 445

Fig. 2. An elderly woman with fractures of the distal radius and ulna was treated in a cast. (A) Synovial nonunions of
both fractures with an ulnar deviation deformity ensued. (B) Through a volar exposure, orthogonal plates (one volar,
one direct radial) were applied. (C ) Good fixation of the radial styloid thereby was achieved. (D) The use of locking
screws enhanced the security of fixation in the osteoporotic metaphyseal bone.

intramedullary canal. Opening of the sclerotic
fracture ends and intramedullary canal facilitates
the ingress of a vascular supply, providing cells,
nutrients, and growth factors to support healing.
To facilitate and stabilize reduction a small
skeletal distractor or other external fixator can be
applied between two 2.5-mm Schanz screws, one
placed in the distal fragment and one in the
proximal fragment. The Schanz screws are placed
so that distraction between them realigns the
fragments but the screws themselves do not in-
terfere with internal fixation devices. In patients
with a severe radial deviation deformity, consid-
eration is given to releasing or z-lengthening the
brachioradialis and flexor carpi radialis tendons
to facilitate realignment of the distal radius, but
this is rarely necessary if the decision has been
made to accept the shortening of the radius and
resect the distal ulna.
Many patients benefit from Darrach resection
of the distal ulna. This technique is preferable in
patients with substantial deformity of the distal
radius for whom length and alignment cannot be
restored without creating a large bony defect. In
addition, attempts to realign the distal radioulnar
joint often risk painful arthrosis if the realignment
is not adequate or if the joint has degenerated
during the period of nonunion and deformity. The
distal ulna usually provides sufficient bone graft
so that obtaining additional bone from the iliac
crest usually is not necessary.
With the skeletal distractor holding the frag-
ments reduced—sometimes with an ancillary
Kirschner wire transfixing the fragments—the
plates and screws are applied. A variety of volar
plates with fixed angle (locked) screws are now
available. The fixed-angle screws or pins are better
suited to fixation of the metaphyseal bone of the
446
Fig. 3. A 75-year-old woman injured her wrist and was convinced that it was just a sprain. (A) On presentation 6 weeks
later she had an unstable complex ununited fracture of the distal radius. (B) This nonunion with associated complex
articular injury was believed not to be amenable to attempts at repair and was salvaged with a wrist arthrodesis.
distal radius, which is often osteopenic. In some
patients with small distal fragments, it can be
useful to enhance the fixation in the more sub-
stantial radial styloid portion of the distal frag-
ment by applying a second plate, orthogonal to
the volar plate on the direct radial surface of the
distal radius. There are several implants designed
for placement on this part of the bone, many with
locking screws. Autogenous cancellous bone graft
is applied to the defect and the wound is closed.
Rehabilitation
Active-assisted motion of the hand and fore-
arm is encouraged the morning after surgery. A
removable plastic wrist splint is used to help
support the wrist for 4–6 weeks after surgery.
Approximately 6 weeks after the surgery the splint
Fig. 4. Some nonunions of the distal radius are asso-
ciated with a marked radial deviation deformity—the so-
called post-traumatic radial club hand.
RING
is discarded and active-assisted wrist motion is
allowed. Strengthening exercises are restricted
until radiographic healing is established.
Complications
The author has not encountered infection,
wound problems, or nerve injury [3,6]. If the frac-
ture fails to heal, the implants eventually loosen
or break and the decision to undertake further
attempts to heal the fracture or to salvage the
situation with wrist arthrodesis is based on the
specific circumstances and the desires of the pa-
tient. Wrist motion is never returned to normal
and some patients regain little wrist motion.
Progressive arthrosis also can compromise the
result and may require subsequent wrist arthrod-
esis in rare cases. The implants often irritate the
overlying tendons and can lead to tendon rupture.
The author has a low threshold for recommending
implant removal when implants are associated
with pain, swelling, or crepitance of the tendons
over the plate.
Summary
Distal radius nonunion is either more common
or more commonly recognized. The success of
operative treatment to gain union seems to have
improved along with improvements in operative
fixation of fractures of the distal radius. Operative
treatment to gain union or arthrodese the wrist
can improve function and comfort with relatively
few complications.
References
[1] Bacorn RW, Kurtzke JF. A study of two thou-
sand cases from the New York State Workmen’s
 NONUNION OF THE DISTAL RADIUS
Compensation Board. J Bone Joint Surg 1953;
38A:643–58.
[2] Watson-Jones R. Fractures and other bone and joint
injuries. 2nd edition. Edinburgh: Livingstone; 1942.
[3] Fernandez DL, Ring D, Jupiter JB. Surgical man-
agement of delayed union and nonunion of distal
radius fractures. J Hand Surg 2001;26A:201–9.
[4] Harper WM, Jones JM. Non-union of Colles’ frac-
ture: report of two cases. J Hand Surg 1990;15B:
121–3.
[5] McKee MD, Waddell JP, Yoo D, Richards RR.
Nonunion of distal radial fractures associated with
distal ulnar shaft fractures: a report of four cases.
J Orthop Trauma 1997;11:49–53.
[6] Prommersberger KJ, Fernandez DL, Ring D, Jupi-
ter JB, Lanz UB. Open reduction and internal fixa-
tion of un-united fractures of the distal radius:
does the size of the distal fragment affect the result?
Chir Main 2002;21:113–23.
[7] Segalman KA, Clark GL. Un-united fractures of the
distal radius: a report of 12 cases. J Hand Surg 1998;
23A:914–9.
[8] Netrawichien P. Radial clubhand-like deformity
resulting from osteomyelitis of the distal radius.
J Ped Orthop 1995;15:157–60.
447
[9] Ono CM, Albertson KS, Reinker KA, Lipp EB. Ac-
quired radial clubhand deformity due to osteomyeli-
tis. J Ped Orthop 1995;15:161–8.
[10] Adams BD, Grosland NM, Murphy DM, McCul-
lough M. Impact of impaired wrist motion on
hand and upper-extremity performance. J Hand
Surg [Am] 2003;28A:898–903.
[11] Helfet DL, Hotchkiss RN. Internal fixation of the
distal humerus: a biomechanical comparison of
methods. J Orthop Trauma 1990;4:260–4.
[12] Ring D, Perey B, Jupiter JB. The functional outcome
of the operative treatment of ununited fractures of
the humeral diaphysis in elderly patients. J Bone
Joint Surg 1999;81A:177–89.
[13] Perren SM. Evolution of the internal fixation of long
bone fractures: the scientific basis of biological inter-
nal fixation: choosing a new balance between sta-
bility and biology. J Bone Joint Surg 2002;84B:
1093–110.
[14] Hastings H, Weiss AP, Quenzer D, Wiedeman GP,
Hanington KR, Strickland JW. Arthrodesis of the
wrist for post-traumatic disorders. J Bone Joint
Surg [Am] 1996;78A:897–902.
[15] Henry AK. Extensile exposure. 2nd edition. Edin-
burgh: Churchill Livingstone; 1973.
 Hand Clin 21 (2005) 449–454

Use of Bone Graft Substitutes and Bioactive

Materials in Treatment of Distal Radius Fractures
Brian J. Hartigan, MDa,b,*, Mark S. Cohen, MDc,d
a
Department of Orthopaedic Surgery, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
b
Northwestern Center for Orthopedics, 676 North St. Clair, Suite 450, Chicago, IL 60611, USA
c
Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
d
Midwest Orthopaedics, 1725 West Harrison Street, Suite 1063, Chicago, IL 60612, USA

Over the past several years, there has been Bone graft properties
significant interest in the development of bioma-
An ideal bone graft possesses four important
terials that can augment fracture healing. Medi-
properties: (1) osteogenic cells, which are naturally
cally there has been increasing interest in restoring
occurring cells with the potential to differentiate
alignment through minimal incisions and with less
into bone forming cells, (2) osteoinductive factors,
invasive fracture fixation. The increased number of
which are proteins, including growth factors, that
fractures related to aging and osteoporosis has
stimulate and signal new bone growth, (3) osteo-
contributed to this trend. Goals of limited invasive
conductive matrix providing a scaffold for new
surgery include earlier mobilization and earlier
bone growth, and (4) structural integrity [3].
return to function. Currently available bone graft
Cancellous and cortical autogenous bone graft
substitutes for the distal radius can help achieve
possess the first three properties. Although cortical
these goals by restoring structural integrity with
grafts are able to provide structural integrity, they
limited morbidity and possibly by achieving more
are less osteogenic and osteoinductive when
rapid healing of bone.
compared with cancellous grafts.
Economically, the high market value of these
Alternatives to autogenous graft, or bone graft
products has created a stimulus for their develop-
substitutes, are judged by their ability to provide
ment [1]. Because of this several products are
aspects of these four components. Unfortunately
currently available for this purpose. Unfortu-
comparison of one substitute with another or with
nately there is currently little consensus on the
autogenous graft is difficult. Each substitute is
indications for use of bone graft substitutes and
made of unique materials and participates in
a paucity of comparative studies between prod-
healing in different ways. Additionally there are
ucts. The United States federal government has
no standardized assays specific for osteoinduction
contributed to this confusion, because regulatory
and osteoconduction in humans, making it im-
control of the different types of products, even
possible to quantify accurately their role in bone
similar products, has fallen under different agen-
healing.
cies within the Food and Drug Administration [2].
This article covers the indications and materials
currently available for use as bone replacements
in the treatment of distal radius fractures. Indications
The distal radius has been the center of attention
for the development of many of the bone graft
substitutes because it is a common area to fracture
* Corresponding author. with a relative lack of associated confounding
E-mail address: bjhartigan@hotmail.com variables [4]. The indications for the use of bone
(B.J. Hartigan). grafts or graft substitutes in the treatment of distal
0749-0712/05/$ - see front matter Ó 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.hcl.2005.02.006 hand.theclinics.com
450 HARTIGAN & COHEN
radius fractures, however, have not been defined
clearly. Additionally, although autogenous graft
has been proven to be beneficial [5–8], there is
no clear consensus with regard to bone graft
substitutes.
The goal of treatment is to restore alignment of
the radius and provide stability with minimal
compromise of hand function [9]. This can be
accomplished with a cast, external fixator, or
a variety of internal fixation techniques, depending
on the fracture pattern, degree of displacement,
stability of the fracture, patient age, and physical
demands. Fracture healing typically is not a prob-
lem, because the fracture involves metaphyseal
bone with ample vascularity [10]. Comminuted
fractures or fractures in osteoporotic bone, how-
ever, often result in cortical comminution and
metaphyseal defects. If left unsupported, these can
lead to collapse of the distal fragments and loss of
alignment. Additionally, osteopenic or osteopo-
rotic bone can limit fixation and can result in loss
of reduction following internal fixation. In either
case, healing typically occurs, but it may result in
a shortened or malaligned radius, which can pro-
duce pain, stiffness, and loss of strength [11,12]. It
is in these osteoporotic or comminuted fractures
that bone graft is particularly desirable.
The use of autogenous bone graft has been
shown to be advantageous to support metaphyseal
defects following distal radius fractures [5–8]. In
addition to providing structural support, autoge-
nous graft can accelerate and augment bone heal-
ing because of the presence of growth factors and
viable osteoblasts. Use of autogenous bone graft
has been associated with donor-site morbidity,
including infection, blood loss, and pain, together
with increased surgical time, hospital stay, and cost
[13]. These potential disadvantages have helped
Table 1
Bone graft properties
Material Osteogenic cells Osteoinductive factors
Autogenous—cortical þ þ
Autogenous—cancellous þ þ
Allograft
þ
DBM
þ/

Mineral (ceramics/coralline)


Composites
þ/

Calcium sulfate


Cement


Bioglass


Growth factors
þ
þ, present;
, absent; þ/
, variable.
lead to the development of numerous bone graft
substitutes.
The decision to use graft or graft substitute
should be based on the particular injury with
emphasis on fracture pattern, stability, comminu-
tion, soft tissue injury, and patient factors. None
of the available graft substitutes are ideal for
all situations. A structural and osteoconductive
material may be considered to augment fixation
in the treatment of fractures with metaphyseal or
diaphyseal defects or significant cortical commi-
nution. An osteoinductive material may be used in
fractures with potential impaired healing. These
include local factors, such as fractures extending
into the diaphysis or those with extensive soft-tissue
disruption, and host factors such as diabetes,
smoking, or poor nutritional status. Further study
regarding growth factors may expand the indica-
tions to include even simple fractures in an effort to
accelerate healing.
Graft substitutes
There are several graft substitutes available for
orthopedic use in the United States. These sub-
stitutes include allograft, demineralized allograft
bone matrix, mineral-derived graft, composite
graft, calcium sulfate, injectable cement, bioactive
glass, and growth factors. These substitutes vary
with regard to their osteoconductive properties,
osteoinductive properties, structural strength, and
rate of disappearance (Table 1).
Allograft
Allograft bone is human bone that is available
as fresh, frozen, or freeze-dried. Although fresh
grafts are available, they are not used routinely
because of their antigenicity and potential for
Osteoconductive matrix Structural integrity
þ þ
þ

þ þ/

þ

þ

þ

þ

þ þ/

þ

þ/


 BONE GRAFT SUBSTITUTES AND BIOACTIVE MATERIALS
disease transmission. Most allografts are frozen or
freeze-dried. The method of preparation affects
their performance, with frozen grafts maintaining
greater strength but also greater infection and
rejection potential compared with freeze-dried. In
both preparations, the osteoprogenitor cells are
killed while maintaining osteoinductive and os-
teoconductive properties and partial structural
integrity.
Allograft is available in various forms, sizes,
and shapes, depending on the individual need.
Corticocancellous graft can be used to reconstruct
larger defects or in cases in which significant
structural support is needed. Cancellous graft is
better for smaller defects, especially in metaphy-
seal areas, and is particularly useful for the distal
radius [14]. It can be used to augment autograft or
it can be mixed with autograft to introduce
osteoprogenitor cells.
The disadvantages of allograft include its vari-
able quality and potential for disease transmis-
sion. There have been several documented cases of
bacterial infections transmitted by allografts and
even a documented case of human immunodefi-
ciency virus transmission [1]. When compared
with autograft, other disadvantages include lack
of osteogenic cells, less osteoinductive factors, and
less structural integrity.
Demineralized bone matrix
Demineralized bone matrix (DBM) is allograft
bone that has been demineralized and processed
by chemical or radiation treatment, leaving colla-
gen and (potentially) proteins and growth factors.
It has been shown to be osteoinductive in an
animal model, and therefore is believed to main-
tain the presence of growth factors despite pro-
cessing [15]. The potential for osteoinduction is
variable, however, even among individual batches
of the same product.
DBM is available from several manufacturers,
differing in its form and carrier. Forms available
include those that can be injected or molded.
Various carrier agents also have been used, in-
cluding saline, glycerol, gelatin, polymers, hyalur-
onic acid, and collagen. Despite significant debate
regarding the best form and carrier, no consensus
exists. There has been concern regarding glycerol
toxicity in an animal model, although this has not
been seen in humans [16].
DBM is believed to have osteoconductive and
osteoinductive properties and therefore may be
useful in those fractures with impaired healing.
451
The indication for use in most distal radius
fractures is limited, however, because healing is
of little concern and there is a greater need for
a more structural, osteoconductive graft material.
The main disadvantages include the possibility of
disease transmission and immunogenicity, poor
structural integrity, and potential concerns about
certain carriers.
Minerals
Calcium phosphate mineral grafts are osteo-
conductive grafts that are composed of hydroxy-
apatite (HA), tricalcium phosphate (TCP), or
a combination of the two. Most of these grafts,
other than coralline HA, are ceramics that are
made by heating mineral salts to high temperatures
in a process known as sintering. This process
increases strength but reduces the resorption and
remodeling of the material. There has been signif-
icant but unsubstantiated concern about the slow
rate of radiographic disappearance when used
clinically. The rate of resorption depends on the
chemical composition and material factors such as
the surface area and pore size. TCPs of greater pore
size allow better resorption but also render them
mechanically weaker. Newer materials have been
developed with increased porosity to increase the
rate of resorption. This rate of resorption may or
may not correlate with remodeling, depending on
the material and the environment [1].
Coralline HA is produced by a thermochemical
reaction between Pacific coral and ammonium
phosphate. This process converts most of the
coral’s calcium carbonate into HA, which is
resorbed more slowly. Technically this is not
a ceramic, because it does not undergo sintering.
The pores are interconnected similarly to cancel-
lous bone, allowing bone ingrowth. Newer prod-
ucts have been produced with calcium carbonate
on the surface to improve bone ingrowth and,
potentially, graft resorption. True osteoclastic
resorption does not occur and the graft disappears
slowly, similar to the ceramics. It has been shown
to be useful to augment fixation of distal radius
fractures [17].
Calcium phosphate mineral grafts function
purely as an osteoconductive implant on which
bone grows. Osteoinduction may be introduced
when grafting is combined with autogenous plate-
lets from a special autotransfusion process. They
may be used to fill defects, although structural
fixation also is needed. As a group, these grafts are
brittle with little tensile strength, limiting their use
452 HARTIGAN & COHEN
to nonloaded defects or defects in which the
bending, shear, and torsional stresses are neutral-
ized with internal or external fixation [18]. Other
disadvantages include variable quality and slow
resorption/remodeling.
Composites
Various composite grafts have been used to
obtain the beneficial properties of the various
materials. Some composites have combined DBM
with cancellous allograft bone or mineral substi-
tutes (calcium sulfate). These have come in
various forms and their indication for use remains
unclear. These grafts are potentially osteoconduc-
tive and osteoinductive but also have the dis-
advantages associated with both materials.
An additional composite is made of bovine
collagen, HA, and TCP. This material is osteo-
conductive but can be used together with aspirated
autogenous bone marrow to make it osteoinduc-
tive and potentially osteogenic. Because it provides
no structural support, it seems to be useful in
fractures that have been stabilized but contain
bone defects. It has been shown to be a viable
alternative to autogenous bone graft in the treat-
ment of fractures, including the distal radius
[19,20].
Calcium sulfate
Calcium sulfate, also known as plaster of Paris,
has been used to fill bone defects for many years.
It acts as an osteoconductive filler for bone
defects, but unlike ceramics, the rate of resorption
is rapid, with some variation depending on the
formulation, configuration, and amount of mate-
rial used. It is available in various forms, in-
cluding pellets, blocks, and in an injectable paste.
Resorption occurs by dissolution and replacement
by bone [21]. It is indicated to fill metaphyseal
defects but requires supplemental fixation.
Cement
Injectable cements are made of calcium phos-
phate and have the advantage of complete filling
of defects. They are injected or molded into
a defect in a liquid or putty form and solidify
within several minutes without generating signif-
icant heat. The solid form provides structural
support with compressive strength that is greater
than cancellous bone, although it resists torsion or
shear poorly [22].
Bone cements have been shown to remodel with
cutting cones and osteoclastic activity, because
they strongly resemble the mineral phase of bone
due to the presence of dahllite [22]. Radiographic
disappearance of the material by 30%–60% has
been seen at 1 year, with cortical remodeling pre-
ceding medullary remodeling [23].
Several studies have evaluated the use of
calcium phosphate cement in the treatment of
distal radius fractures. An initial study demon-
strated improved clinical outcome compared with
casting alone [24]. A larger, multicenter, prospec-
tive study compared bone cement (with or without
K-wires) to control subjects treated with casting
or external fixation (with or without K-wires) [23].
This study demonstrated earlier functional return
in the cement group without loss of measured
radiographic parameters. Long-term outcomes
were similar, however.
The advantage of structural integrity and
remodeling of this osteoconductive material cer-
tainly makes is attractive for use in the distal
radius. Disadvantages include lack of osteoinduc-
tion and weakness of the material in torsion and
shear. Additionally, care must be exercised during
injection, because the material may extrude and
solidify in the surrounding soft tissues.
Bioactive glass
Bioactive glass is a combination of silica,
calcium, and phosphate materials that forms
a bond between the graft and host tissue. The
silica is broken down rapidly with the release of
calcium and phosphate. This process may prove
useful for the delivery of newly derived growth
factors. These substitutes are osteoconductive
but do not provide structural support.
Growth factors
Inflammation is the earliest stage of fracture
healing and begins as a result of the hematoma
from fracture bleeding. Cells within this initial
fibrin clot secrete growth factors that regulate the
early events of fracture healing. These factors
stimulate and regulate bone formation. One of the
main limitations of most of the currently available
graft substitutes is the lack of this osteoinductive
or osteogenic potential. This is currently the most
intense area of research with regard to bone graft
substitutes [1].
Autogenous bone marrow has been used to fill
this deficit. It can be used to augment many
synthetic or allogenic substitutes to add osteoin-
ductive factors and, potentially, osteogenic cells
[25]. Typically harvested from the ilium with
 BONE GRAFT SUBSTITUTES AND BIOACTIVE MATERIALS
limited morbidity, it must be used immediately to
maintain the viability of the existing cells. Marrow
has been shown to contain osteoprogenitor cells
and growth factors [26].
Platelet rich plasma is another source of these
factors. This is obtained from an ultra concentra-
tion of centrifuged blood and therefore is used
most often when significant blood loss occurs
during a surgical procedure, which is not common
in fractures of the distal radius.
More recently, recombinant growth factors
and synthetic peptides have been introduced,
primarily for the augmentation of spinal fusion.
These require an additional substitute to act as
a carrier and to provide an osteoconductive
matrix. Antibodies to these factors, and also the
carriers, have been seen in humans, but it is
unclear if this represents a clinical problem [27].
Newer techniques certainly continue to develop,
and together with genetic engineering, most likely
represent the future of bone graft substitution.
Summary
Although autogenous bone graft has been
shown to be useful in the treatment of distal
radius fractures, the role of bone graft substitutes
and the optimal replacement material remains
unclear. Several products are commercially avail-
able, each with differing osteoconductive, osteoin-
ductive, and structural properties. Indications and
choice of graft substitute should be based on the
needs of the individual case with regard to need
for structural support, gap filling, or bone healing
stimulation. Further comparative research will
help clarify the indications and most appropriate
material for a given fracture and clinical situation.
References
[1] Ladd AL, Pliam NB. Bone graft substitutes in the
radius and upper limb. J Am Soc Surg Hand 2003;
3(4):227–45.
[2] Bauer TW, Smith ST. Bioactive materials in ortho-
paedic surgery: overview and regulatory considera-
tions. Clin Orthop 2002;395:11–22.
[3] Gazdag AR, Lane JM, Glaser D, Forster RA. Alter-
natives to autogenous bone graft: efficacy and indi-
cations. J Am Acad Orthop Surg 1995;3:1–8.
[4] Owen RA, Meltron LJ, Johnson KA, Ilstrup DM,
Riggs BL. Incidence of Colles’ fracture in a North
American community. Am J Public Health 1982;
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[5] Swigart CR, Wolfe SW. Limited incision open tech-
niques for distal radius fracture management.
Orthop Clin N Am 2001;32:317–27.
[6] Axelrod T, Paley D, Green J, McMurtry RY. Lim-
ited open reduction of the lunate facet in commi-
nuted intra-articular fractures of the distal radius.
J Hand Surg 1988;13A:372–7.
[7] Axelrod TS, McMurtry RY. Open reduction and
internal fixation of comminuted, intra-articular
fractures of the distal radius. J Hand Surg 1990;
15A:1–11.
[8] Seitz WH, Froimson AI, Leb R, Shapiro JD. Aug-
mented external fixation of unstable distal radius
fractures. J Hand Surg 1991;16A:1010–6.
[9] Simic PM, Weiland AJ. Fractures of the distal as-
pect of the radius: changes in treatment over the
past two decades. J Bone Joint Surg 2003;85A(3):
552–64.
[10] Segalman KA, Clark GL. Un-united fractures of the
distal radius: a report of 12 cases. J Hand Surg 1998;
23A:914–9.
[11] Knirk JL, Jupiter JB. Intra-articular fractures of the
distal end of the radius in young adults. J Bone Joint
Surg 1986;68A:647–59.
[12] Jupiter JB. Current concepts review: fractures of the
distal end of the radius. J Bone Joint Surg 1991;73A:
461–9.
[13] Younger EM, Chapman MW. Morbidity at bone
graft donor sites. J Orthop Trauma 1989;3:
192–5.
[14] Herrera M, Chapman CB, Roh M, Strauch RJ,
Rosenwasser MP. Treatment of unstable distal
radius fractures with cancellous allograft and exter-
nal fixation. J Hand Surg 1999;24A:1269–78.
[15] Urist MR, Silverman BF, Burning K, Dubuc FL,
Rosenberg JM. The bone induction principle. Clin
Orthop 1967;53:243–83.
[16] Bostrom MP, Yang X, Kennan M, Sandhu H,
Dicarlo E, Lane JM. An unexpected outcome during
testing of commercially available demineralized
bone graft materials: how safe are the nonallograft
components? Spine 2001;26:1425–8.
[17] Wolfe SW, Pike L, Slade JF III, Katz LD. Augmen-
tation of distal radius fracture fixation with coralline
hydroxyapatite bone graft substitute. J Hand Surg
1999;24:816–27.
[18] Bucholz RW. Nonallograft osteoconductive bone
graft substitutes. Clin Orthop 2002;395:44–52.
[19] Chapman MW, Bucholz R, Cornell C. Treatment of
acute fractures with a collagen–calcium phosphate
graft material: a randomized clinical trial. J Bone
Joint Surg 1997;79:495–502.
[20] Scaglione PH, Buchman MT. Collagraft bone sub-
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study. Surg Forum 1997;48:563–5.
[21] Kelly CM, Wilkins RM, Gitelis S, Hartjen C,
Watson JT, Kim PT. The use of surgical grade
calcium sulfate as a bone graft substitute: results of
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[22] Constantz BR, Ison IC, Fulmer MT, Poser RD,
Smith ST, Van Wagoner M. Skeletal repair by in
situ formation of the mineral phase of bone. Science
1995;24:1796–9.
[23] Cassisdy C, Jupiter JB, Cohen M, et al. Norian SRS
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 Hand Clin 21 (2005) 455–468
Rehabilitation of Distal Radius Fractures:
A Biomechanical Guide
David J. Slutsky, MD, FRCS(C)*, Mojca Herman, MA, OTR/L, CHT
3475 Torrance Blvd., Ste. F, Torrance, CA 90503, USA
Watson-Jones pointed out that a fracture is
a soft tissue injury that happens to involve the
bone [1]. One must keep in mind that the soft
tissue envelope greatly influences the final func-
tional result, even though all of the initial atten-
tion may be focused on the fracture position. The
inflammatory cascade that results in edema, pain,
and joint stiffness must be treated aggressively and
concomitantly with the bony injury. Distal radius
fractures range from simple extra-articular frac-
tures to daunting complex multi-fragmented frac-
ture dislocations. Extra-articular and minimally
displaced intra-articular fractures often can be
treated with closed reduction and cast application.
Comminuted extra-articular and displaced intra-
articular fractures often require more rigid fixa-
tion. The basic science behind fracture healing
and the inflammatory response is reviewed in this
article, with a mind to the rehabilitation forces
that can be applied during various stages of the
healing process.
Basic fracture healing
The major factors determining the mechanical
environment of a healing fracture include the
rigidity of the selected fixation device, the fracture
configuration, the accuracy of fracture reduction,
and the amount and type of loading at the
fracture gap [2]. The fracture site stability may
be enhanced artificially by a variety of external or
internal means that includes cast treatment, pins,
external fixation, and plates. Fracture healing
under unstable or flexible fixation typically occurs
* Corresponding author.
E-mail address: d-slutsky@msn.com (D.J. Slutsky).
0749-0712/05/$ - see front matter Ó 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.hcl.2005.01.004
by callus formation. This applies to cast treatment
with or without supplemental pin fixation and
external fixation. The sequence of callus healing
can be divided into four stages [3]. The stages
overlap and are determined arbitrarily as follows.
Inflammation (1–7 days)
Immediately after a fracture there is hematoma
formation and an inflammatory exudate from
ruptured vessels. The fracture fragments are freely
movable at this point.
Soft callus (3 weeks)
This corresponds roughly to the time that the
fragments are no longer freely moving. By the end
of this stage there is enough stability to prevent
shortening, although angulation at the fracture
site still can occur.
Hard callus (3–4 months)
The soft callus is converted by enchondral
ossification and intramembranous bone formation
into a rigid calcified tissue. This phase lasts until
the fragments are united firmly by new bone.
Remodeling
This stage begins once the fracture has united
solidly and may take from a few months to several
years.
Four biomechanical stages of fracture healing
also have been defined: stage I, failure through
original fracture site, with low stiffness; stage II,
failure through original fracture site, with high
stiffness; stage III, failure partially through orig-
inal fracture site and partially through intact
hand.theclinics.com
456 SLUTSKY & HERMAN
bone, with high stiffness; and stage IV, failure
entirely through intact bone, with high stiffness.
These data help determine the level of activity that
is safe for patients with a healing fracture [4].
The distal radius is composed largely of can-
cellous metaphyseal bone. Bone healing in cortical
and cancellous bone is qualitatively similar, but the
speed and reliability of healing is generally better in
cancellous bone because of the comparatively large
fracture surface [5]. Most extra-articular fractures
heal by 3–5 weeks after injury [6].
For distal radius fractures, stage I would
correspond roughly to the initial 4 weeks or the
soft callus phase. Protection of the fracture from
excessive force is needed to prevent shortening
and angulation. Stage II would coincide with the
4–8-week time period. The period beyond 8 weeks
would represent stages III and IV in which the
fracture has united clinically and can tolerate
progressive loading.
Fracture site forces
Movement of the bone fragments depends on
the amount of external loading, stiffness of the
fixation device, and stiffness of the tissue bridging
the fracture. The initial mechanical stability of the
bone fixation should be considered an important
factor in clinical fracture treatment [7].
The physiologic forces with wrist motion have
been estimated to lie between 88–135 Newtons (N)
[8,9]. Eighty-two percent of the loads across the
wrist are transmitted through the distal radius
[10]. Cadaver studies have demonstrated that for
every 10 N of grip force, 26 N is transmitted
through the distal radius metaphysis. Given that
the average male grip force is 463 N [11] or 105 psi
(1 lb of force = 4.48 N), this would imply that up
to 2410 N of force could be applied to the distal
radius during power gripping [12]. Previous stud-
ies of radius osteotomies showed that plates fail at
830 N [13]. External fixators compress as much as
3 mm under a 729 N load [14]. To prevent a failure
of fixation the grip forces during therapy should
remain less than 159 N (36 psi) for plates and less
than 140 N (31 psi) for external fixators during the
initial 4 weeks [13,14]. Gripping and strengthening
exercises should be delayed until there is some
fracture site healing.
When a bone fractures, the stored energy is
released. At low loading speeds the energy can
dissipate through a single crack. At high loading
speed the energy cannot dissipate rapidly
enough through a single crack. Comminution
and extensive soft tissue damage occur [15].
Fractures that exhibit multiple fracture lines are
thus inherently more unstable because of the
greater energy absorption at the time of injury.
The difference in stability between an undisplaced
fracture and a displaced fracture with comminu-
tion is significant and dictates a slower pace of
fracture site loading during rehabilitation.
Biochemical response to injury
The basic response to injury at the tissue level
is well known. It consists of overlapping stages,
including an inflammatory phase (1–5 days),
a fibroblastic phase (2–6 weeks), and a maturation
phase (6–24 months) [16]. Following a fracture
there is bleeding from disrupted vessels, which
leads to hematoma formation. Several chemical
mediators, including histamine, prostaglandins,
and various cytokines are released from damaged
cells at the injury site, inciting the inflammatory
cascade [17,18]. The resultant extravasation of
fluid from intact vessels causes tissue swelling [19].
Edema fluid
Simple hand edema is a collection of water and
electrolytes. It is precipitated by myriad events,
such as limb immobilization or paralysis, axillary
lymph node disorders, and thoracic outlet com-
pression. Edema restricts finger motion by in-
creasing the moment arms of skin on the extensor
side and by direct obstruction on the flexor side.
Since the work that is needed to effect a joint angle
change is dependent upon the product of the
tissue pressure and the volumetric change during
angulation, there is an increase in the muscular
force that is necessary to bend a swollen finger.
Compression, repeated finger flexion, and dy-
namic splinting redistribute this fluid to areas
with lower tissue pressure. This allows the skin to
lie closer to the joint axis, which decreases the
effort needed for finger flexion [20].
Inflammatory hand edema has the same me-
chanical effects as simple edema and is treated in
a similar fashion. The consequences of neglect,
however, are dire. The swelling that occurs after
wrist trauma as a part of the inflammatory
response consists of a highly viscous protein laden
exudate. This exudate leaks from capillaries and
contains fibrinogen. In many instances the fibrin
network is resorbed by approximately 7–10 days.
Other times the fibrinogen is polymerized into
fibrin, which becomes a lattice work for invading
 REHABILITATION OF DISTAL RADIUS FRACTURES
fibroblasts. The fibroblasts produce collagen,
which, if the part is immobilized, forms a randomly
oriented, dense interstitial scar that obliterates the
normal gliding surfaces [21]. The excessive fibrosis
also impedes the flow of lymphatic fluid [22], which
perpetuates the edema (Box 1).
Tendon gliding
Much of the work on tendon gliding has been
applied to tendon repairs. The information gleaned
from this work, however, has therapeutic implica-
tions with regard to distal radius fractures (Box 2).
The dorsal connective tissue of the thumb and
phalanges forms a peritendinous system of collagen
lamellae that provides gliding spaces for the exten-
sor apparatus [24–26]. The extensor retinaculum is
divided into six to eight separate osteofibrous
gliding compartments. Within the tunnels and
proximal and distal to it, the extensor tendons are
surrounded by a synovial sheath [27]. The flexor
tendons are surrounded similarly by a synovial
bursa and pass through a clearly defined pulley
system. Hyaluronic acid is secreted from cells lining
the inner gliding surfaces of the extensor retinacu-
lum and the annular pulleys [28,29]. The hyaluro-
nate serves to decrease the friction force or gliding
resistance at the tendon pulley interface through
boundary lubrication [30]. This in turn influences
the total work of finger flexion [31].
Fracture hematoma can interfere with this
boundary lubrication. Injury to the gliding surfa-
ces by fracture fragments or surgical hardware can
affect tendon excursion and can lead to adhesions.
Adhesions also can occur in nonsynovial regions
such as the flexor mass of the forearm and can
restrict the muscle’s gliding and lengthening
properties [32]. Differential tendon gliding and
active finger flexion are necessary to restore range
of motion.
Box 1. Edema management
Acute edema
 Compression, elevation
 Active/passive finger motion
 Icing
 Retrograde massage
Chronic edema
 Jobst intermittent compression unit
(Jobst Co.; Toledo, OH); ratio of
inflation to deflation time is 3:1 [23]
457
Box 2. Tendon gliding exercises
Immobilized wrist
 Straight position (MP, PIP, and DIP
joints extended)
 Platform position (MP joints flexed,
PIP and DIP joints extended)
 Straight fist (MP and PIP joints flexed,
DIP joints extended)
 Hook fist (MP joints extended, PIP
and DIP joints flexed)
 Full fist (MP, PIP, and DIP joints flexed)
Mobile wrist
 Synergistic wrist flexion and finger
extension
 Synergistic wrist extension and finger
flexion
 Active and passive finger extension
with wrist extended >21(
 Active and passive thumb extension
with wrist neutral in ulnar deviation
Tendon excursion
Wehbe and Hunter studied the in vivo flexor
tendon excursion in the hand. With the wrist in
neutral, the superficialis tendon achieved an
excursion of 24 mm and the profundus tendon
32 mm. The flexor pollicis longus excursion was
27 mm. When wrist motion was added, the
amplitude of the superficialis became 49 mm, the
profundus tendon, 50 mm, and the flexor pollicis
longus tendon, 35 mm [33,34]. Passive proximal
interphalangeal (PIP) flexion results in more
flexor tendon excursion than distal interphalangeal
(DIP) flexion [35]. This knowledge formed the basis
for an exercise program including three basic fist
positions: hook, fist, and straight fist, which allows
the flexor tendons to glide to their maximum
potential [36]. Synergistic wrist extension and finger
flexion increase passive flexor tendon excursion by
generating forces that pull the tendon through the
pulley system [37].
Extensor tendon gliding can be facilitated by
extending the wrist more than 21(. This allows the
extensor tendons to glide with little or no tension
in zones 5 and 6 [38]. Similarly, positioning the
wrist close to neutral with some ulnar deviation
minimizes friction in the extensor pollicis longus
sheath [39].
458 SLUTSKY & HERMAN
Immobilization
There is a constant turnover and remodeling of
tissue components. Collagen in particular is ab-
sorbed and then laid down again with updated
length, strength, and new bonding patterns in
response to stress. The periarticular tissue adap-
tively shortens if immobilized in a shortened
position, which leads to clinical joint stiffness
[40]. This tissue includes the skin, ligaments,
capsule, and the neurovascular structures [41].
To restore the length of the shortened tissue, one
must hold the tissue in a moderately lengthened
position for significant time so that it grows.
Growth takes a matter of days, and the stimulus
(ie, splinting) needs to be continuous for hours at
a time to be most effective.
Tissue biomechanics
Stress is the load per unit area that develops in
a structure in response to an externally applied
load. Strain is the deformation or change in length
that occurs at a point in a structure under loading
[42]. Various materials have an elastic region
whereby there is no permanent deformation of the
material after the load is removed, eg, a rubber
band. When the point of no return is exceeded (the
yield point), there is permanent deformation of the
material, eg, bending a paper clip until it deforms.
Collagen contributes up to 77% of the dry
weight of connective tissue. The fibers are brittle
and can elongate only 6%–8% before rupturing
[43]. Elastin comprises only 5% of the soft tissue
weight, but it can elongate 200% without de-
formity [44].
Viscosity is the property of a material that
causes it to resist motion in an amount propor-
tional to the rate of deformation. Slower lengthen-
ing generates less resistance. Any tissue whose
mechanical properties depend on the loading rate
is said to be viscoelastic. Biologic tissue is visco-
elastic in that it has elastic properties but also
demonstrates viscosity at the same time.
Skin and connective tissue is a polymer of loosely
woven strands of elastin and coiled collagen chains.
With the initial application of tension, little force is
needed for skin elongation. The elastin and the
collagen chains are unfolding and aligning with the
direction of the stress rather than stretching per se.
When all of the fibers are lined up parallel to the line
of pull, the tissue becomes stiff. Each fiber is
uncoiled and can elongate only 6%–8%. A much
greater force now produces minimal additional
gains in length. Further attempts at rapid lengthen-
ing exceed the fiber’s elastic limit, causing micro-
scopic tearing, bleeding, and inflammation. This
leads to fibrin deposition with secondary interstitial
fibrosis, which may result in further contracture [20].
If the stretching force is applied slowly, the
collagen microfibrils have time to slide past one
another. This slippage (or creep) allows the poly-
mer chains to recoil. The tissue now has been
lengthened permanently (plastic behavior) to-
gether with lessening of the tension over time
(stress relaxation). If the same tissue is held in
a slightly lengthened position for a period of
hours or days, the collagen fibers are absorbed
then laid down again with modified bonding
patterns, without creep or inflammation. Brand
refers to this as growth rather than stretch [20].
Types of splints
The principles of splinting exploit the bio-
mechanical properties of tissue to overcome con-
tracture and regain joint motion following injury.
The types of splints may be grouped as follows:
 Static: Rigid splints used for immobilization.
Restrict unwanted arcs of motion (Fig. 1A,B).
 Serial static: Serial application of plaster
casts. Relies on tissue growth [45].
 Dynamic: Continuous load applied through
elastic bands or springs. Relies on time-
dependent material property creep. The dy-
namic force continues as long as the elastic
component can contract, even beyond the
elastic limit of the tissue (Fig. 2A,B).
 Static-progressive: Static progressive stretch.
Relies on the principle of stress-relaxation
[46]. Construction is similar to dynamic
splints except these splints use nonelastic
components, such as nylon fishing line, turn-
buckles, and splint tuners. Once the joint
position and tension are set, the splint does
not continue to stress the tissue beyond its
elastic limit [47]. As the tissue lengthens, the
wearer adjusts the joint position to the new
maximum tolerable length (Fig. 3A–C).
Fracture rehabilitation
For the purposes of rehabilitation it is useful to
consider the stability of the distal radius fracture
site in three phases, which in turn guides the
therapist as to the loads that can be placed across
the fracture site. When internal or external fixa-
tion is used, the loads placed on the fracture site
 REHABILITATION OF DISTAL RADIUS FRACTURES 459

Fig. 1. Restrictive splint. (A) Above elbow splint restricts wrist motion and forearm pronation and supination. (B) Splint
does allow elbow flexion and extension.

may be adjusted accordingly. A rough knowledge Phase III

of the intrinsic or augmented fracture site stability
and the expected forces that are generated during
therapy are necessary to minimize fracture site
deformity (see section on fracture site forces).
Phase I
This phase is defined by low fracture site stiffness
(stage I; see section on basic fracture healing). The
wrist splints used at this stage are static and are used
for immobilization to limit unwanted motion, to
prevent displacement at the fracture site, and to
prevent or correct joint contractures. Protected
wrist motion is initiated in this phase.
Phase II
This phase is characterized by increasing frac-
ture site stiffness that should be able to withstand
the forces generated with light strengthening and
dynamic/static progressive wrist splinting (stage II).
In this phase there is sufficient fracture site
stability to tolerate the loads generated during
gripping and lifting (stages III and IV). Dynamic/
static progressive wrist splinting continues until
motion plateaus.
South Bay Hand Surgery Center protocol
Controlled and progressive joint mobilization
following trauma has been shown to give superior
results to immobilization [48]. The biochemical and
biomechanical events that occur during fracture
healing provide the underlying foundation for the
rehabilitation program following a distal radius
fracture. The therapy protocol for regaining finger
motion is tiered and instituted immediately in
all patients (Box 3). Tendon gliding exercises
and passive finger motion with the wrist neutral
are started immediately, because there are no

Fig. 2. Dynamic splints. (A) Dynamic supination splint relies on elastic band tension. (From Kleinman WB, Graham TJ.
The distal radioulnar joint capsule: clinical anatomy and role in posttraumatic limitation of forearm rotation. J Hand
Surg [Am] 1998;23:588–99; with permission.) (B) Dynamic PIP flexion splint added to allow simultaneous finger and
forearm splinting.
460
Fig. 3. Static progressive splints. (A) Static progressive wrist flexion splint. (B) Static progressive PIP extension splint.
(C) PIP and DIP flexion strap used to regain DIP motion. Note that it cannot increase PIP motion beyond 90( because
of its vector force.
biomechanical concerns regarding phalangeal sta-
bility. Dynamic and static progressive splinting are
instituted early if necessary, based on the observa-
tion that the total active finger motion typically
plateaus by 3 months [49]. In the authors’ experi-
ence, static progressive splinting of the fingers is
more painful and hence is instituted only after no
further gains are seen with dynamic splinting.
Wrist motion is initiated at different times de-
pending on the fracture site stability and the type
of splinting or fixation (Box 4). Patient factors,
such as age, bone density, pain tolerance, and
systemic disease may influence significantly the
pace of therapy, which should be adjusted accord-
ingly. Synergistic wrist and finger motion for
tendon excursion are started in tandem with wrist
motion (see Box 2). Forceful gripping is delayed
until there is some fracture site healing.
Procedure-specific treatment
Cast treatment
Cast treatment is nonrigid fixation: it reduces
fracture site mobility but does not abolish it
SLUTSKY & HERMAN
because of the intervening soft tissue. A cast relies
on three-point fixation to maintain the fracture
position. If the wrist is casted in a flexed and ulnar
deviated position, a component of ligamentotaxis is
also in play. The initial focus of therapy is directed
toward reestablishing finger motion. Active finger
motion should be gentle and not pushed early on,
because the flexed and ulnar deviated wrist position
relaxes the flexor tendons and tightens the exten-
sors, making it painful to make a fist.
Displaced fractures often are associated with
more soft tissue trauma, which leads to more
swelling and slower healing. The loss of the
immobilizing soft tissue envelope around the
bones also leads to greater fracture site instability.
In these cases it may be necessary to delay
strengthening exercise as well as dynamic splinting
of the wrist.
Rehabilitation
 Week 1–6: finger rehabilitation protocol
 Week 6–8 (after cast removal): phase I wrist
exercises
 Week 8–10: phase II wrist exercise
 >10 weeks: phase III wrist exercises
 REHABILITATION OF DISTAL RADIUS FRACTURES
Box 3. Finger rehabilitation protocol
Day 1–7
 Individual passive and active finger
and thumb motion
 Thumb opposition exercises
 Intrinsic muscle stretching exercises
 Aggressive edema management (see
Box 1)
 Tendon gliding exercises (see Box 2)
Week 2–4
 Dynamic PIP flexion splint if passive
PIP flexion <60(
 Switch to PIP flexion strap after >80(
of passive PIP flexion achieved
 Dynamic MP flexion splint if passive
MP flexion <40(
 Dynamic PIP and DIP flexion strap if
passive DIP flexion <40(
 Intrinsic muscle tightness: dynamic
PIP flexion splint with MP blocked
in full extension
Week 4–8
 Switch to static progressive PIP splint
if flexion is still <60(
 Switch to static progressive MP splint
if flexion is still <40(
 Dynamic/static progressive PIP
extension splint if PIP flexion
contracture >30(
 Dynamic MP extension splint if MP
flexion contracture >30(
 Dynamic/static progressive thumb
opposition splint if opposition >2 cm
from fifth MPJ
After week 8
 Home splinting until motion plateaus
Special considerations
 Ensure the cast does not block thumb and
finger metacarpophalangeal (MP) flexion
creases to minimize collateral ligament con-
tracture/intrinsic tightness.
 Avoid wrist hyperflexion in the cast. Bivalve/
remove cast with any signs of acute car-
pal tunnel syndrome (may require additional
fixation).
 If an above-elbow cast is used, regaining
forearm rotation is more difficult. Institute
461
Box 4. Wrist rehabilitation protocol
Phase I: low fracture site rigidity
 Custom or noncustom below-elbow
splint
 Gentle active and passive wrist flexion/
extension, pronation/supination
Phase II: intermediate fracture site
rigidity
 Add dynamic/static progressive
splinting if wrist flexion <30(
 Add dynamic/static progressive
splinting if wrist extension <30(
 Dynamic/static progressive supination
splinting if <60(
 Dynamic/static progressive pronation
splinting if <60(
 Address functional activities, light
strengthening
Phase III: high fracture site rigidity
 Progressive strengthening exercises
 Home splinting until motion plateaus
static progressive elbow extension splints if
elbow flexion contracture is >30( at 8 weeks.
 Satisfactory results can be achieved with a
home program in uncomplicated Colles frac-
tures [50].
Intrafocal pinning
Intrafocal pinning is indicated in unstable
extra-articular distal radius fractures. Intrafocal
pinning, however, does not provide rigid fixation.
Supplemental cast or splint immobilization is
necessary for 4–6 weeks; otherwise, early wrist
motion may produce pain and dystrophy. The
therapy protocol differs little from cast treatment
alone, but there are added requirements for pin
site care. Typically K-wires are introduced
through the snuffbox, where injury and irritation
of the superficial radial nerve branches (SRN) are
common [51]. Pin site interference with thumb or
finger extensors requires added emphasis on
thumb opposition and extensor tendon gliding
exercises (see Box 2). If comminution involves
more than two cortices or if the patient is older
than 55 years of age, there is a high likelihood of
subsequent fracture collapse [52]. In these cases
supplemental external fixation or a spanning
bridge plate may be used. Wrist motion therefore
is delayed until after fixator/plate removal.
462 SLUTSKY & HERMAN
Rehabilitation
 Week 1–6: finger rehabilitation protocol
 Week 6–8 (after pin removal): phase I
exercises
 Week 8–10: phase II exercises
 >10 weeks: phase III wrist exercises
Special considerations
 Pin site care
 After pin removal
Superficial radial nerve (SRN) desensitiza-
tion
Ulnar deviation exercises (with radial sided
pins)
External fixation
External fixation may provide improved wrist
motion through less interference with the soft
tissue envelope [53]. External fixation is consid-
ered flexible fixation. Regardless of the type of
external fixator, callus development is the over-
riding element providing the rigidity of the fix-
ator–bone system [37]. The stability of fixation
can be enhanced significantly through the addi-
tion of 0.62 percutaneous K-wires, which ap-
proaches the rigidity of a 3.5-mm dorsal AO
plate (Synthes, Inc.; Paoli, PA) [54,55]. With
intra-articular fractures, increasing the rigidity of
the fixator does not increase appreciably the
rigidity of fixation of the individual fragments
[56]. Augmentation with percutaneous K-wire
fixation reduces the dependence on ligamentotaxis
to position the fragment and significantly in-
creases the stability of the construct, especially
when the K-wire is attached to an outrigger [9].
Pitfalls of ligamentotaxis
External fixators may be applied in a bridging
or nonbridging manner. Bridging external fixation
relies on ligamentotaxis. Wrist distraction com-
bined with hand swelling predisposes toward
extensor tightness, which mandates an emphasis
on MP to DIP flexion exercises. If necessary
a dynamic MP flexion splint is applied while the
fixator is still in place (Fig. 4). Added extensor
tendon stretch is accomplished by strapping the
PIP and DIP joints in full flexion while using
the dynamic MP flexion splint. Overdistraction of
the wrist leads to intrinsic tightness and sub-
sequent clawing of the fingers [57]. The index
finger extensor tendons are especially sensitive to
this and act as an early sentinel warning device.
Fig. 4. Dynamic MP flexion splint. This splint is
converted easily to a static progressive splint by using
a nonelastic nylon line and substituting a splint tuner for
the post.
Patients with external fixators often keep their
forearms in pronation, which may lead to con-
tractures of the distal radioulnar joint [58].
Distraction, flexion, and locked ulnar deviation
of the external fixator should be avoided, because
they encourage pronation contractures and may
predispose to acute carpal tunnel syndrome
(Fig. 5A). Ideally the wrist should be positioned
in mild extension, which relaxes the extensor
tendons and facilitates finger flexion [57]. This
often requires augmentation with percutaneous
K-wire fixation of the fracture (Fig. 5B). Dynamic
or static progressive supination splinting can be
effective and should be instituted soon after
fixator removal [59].
Because ligaments are viscoelastic, there is
a gradual loss of the initial distraction force
applied to the fracture site. The initial immediate
improvement in radial height, inclination, and
volar tilt are decreased significantly by the time of
fixator removal [60]. For this reason, light grip-
ping exercises or using the hand for activities of
daily living (ADL) should not be encouraged in
the initial 4 weeks, with fracture site loading being
limited to <31 psi [12].
Nonbridging fixators allow the institution of
early wrist motion (Fig. 6A,B). In these cases
therapy includes the addition of early wrist flexion
and extension in addition to the finger exercises.
Radial deviation usually is blocked by the fixator
itself, and ulnar deviation exerts traction on the
fixator pin sites, which is painful. Simple extra-
articular fractures can tolerate the earlier onset of
loading as compared with comminuted extra-
articular fractures. When nonbridging external
fixation is used for complex intra-articular
 REHABILITATION OF DISTAL RADIUS FRACTURES 463

Fig. 5. External fixation. (A) Note the marked wrist flexion, which should be avoided. (B) Augmentation with K-wires
allows external fixation with mild wrist extension.

fractures, articular incongruity is common [61]. Special considerations

This may be prevented by use of custom designed
fixators with dorsal outriggers (Fig. 7).
Rehabilitation
Bridging external fixator
 Week 1–6: finger rehabilitation protocol
 Week 6–8 (after fixator removal): phase I
wrist exercises
 Week 8–10: phase II wrist exercises
 >10 weeks: phase III wrist exercises
 Pin site care
 Aggressive MP flexion; add dynamic MP
flexion splint if MP flexion <40( by 2 weeks
 Intrinsic tightness stretching; add dynamic
intrinsic tightness splint as needed (MP
extended, PIP/DIP flexed)
 After pin removal
SRN desensitization
Ulnar deviation exercises (with radial sided
pins)

Fig. 6. Nonbridging external fixator. (A) Nonbridging application of an external fixator. (B) Fracture position is
maintained without spanning the joint.
464 SLUTSKY & HERMAN
Fig. 7. Custom nonbridging external fixator with dorsal
outrigger bar.
Nonbridging external fixator
 Week 1–6: finger rehabilitation protocol;
phase I wrist exercises
 Week 6–10 (after fixator removal): phase II
wrist exercises
 >10 weeks: phase III exercises
Plate fixation
Rigid fixation of fractures by plating alters the
biology of fracture healing. When motion is
abolished completely between fracture fragments,
no callus forms [62]. This has been termed direct
healing, whereby osteons directly bridge the
fracture gap to regenerate bone, and the fracture
heals by remodeling [63]. Conventional plate
fixation relies on friction between the plate and
bone interface for stability and the dynamic
compression properties of the plate, which pre-
load the fracture site [64]. In general, plate fixation
allows earlier loading of the fracture site.
Newer locking plates act by splinting the
fracture site without compression, resulting in
flexible elastic fixation and stimulation of callus
formation. Locking plates do not require friction
to secure the plate to the bone. Comminuted
diaphyseal or metaphyseal fractures are suited
particularly to bridging fixation using locked
plates [65]. Fragment-specific fixation (TriMed,
Inc.; Valencia, CA) relies on a combination of low
profile pin plates with a variety of flexible wire
form buttress plates. The pin plates usually are
applied dorsoradially underneath the first exten-
sor compartment and dorsoulnarly between the
finger extensors and the extensor digiti minimi,
although volar applications are not uncommon.
Initially the plate bears all the stress; hence, the
rehabilitation forces must not exceed their toler-
ance. As healing progresses the plate load shares
until the fracture is healed and bears almost the
entire stress [66]. Feedback from the operating
surgeon is necessary as to the stability of fixation
before instituting wrist motion and gripping,
especially when there is significant intra-articular
comminution.
Dorsal plating
Newer low profile dorsal plate designs were
greeted with much enthusiasm [67,68]. Extensor
tendon irritation is still a problem [69,70]. Rapid
tendon acceleration through preload has been
proposed as one method to maximize extensor
tendon excursion [71].
Rehabilitation
 Week 1–4: finger rehabilitation protocol;
phase I wrist exercises
 Week 4–8: phase II wrist exercises
 >8 weeks: phase III exercises
Special considerations
 Emphasize extensor tendon gliding (see
Box 2)
 Emphasize wrist flexion
 Suspect extensor pollicus longus (EPL) im-
pingement/entrapment with resistant thumb
extensor tightness
Volar plating
Volar fixed angle plating is currently in vogue
[72]. Proponents of this procedure cite improved
fracture stability and better soft tissue coverage of
the implant. Normal wrist extension may be
difficult to regain, which has led some to recom-
mend splinting the patient’s wrist in 30( of ex-
tension between therapy sessions [71]. Dynamic or
static progressive splints may be used if needed.
Flexor tendon tightness may occur. This should
be treated with dynamic MP extension splinting
combined with static extension splinting of the
PIP and DIP joints, while the wrist is incremen-
tally brought from neutral to extension.
Rehabilitation
 Week 1–4: finger rehabilitation protocol;
phase I wrist exercises
 Week 4–8: phase II wrist exercises
 Late (>8 weeks): phase III exercises
 REHABILITATION OF DISTAL RADIUS FRACTURES 465

Fig. 8. Volar perspective, 3-D CT reconstruction of a right distal radius malunion. (A) The distal fragment is pronated
(arrow) at the fracture site (*), which blocks supination at the distal radioulnar joint. S, scaphoid; L, lunate; T,
triquetrum. (B) Clinical photograph showing attempted supination on the right.

Special considerations  Delay strengthening until there is evidence of

 Suspect FPL entrapment with resistant thumb scaphoid union by CT scan
flexor tightness

Fragment-specific fixation Causes of treatment failures

Same as for dorsal and volar plate fixation: There are a large number of extrinsic tendons
hardware irritation of the first extensor compart- crossing the fracture site. Dorsal angulation of
ment tendons and the finger extensors may occur >30( and radial angulation >10( greatly affects
from pins backing out. Emphasize thumb/finger the moment arms and subsequently the excursion
extension with dynamic splinting as necessary. and strength of these tendons [73].
If joint malalignment is the etiology of loss of
Combined fixation forearm rotation, then continued therapy is of no
benefit (Fig. 8A,B). Biomechanical studies have
Some intra-articular fractures are so inherently
demonstrated that radial shortening 10 mm
unstable that combined internal and external
caused a 47% pronation loss and a 27% supina-
fixation is necessary for the initial 6 weeks. In
tion loss [74]. More than 10( of dorsal tilt leads to
these instances strengthening exercises may need
a dorsal carpal shift with compressive forces. This
to be delayed longer than usual because of the risk
leads to feelings of pain and insecurity with
for displacing the articular fragments. Combined
gripping and difficulties with ADL [75]. More
volar and dorsal plating may devascularize bone
fragments, which also may contribute to these
delays. In these complex fractures it is important
to have frequent communication with the treating
surgeon together with a review of the radiographs
before loading the fracture site.

Rehabilitation
 Same as for plate or external fixation,
although fracture site loading may be delayed
as necessary
Combined radius and scaphoid fixation
 Same as for plate or external fixation

Fig. 9. Malunited Colle’s fracture. Note the marked

Special considerations dorsal tilt of the joint surface with dorsal migration of
 Variable delay in implementing wrist motion the carpus resulting in a secondary dorsal intercalated
with carpal fracture–dislocation segmental instability pattern.
466 SLUTSKY & HERMAN
severe dorsal tilt leads to a dynamic dorsal
intercalated segmental instability (Fig. 9) [76].
Summary
Fracture healing and surgical decision making
are not always predictable. The suggested proto-
cols are intended to be flexible rather than rigid to
be responsive to patient progress and the fracture
site stability. A methodologic approach to the
rehabilitation following a distal radius fracture,
based on a knowledge of the biology of fracture
healing and biomechanics of fixation, may pre-
empt some of the pitfalls associated with distal
radius fracture healing.
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 Hand Clin 21 (2005) 469–487

Extra-articular Distal Radial Fracture Malunion

Frances Sharpe, MDa, Milan Stevanovic, MDb,*
a
Department of Orthopedic Surgery, Southern California Permanente Medical Group,
9985 Sierra Avenue, Fontana, CA 92335, USA
b
Department of Orthopedics, University of Southern California Keck School of Medicine,
Los Angeles County Medical Center, 2025 Zonal Avenue, GNH Room 3900,
Los Angeles, CA 90033, USA

Fractures of the distal radius represent one of
the most common fractures of the upper extrem-
ity. Although they were described by Abraham
Colles [1] as eventually healing with good resto-
ration of function, other early authors recognized
and began surgically treating symptomatic mal-
unions of the distal radius [2–4]. More critical
analyses of outcomes of closed treatment of distal
radius fractures by DePalma in the 1950s [5],
Frykman in the 1960s [6], and Cooney and
colleagues in the 1980s [7], demonstrated a higher
rate of unsatisfactory results than previously
expected or recognized. These outcome studies
found an unsatisfactory outcome in up to 30% of
cases, with a portion of these unsatisfactory
results associated with fracture malunion.
Based on these outcome studies and improve-
ments in biotechnology, a more surgically aggres-
sive approach to these injuries has been advocated,
reducing the overall numbers of malunions. Long-
term follow-up studies of large numbers of surgi-
cally treated patients have yet to be done; therefore,
it cannot be categorically stated that the overall
goals of improved function, decreased pain, and
reduced complication rate have been achieved.
Despite the increase in the acute surgical treatment
of fractures, malunions can and still do occur. In
reviewing several series, Amadio and Botte [8] and
McGrory and Amadio [9] reported the pooled
averaged malunion rate for distal radius fractures
treated with closed reduction and casting at 23.6%.
* Corresponding author.
E-mail address: stevanov@hsc.usc.edu
(M. Stevanovic).
0749-0712/05/$ - see front matter Ó 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.hcl.2005.04.005
For distal radius fractures treated surgically, the
pooled averaged malunion rate was 10.6%.
Fracture malunions can be intra-articular or
extra-articular. This article addresses the treat-
ment of extra-articular fractures of the distal
radius. Fracture malunions are described based
on radiographic parameters. Based on the work of
Knirk and Jupiter [10] and supported by bio-
mechanical studies, intra-articular fracture mal-
unions are defined by an articular surface step-off
of 2 mm or greater. Extra-articular fracture
malunions are more difficult to define. Fracture
outcome is multifactorial, and clearly defined
parameters for acceptable degrees of angular
deformity have been difficult to isolate. The
radiographic parameters used to describe the
malunion are dorsal or volar angulation, radial
shortening, radial inclination, and rotational de-
formity. Acceptable values for satisfactory re-
duction vary greatly. Most authors agree that
radial shortening more than 5 mm leads to
unsatisfactory outcomes [11–24]. Loss of normal
radial inclination contributes to the cosmetic
deformity of the wrist, with more severe loss of
inclination leading to decreased grip strength [18].
Disabling limitation of ulnar deviation occurs
with severe loss of radial inclination of 20 or
greater. The greatest variation for what has been
considered an acceptable degree of angular de-
formity has been the amount of radial tilt, with
some authors accepting only a neutral tilt [25]
and others accepting up to 25 of dorsal angula-
tion [15,16,26]. Acceptable parameters as summa-
rized by Graham [27] are as follows:
Radial shortening of less than 5 mm as com-
pared with the contralateral wrist
hand.theclinics.com
470 SHARPE & STEVANOVIC
Radial inclination on the posteroanterior (PA)
radiograph greater than 15
Radial tilt measured on the lateral radiograph
between 15 dorsal and 20 volar.
Radiographic parameters offer a guideline for
defining a malunion; however, fractures healing
outside these parameters do not necessarily define
a symptomatic malunion. Pain-free and func-
tional range of motion are often achieved de-
spite poor radiographic outcomes. This is more
frequent in the elderly or low-demand patient.
Younger and more active patients, particularly
those who engage in heavy manual labor and who
require a normal range of motion for daily
activities, are more likely to develop symptoms
shortly after fracture healing. It is especially for
this group of patients that early surgery should be
considered.
Sequelae of malunion
Patients who have symptomatic extra-articular
malunions of the distal radius present with pain,
loss of motion, cosmetic deformity, and decreased
grip strength. Pain can be at the radiocarpal,
midcarpal, or distal radioulnar joints. The timing
of onset can vary from weeks to months to years.
Loss of motion is often multidirectional, but can be
more affected in one plane, based on the direction
and magnitude of the deformity. For example,
dorsally angulated fractures (Colles’ fractures)
generally have significant loss of volar flexion.
Volarly angulated fractures (Smith fractures) often
result in loss of dorsiflexion. Ulnar abutment,
disruption of the triangulofibrocartilage complex
(TFCC), decreased tendon efficiency, nerve com-
pression neuropathy, and eventual radiocarpal,
midcarpal, or distal radioulnar joint arthrosis or
arthritis are other potential sequelae of fracture
malunion.
The most common presenting symptom of
extra-articular fracture malunion is pain. The pain
can be at the radiocarpal joint, distal radioulnar
joint, or the midcarpal joint. The timing of onset of
pain can vary from weeks to months. Loss of
motion is common, with the direction and magni-
tude of deformity resulting in greater loss of motion
in a particular plane. Weakness and decreased grip
strength are frequently noted.
Dynamic carpal malalignment and instability
can occur in the absence of ligamentous injury.
This represents a compensatory malalignment of
the lunate in response to angulation of the radius,
resulting in a disruption of the radio-luno-capti-
tate link. Taleisnik and Watson [28] reported
symptomatic midcarpal instability with even small
deviations from normal palmar tilt, though most
of their patients’ deformity ranged between -10
and -30 . Fernandez [15,16] described dorsal
translation of the entire carpus associated with
fracture angulation more than 35 , leading to
radiocarpal instability, such that the radiocarpal
joint is stable only in the dorsiflexed position.
Ulnar abutment and triangulofibrocartilage
tears can occur. Ulnar abutment in particular is
associated with radial shortening. Another cause
of ulnar-sided wrist pain is disruption or malalign-
ment of the distal radioulnar joint. In a biome-
chanical study, Pogue and coworkers [29] showed
that radial shortening greater than 6 mm led to
impingement of the ulnar head on the triquetrum
or ulnar-most aspect of the lunate. In a cadaver
study to evaluate the effect of radial deformity on
kinematics of the distal radioulnar joint, Adams
[11] found that radial shortening caused the
greatest disturbance on kinematics of the distal
radioulnar joint and the greatest distortion of the
TFCC.
Arthrosis and arthritis at the radiocarpal and
distal radioulnar joints can be late sequelae of
fracture malunion (Fig. 1). Biomechanical studies
have evaluated the effect of radial deformity on
contact pressures at the distal radioulnar and
radiocarpal joints, suggesting that fractures heal-
ing with greater than 20 of dorsal angulation or
more than 6 mm of radial shortening lead to
significantly altered contact pressures in the radio-
carpal and distal radioulnar joints [29–31]. The
measurable differences in radiocarpal contact
pressure occur at degrees of dorsal angulation
not usually clinically accepted. This may account
for the clinical discrepancy in observed rates of
radiocarpal versus distal radioulnar joint arthritis.
Cooney and colleagues [7] reported 1.8% inci-
dence of radiocarpal arthritis in a series of 565
patients who had Colles’ fractures, compared with
a 4.8% incidence of distal radioulnar joint arthro-
sis in the same group.
Other complications of radial malunion in-
clude tendon rupture, most commonly the exten-
sor pollicis longus. Compression neuropathy has
also been described, most commonly median
nerve compression at the carpal canal. Sympa-
thetically mediated pain syndrome or shoulder-
hand syndrome can occur in conjunction with the
inciting injury, and are not specifically related to
malunion [6–8,20,32–34].
 EXTRA-ARTICULAR DISTAL RADIAL FRACTURE MALUNION 471

Fig. 1. (A,B) Late sequelae of fracture malunion. This 60-year-old right hand dominant man sustained a distal radius
fracture at age 19. He remained relatively asymptomatic throughout his sedentary career, retaining excellent range of
motion. Symptoms developed after a change in work type to a more physically demanding position. He now has
radiocarpal, midcarpal, and distal radioulnar joint pain and arthritis.

Indications for surgery outcomes in a group of patients who underwent

Identifying patients who will benefit from
surgery includes both clinical and radiographic
evaluation. Clinical examination should include
evaluation of the patient’s age, type of work, and
functional demands. Age alone should not be
a contra-indication for surgical reconstruction; it
should be considered in relation to the patient’s
functional needs and activities, and in relation to
the overall health of the patient. The severity and
location of pain should be identified, with atten-
tion to distal radioulnar joint, radiocarpal, or
midcarpal locations. Evaluation of stability of
the distal radioulnar joint and midcarpal joints
should be performed. Measurement of wrist range
of motion and grip strength should be compared
with the opposite hand.
It has been advocated that surgical intervention
be delayed until functional limitations and persis-
tence of pain have been determined. This is based
on the clinical finding that many patients do well
despite the radiographic malunion. Although this
holds true in some cases, it is less likely to hold true
in young, active patients. Delayed surgical inter-
vention can lead to soft-tissue contracture and
distal radioulnar joint dysfunction. More recently,
early reconstruction has been advocated for exces-
sive dorsal tilt (R20 degrees), fixed carpal malalign-
ment, or significant malalignment of the distal
radioulnar joint due either to excessive shortening
or angulation [35]. Jupiter and Ring [35] compared
early reconstruction (6 to 14 weeks postinjury) and
late reconstruction (30 to 48 weeks) of malunited
fractures of the distal radius. They found that early
reconstruction resulted in shorter overall period
of disability and was technically easier. Outcomes
were similar with respect to final range of motion;
however, final grip strength was greater in the early
reconstruction group.
Preoperative evaluation
Radiographic evaluation at a minimum should
include PA and lateral radiographs of both wrists.
Patients who have clinically significant loss of
rotation should also have radiographic evaluation
of the forearm and elbow. There are well-defined
radiographic parameters for defining the anatomy
and deformity of the distal radius.
Radial inclination
Radial inclination is measured from the PA
radiograph and describes the angle between a line
drawn perpendicular to the longitudinal axis of
the radius and a line drawn between the tip of the
radial styloid and the ulnar-most aspect of the
lunate facet. The average value from several
studies for radial inclination is 22 , with a range
from 12.9 to 35 (Fig. 2A). This has not been
reproducibly found to be a strong prognostic
parameter [23,36].
472 SHARPE & STEVANOVIC
Fig. 2. (A) Radial inclination. (B) Radial tilt. (C) Radial height. (D) Ulnar variance.
Radial tilt
Radial tilt is measured from the lateral radio-
graph (Fig. 2B). It is important to have a true
lateral radiograph to accurately assess the palmar
tilt. There are no well-established criteria for
determination of a true lateral radiograph of the
wrist; however, Baratz and Larsen [36] use the
projection of the pisiform, such that the palmar
cortex of the pisiform overlies the midportion of
the scaphoid between the ventral surface of the
distal pole of the scaphoid and the ventral cortex
of the capitate head. An easier approach is to
evaluate the alignment of the third metacarpal
and the radius [37]. The radial tilt is determined by
the line joining the most distal points of the dorsal
and ventral cortices of the distal articular surface
of the radius and a line perpendicular to the long
axis of the radius. The average value from
multiple studies is 11 of volar angulation, with
a range from (-)2 to 28 . There is no consensus as
to the amount of angulation that can be accepted.
There seems to be less tolerance for increases in
volar angulation than for dorsal angulation.
McQueen and Caspers [21] found that grip
strength and performance of activities of daily
living were considerably worse in wrists healing
with more than 12 of dorsal angulation. Fryk-
man [6] found that more than 10 of dorsal
angulation more likely predicted a worse out-
come. Again, however, there were several patients
who healed well outside these parameters and still
achieved a good functional result.
Radial shortening
Radial shortening, also known as radial height,
is measured from lines drawn perpendicular to the
tip of the radial styloid and a second line drawn
perpendicular to the ulnar head (Fig. 2C). The
average radial height from two studies is 12.3 mm,
with a range of 8 to 17 mm [36]. Shortening of the
radius depends to a large extent on the amount
of metaphyseal comminution and collapse. The
shortening of the radius relative to the ulna leads
to malalignment and disruption or attenuation of
the stabilizers of the distal radioulnar joint, often
leading to subluxation of the radioulnar joint. A
simpler assessment of radial metaphyseal collapse
is a measurement of ulnar variance.
 EXTRA-ARTICULAR DISTAL RADIAL FRACTURE MALUNION 473

Ulnar variance
Ulnar variance describes the relative position of
the articular surface of the radius, measured at the
lunate facet and the ulna, measured at the ulnar
head (Fig. 2D). A neutral ulnar variance occurs
when the distal cortical surface of the ulna lies at the
same level as the lunate fossa. A negative ulnar
variance occurs when the distal cortical surface of
the lunate facet projects more distally than the
ulnar head. Similarly, a positive ulnar variance
occurs when the ulnar head projects more distally
than the adjacent articular surface of the radius.
Once again, assessment of ulnar variance requires
a properly positioned radiograph. A neutral rota-
tion PA radiograph of both wrists allows appro-
priate assessment of the degree of radial shortening.

Radial shift
Van derLinden and Ericson [38] described
measuring radial shift in both the coronal and
sagittal planes. They evaluated the interdepen-
dence of radiographic parameters. They deter-
mined that only the translation of the distal
fragment in the coronal and sagittal planes were
independent measurements, and felt that these
measurements alone were adequate to describe
fracture alignment. Fracture outcome was deter-
mined by both the original displacement, as
measured with the radial shift, and initial fracture
reduction, measured by the same parameters. Use
of radial shift in reported series has not gained
widespread use.
Carpal malalignment
Adaptive or compensatory carpal malalign-
ment associated with distal radial fracture mal-
union has been described as early as 1919 during
the 28th French Congress of Surgery [28]. This
problem did not receive much subsequent atten-
tion until Linscheid and associates [39] described
three cases in 1972 and Taleisnik and Watson
[28] reported on 13 cases in 1984. Increased dor-
sal radial tilt was associated with two distinct
patterns of carpal malalignment. The first pattern
is dorsal subluxation of the entire carpus [16,40].
The second, a more common type, is dorsal tilting
of the proximal carpal row with associated flexion
of the midcarpus, radiographically showing a zig-
zag collapse of the wrist (Fig. 3) [28,40]. Abnor-
mal alignment and motion of the carpus leads to
mechanical overload of the wrist, in turn leading
to ligament attenuation, synovitis, and progressive
dynamic instability. Eventually, the flexible carpal
Fig. 3. Adaptive carpal malalignment secondary to
distal radial malunion.
malalignment can become fixed. Abnormal load-
ing of the radiocarpal and midcarpal joints can
lead to later post-traumatic arthrosis. In a cadaver
study, Park and coauthors [40] noted that each
specimen demonstrated different patterns of ma-
lalignment. Taleisnik and Watson [28] found that
midcarpal instability could occur with minimal
changes in the radial tilt, though more typically
their patients had more than 10 of dorsal
angulation. The cadaveric study by Park and
colleagues [40] suggests that progressive increases
in dorsal radial tilt lead to progressively abnormal
carpal kinematics. Based on their study, they felt
that corrective osteotomy should be considered
for a dorsal intercalated segment instability (DISI)
alignment of 15 or more, and that early correc-
tion may prevent progression of a flexible mala-
lignment to a fixed malalignment.
Need for comparison views
As noted above, with the wide ranges of values
for the above parameters, an accurate radiograph-
ic assessment of deformity can only be obtained
by comparison with the opposite uninjured wrist.
Injuries and malalignments of the distal radio-
ulnar joint and rotational malunion of the distal
radius are more difficult to evaluate with standard
radiographs.
474 SHARPE & STEVANOVIC

Computed tomography options depend upon the anatomy of the de-

formity, the involvement of the distal radioulnar
Jupiter and coauthors [41] and Bilic and
joint, and the presence of arthrosis. To a lesser
associates [42] separately reported the use of
extent, the options depend upon the underlying
three-dimensional CT modeling of the radial de-
bone quality, patient age, and the patient’s
formity. They felt that this method allowed
functional demands.
a more accurate assessment of the deformity and
Procedures designed to restore normal ana-
allowed for better preoperative planning.
tomic alignments are usually osteotomies of the
The distal radioulnar joint (DRUJ) remains
radius, but may include ulnar shortening alone or
the most common source of pain, and is the most
in combination with radial osteotomies. The aims
cited reason for poor outcome following distal
of these procedures should be to correct radial
radius fracture and even following corrective
height, inclination, tilt, and rotation. Restoration
osteotomy [6,7,16,43]. It can be affected by
of congruity of the distal radioulnar joint is one
fracture line into the joint, either with fracture
of the keystones to successful outcome of these
into the sigmoid notch or with fracture involving
procedures. These procedures should be done only
the ulnar head. The DRUJ may also be affected
in the absence of radiocarpal or distal radioulnar
by malalignment of ulnar head within the sigmoid
joint arthrosis. Osteotomies can be combined with
notch, either from bony malalignment or from
other procedures at the distal radioulnar joint to
ligament injury. The best assessment of the joint
achieve the best functional pain-free outcome.
can be done with CT scan through the distal
Distal radioulnar joint instability or arthrosis
radioulnar joint, comparing both wrists in posi-
must be addressed by simultaneous stabilization
tion of pronation and supination. Frank disloca-
procedures in the case of instability, or with dis-
tion of the DRUJ does not require CT scanning;
tal ulna procedures such as Darrach, Sauve-
however, subtle malposition and alignment can be
Kapandji, or Bower’s procedures. The selection of
detected with this method.
the procedure depends on the degree of deformity
Rotational malalignment of the distal radius
and presence of instability, in conjunction with
fractures can be a contributing component to loss
arthrosis, age, and activity level of the patient.
of rotation. Prommersberger and colleagues [44]
Radiocarpal joint arthritis can be addressed
evaluated 37 fracture malunions. Using the tech-
with radiocarpal or complete wrist fusion.
nique of Frahm and associates, the radial torsional
angles were compared proximal and distal to the
fracture site. By this technique, 25 patients were Osteotomies
noted to have rotational malalignments. Despite
Osteotomies allow for correction of uniplanar
the deformity, most patients had a functional range
or multiplanar deformities. Open wedge osteoto-
of rotation. Of note, however, volarly angulated
mies are the most common type of correction.
fractures in patients who had rotational malalign-
Dorsal opening wedge osteotomies are the most
ment had greater reduction of supination than
commonly performed procedures, because dorsal
dorsally angulated fractures with malrotation.
angular malunion (Colles’ type fracture) is the
Radiographic evaluation should include an
most commonly seen deformity. Volar opening
evaluation of bone density. Although it is not
wedge osteotomies are done to correct Smith-type
necessary to obtain a preoperative bone density
fracture malunions. Some authors have advocated
scan, a general impression of radiographic bone
closing wedge osteotomies to reduce the risk of
density can aid in planning the surgical procedure,
radial nonunion and avoid the need for bone
especially with respect to the type of implant and
grafting. When this procedure is selected, it must
fixation, or in considering alternatives to radial
be combined with an ulnar shortening. In cases
osteotomy.
where there is minimal angular deformity of the
radius in combination with significant telescopic
shortening, an ulnar-shortening osteotomy alone
Surgical procedures can correctly reestablish the distal radioulnar joint
relationship and reduce ulno-carpal impingement.
Goals
The goals of surgery for symptomatic mal- Dorsal opening wedge osteotomies
unions of the radius should be to reduce or The deformity following Colles’ fractures
eliminate pain and improve function. The surgical is often more than dorsal angulation of the
 EXTRA-ARTICULAR DISTAL RADIAL FRACTURE MALUNION
distal fragment in the sagittal plane. There is often
radial deviation in the coronal plane (loss of radial
inclination). There may be overall loss of radial
height due to metaphyseal collapse with telescopic
shortening, and the distal fragment is in a position
of supination. A dorsal opening wedge osteo-
tomy allows for correction of all planes of this
deformity.
Preoperative planning is critical in determining
the planes and degree of correction necessary to
reestablish the normal anatomy. Measurement of
the length of radial and dorsal height needed to
restore radial height, inclination, and tilt is useful
in evaluating the osteotomy site and in estimating
the size of the structural bone graft to be harvested.
Templating against the normal side is the best
method for obtaining the anatomic correction for
that patient. Traditionally, the dorsal opening
wedge osteotomy has been performed through
a dorsal approach. This technique has been ele-
gantly described by Fernandez and Jupiter
[15,16,45,46]. The radius is approached through
a dorsal incision between the third and fourth
extensor compartments. Kirschner wires (K-wires)
placed perpendicular to the proximal and distal
fragments are used as a guide to anatomic correc-
tion. The radial osteotomy is performed between 2
and 2.5 cm proximal to the joint line, often through
the site of the healed fracture. Fluoroscopic
guidance is used to be certain that the cut does
not enter the distal radioulnar joint, and is useful in
directing the angle of the osteotomy. The osteot-
omy is made parallel to the joint surface of the
distal radius. Distraction between the fragments
can be performed with lamina spreader or with an
external fixator. The authors have also found
cervical spanners to be useful. Bicortical iliac crest
bone graft is harvested and shaped to fit the defect.
This should be close to the size estimated from the
preoperative planning. The cortical portion of the
iliac crest graft should be radial and dorsal, giving
the most structural support to the cortices where
the most shortening occurred and to where the
most distraction is necessary. After the graft is
placed, a 0.062 K-wire is used to secure the graft
and prevent the graft from displacing dorsally. It is
helpful to preposition this K-wire through the
radial styloid, so that the position of the wire at
the osteotomy can be properly located under direct
visualization. Dorsal fixation with an T-plate or an
oblique T-plate is used for definitive stabilization.
Lister’s tubercle should be removed to allow the
plate to sit flat against the cortex of the distal
fragment. The K-wire may be left in place or
475
removed. During closure, the periosteum should
be closed over the plate when possible. The
periosteum is often thin and noncompliant to
stretch; however, a strip of extensor retinaculum
can be transposed below the extensor tendons and
used to cover the plate, especially the distal portion
of the plate, where the extensor tendons are most
susceptible to injury and rupture from mechanical
wear against the plate. The extensor pollicis longus
is left transposed in a subcutaneous position
(Fig. 4).
Successful distraction across the osteotomy site
can be difficult. The authors have found that
partial release of the pronator quadratus through
the osteotomy site provides little benefit in re-
ducing tension across the distraction site. Release
of brachioradialis, either by transaction at the
osteotomy site or subperiosteal release from the
styloid, allows much easier distraction. We prefer
not to use an external fixator as a distraction tool,
because the bone is often osteopenic, and a single
Schanz pin may loosen within the epiphyseal bone
or may even cause fracture of the distal fragment.
Our preference is for the use of a lamina spreader,
beginning with a spreader with a wider blade to
more evenly distribute force across the osteotomy
site. We distract gradually, and progressively open
the lamina spreader. Iliac crest bone graft can be
harvested while allowing time for soft-tissue re-
laxation, periodically returning to the radius to
increase the distraction. Once the soft tissues have
begun to relax, the wider lamina spreader is
replaced by two narrow blade lamina spreaders,
placed at the radial and ulnar cortices of the
osteotomy site. We try to obtain slight over-
distraction to facilitate placement of the graft.
To prevent the distal fragment from collapsing
around the bicortical graft, the cortical margins of
the graft should abut the cortical margins of the
distal fragment on the dorsal side (Fig. 5).
Perhaps the most significant innovation in the
treatment of distal radius fracture malunions has
been the introduction of fixed-angle locking
plates. This was initially introduced as a dorsal
fixed-angle plate. More recently, the volar fixed-
angle plates offer a new option for managing
extra-articular fracture deformity. There are sev-
eral options for volar fixed-angle plates (Synthes
pi plate; Synthes Ltd., Paoli, Pennsylvania). All of
these have similar advantages, especially for use in
osteoporotic bone, providing stable distal fixation
through multiple pegs or screws that lock into the
plate. Although these plates are based on similar
principles, each plate has unique features that may
476 SHARPE & STEVANOVIC
Fig. 4. (A–D) Technique of dorsal opening wedge osteotomy.
be more applicable to a different fracture pattern
or patient anatomy. These plates help in re-
establishing the normal angles of the radius, and
through the use of multiple points of fixation
provide a wide base of support for the distal
fragment (Fig. 6).
The technique of dorsal opening wedge osteo-
tomy through a volar incision is similar in principle
to that done through a dorsal incision. It requires
preoperative planning and an estimation of the
amount of correction necessary. The approach is
Henry’s incision, opening the interval between
flexor carpi radialis and the radial artery. The
pronator quadratus is elevated off of the volar
surface of the radius. The brachioradialis is re-
leased. The osteotomy is performed proximal to
the sigmoid notch, paralleling the distal radial
joint line. The correction of the deformity is
similar to that described for the dorsal side, using
a lamina spreader or other form of distraction to
achieve correction. Fluoroscopy is used to evalu-
ate the correction, and when satisfactory correc-
tion is achieved, provisional stabilization is
performed with a K-wire placed from the radial
styloid into the proximal fragment. The plate is
then applied and provisionally fixed with either
a K-wire or a single screw placed through the
gliding hole. Fluoroscopy is used to check the
position of the plate in the AP and lateral planes.
Because of the fixed angle position of the distal
screws, careful attention to the position of the
plate is necessary to prevent the screws from
traversing the articular surface (Fig. 7).
If the correction of the deformity does not
require significant lengthening, an alternative
technique to produce correction is to use the fixed
angle plate to recreate the normal anatomy. Once
the osteotomy has been created, the plate is
applied first to the distal fragment, making certain
that the distal plate is flush with the cortical
surface of the distal fragment. This leaves the
proximal portion of the plate lifted off the cortex
of the proximal fragment. The angle between the
plate and the proximal radial fragment should be
the angle of correction in the sagittal plane. By
then bringing the plate down to the proximal
fragment, a dorsal opening wedge osteotomy is
created (Fig. 8). Fluoroscopy is used to confirm
the correction in the coronal and sagittal planes.
Adequate correction of radial height and the
relationship of the distal radioulnar joint should
also be confirmed under fluoroscopy. Correction
of rotational malalignment is usually achieved
simply with plate application.
 EXTRA-ARTICULAR DISTAL RADIAL FRACTURE MALUNION 477

Fig. 5. Dorsal opening wedge osteotomy. This 16-year-old elite pitcher presented with radial deformity, pain, and
decreased motion. Growth arrest from a fracture 2 years before presentation had resulted in significant radial deformity.
Corrective osteotomy produced good anatomic correction with improved range of motion and alleviation of pain,
allowing patient to continue toward a professional sports career. (A) Preoperative AP radiograph of the wrist. (B)
Preoperative templating. (C) PA radiograph of correction. (D) Lateral radiograph of correction. (E) Pre- and
postoperative comparison. (F) Postoperative volar flexion. (G) Postoperative dorsiflexion.
478 SHARPE & STEVANOVIC

There have been reports of successful union
using bone allograft and bone substitutes; how-
ever, the authors’ experience has been best with
autogenous iliac crest bone graft. Traditionally,
most authors have recommended the use of
structural bone graft; however, the use of struc-
tural or nonstructural graft was evaluated by Ring
and colleagues [47] in combination with dorsal
fixed locking plates. They found the all osteoto-
mies healed without loss of surgical correction.
Extrapolating to volar fixed-angle locking plates,
use of nonstructural graft seems appropriate with
this type of fixation. Watson and Castle [48] used
local bone graft harvested from the central portion
of the radius from the proximal fragment. Longi-
tudinally harvested bone was transposed and
rotated in to the defect in the radius. Although it
reduces pelvic donor site morbidity, this technique
should be reserved for patients who have an
adequately wide radius in the coronal plane and
for patients with contra-indications to iliac crest
bone graft [27]. Other bone graft substitutes have
also been used [49,50]. Luchetti [49] reported use of
carbonated hydroxyapatite as an alternative to
traditional bone grafting. In combining this with
K-wire fixation, he found no loss of reduction and
progression of radiographic union with gradual
reabsorption of the hydroxyapatite and replace-
ment with bony calcification over time [49].
the treatment of fractures that have healed with
excessive radial volar tilt (Smith fractures). These
fractures are less commonly seen, and represent
approximately 5% of fractures of the distal radius
[19,51]. They are usually easier to correct, because
they are generally associated with less metaphy-
seal collapse. As with the Colles’ fractures, the
deformity is usually multiplanar, with increased
radial volar tilt and often a pronation deformity
associated with dorsal subluxation of the distal
ulna. There is seldom any significant shortening
associated with these fractures.
The approach is as outlined above, through
Henry’s approach between the flexor carpi radialis
and the radial artery. The osteotomy is made
parallel to the joint surface. Application of the
volar plate alone is often sufficient to correct
the deformity. Bone graft can be used to augment
the osteotomy site, but may not be necessary in all
cases (Fig. 9) [52,53].
Thivaios and McKee [51] described a technique
of a sliding osteotomy of the radius. They felt that
one component of the deformity from a Smith’s
fracture is a volar translational deformity. By
creating an oblique osteotomy and sliding the
distal fragment dorsally, they were able to correct
angulation and improve function in a series of ten
patients.

Volar osteotomies Volar closing wedge osteotomy. A volar closing

Volar opening wedge osteotomy. Volar opening wedge osteotomy to correct radial angular mal-
wedge osteotomies are generally performed for union may have a role in particular for the

Fig. 6. Some of the options for volar fixed angle plating. Several companies now produce fixed-angle locking plates.
Volar fixation of dorsally displaced fractures and dorsal opening wedge osteotomies through a volar approach has
become a reliable method of treatment. Although far from comprehensive, this figure shows some of the plate designs
available. Although similar in principle, each plate has unique design features that may make it more appropriate for
a particular patient’s anatomy or malunion pattern. Some plates offer a double row of distal fixation. Although most of
the plates have a low profile, some have a lower profile than others. (A) From left to right: Hand Innovations, Accumed,
Synthes low-profile volar locking plate, Trimed fixed angle plate, and Trimed volar bearing plate. A unique feature of the
Trimed volar bearing plate is that the design of the distal locking system allows the surgeon to select the peg angle within
a 15 range before the peg locks into the plate. (B) The angular range in the sagittal plane is shown. The volar bearing
plate is seen in the last two images on the right and demonstrates the range of angulation for this plate.
 EXTRA-ARTICULAR DISTAL RADIAL FRACTURE MALUNION 479

Fig. 7. Early osteotomy and use of a volar fixed-angle plate to correct dorsal angulation and radial inclination. (A)
Preoperative PA. (B) Preoperative lateral. (C) Postoperative PA. (D) Postoperative lateral.

treatment of patients who have severe osteopenia
or a contraindication to bone grafting [54–56]. As
reported by Posner and Ambrose [54], the angular
deformity of the radius was corrected with a
biplanar osteotomy, whereas correction of the
positive ulnar variance was corrected with a dis-
tal ulnar resection (Darrach procedure). They
reported good outcome in their series, suggesting
that the procedure was best suited to older
osteopenic patients, especially to low-demand pa-
tients and nondominant extremities. Based on few
additional publications of this technique, it has
never gained popularity in the literature, but does
provide an opportunity to correct radial defor-
mity while minimizing the risk of nonunion or
bone-failure around the surgical fixation device.
Because of the morbidity associated with distal
ulna excision, especially in the younger or higher
demand patient, Wada and colleagues [56] recom-
mended a closed-wedge osteotomy of the radius in
combination with diaphyseal shortening of the
ulna, thereby restoring the congruity of the distal
radioulnar joint. Although no long-term pro-
spective or retrospective studies exist, the authors’
prefer preservation of the distal radioulnar
joint whenever possible, provided that there is
no underlying arthrosis of the sigmoid notch
(Fig. 10).
Distraction corticotomy of the radius
A final alternative to addressing deformity of
the distal radius is that of radial corticotomy
combined with external fixation and distraction
osteogenesis for correction of radial deformity.
This can involve significant complexity for multi-
planar correction with a ringed external fixator
and difficult placement of fine wires. Uniplanar
distraction osteogenesis, although possible, allows
for little fixation in the distal metaphyseal frag-
ment. The amount of correction achieved is not as
much as that achieved with immediate correction
and plate stabilization. Although this is a useful
technique to be aware of, there is little indication
for use [57].
Ulnar shortening osteotomy (Milch procedure)
Diaphyseal ulnar shortening is rarely indicated
as an isolated procedure. In cases of telescopic
radial shortening, when the fracture line is prox-
imal to the sigmoid notch and the radial shaft is
480 SHARPE & STEVANOVIC
Fig. 8. Technique of application of the fixed angle plate
first to the distal fragment (A), then using the plate to
correct the deformity (B).
impacted into the metaphysis, the radial tilt and
radial inclination can be preserved. In these rare
cases, an isolated ulnar diaphyseal shortening can
restore the ulnar variance and the congruity of the
distal radioulnar joint [22,58].
More typically, ulnar shortening is a useful
adjunct to radial osteotomy, either as a simulta-
neous or staged procedure to correct residual
ulnar positive variance (Fig. 11) [56,59].
Arthroscopic ulnar shortening with wafer
resection
In cases of minor shortening of the radius
and a stable radioulnar joint, arthroscopic short-
ening of the ulna with a wafer procedure can be
done if there is a central tear in the TFCC. This
may provide sufficient room to prevent ulnar
impingement.
Ulnar side options
The ulnar side of the wrist, and in particular
the DRUJ, can be the more troubling site of pain
and symptoms following distal radius fracture and
distal radius fracture malunion. In his compre-
hensive study of fractures of the distal radius,
Frykman [6] noted distal radioulnar joint symp-
toms in 19% of patients, one of the more common
determinants of persistent pain after distal radius
fracture. In Cooney and coauthors’ review of com-
plications following distal radius fracture [7], the
incidence of distal radioulnar joint arthrosis was
4.8%, which exceeded the incidence of radiocarpal
arthrosis (1.8%). Of the patients who had DRUJ
arthritis, 70.4% ultimately required surgical treat-
ment. Fernandez [43] found that 25% to 50% of
patients after radial osteotomy had persistent pain
related to symptoms at the distal radioulnar joint,
leading him to recommend simultaneous proce-
dures to address both the radial deformity and the
distal radioulnar joint.
Graham [27] and Hunt and coworkers [60]
separately outlined an algorithm to address prob-
lems of the distal radioulnar joint associated with
distal radial fracture malunion. The determination
of treatment was based on four factors: (1) the
radius fracture parameters, (2) the amount of
radial shortening, (3) whether the DRUJ is re-
ducible by radial osteotomy, and (4) whether there
is potential for congruity of the DRUJ. Because
it is preferable to maintain the distal radioulnar
joint articulation, anatomic reconstruction, either
through radial osteotomy, ulnar shortening, or
a combined procedure, is recommended. Only
where a stable congruous DRUJ cannot be re-
established, or where there is underlying arthrosis,
are DRUJ salvage procedures preferred.
Although loss of rotation is frequently associ-
ated with malalignment of the distal radioulnar
joint, fibrosis and loss of compliance of the soft
tissues can also compromise motion. In a cadaver
study, Moore and colleagues [61] evaluated the
effect of radial malunion on the kinematics of
rotation about the ulnar head. They found that
there was little effect on rotation based on radial
malunion and felt that the soft tissues may play
a larger role in limiting rotation. Kleinman and
Graham [62] described pathologic thickening of
the DRUJ capsule in association with restriction
of rotation. In patients in whom the bony
anatomy has been restored but who still have
loss of rotation, resection of the volar capsule of
the DRUJ can improve supination, and resection
of the dorsal capsule of the DRUJ can improve
pronation. Careful attention to preservation of
the TFCC and volar and dorsal radioulnar
ligaments is important to prevent iatrogenic de-
stabilization of the DRUJ.
In cases of nonarthritic DRUJ instability,
several treatment options exist. If the DRUJ
instability is recognized or evident at the time of
corrective osteotomy, pinning of the radioulnar
joint in a fully reduced position for 6 weeks may
provide sufficient stability to the joint to prevent
later subluxation or dislocation. When late in-
stability occurs, several options for soft-tissue re-
construction are available. Initial evaluation with
 EXTRA-ARTICULAR DISTAL RADIAL FRACTURE MALUNION 481

Fig. 9. Volar malunion This 50-year-old patient had been treated with external fixation for a distal radius fracture. She
presented with disabling loss of supination. Radiographs showed mild volar malunion, and a CT scan showed mild
pronation deformity of the distal fragment. Surgery included arthroscopy, manipulation under anesthesia, and a volar
capsulectomy of the distal radioulnar joint. Supination improved, but was not fully restored, and a springy endpoint was
still present after soft-tissue release. A volar osteotomy was performed. Application of the plate corrected both the volar
flexion and rotational malalignment. Full supination was restored on the operating table and maintained
postoperatively. (A) Preoperative PA. (B) Preoperative lateral. (C) Postoperative PA. (D) Postoperative lateral.

arthroscopy can identify a TFCC tear. In cases of
peripheral rim tear, repair alone or in conjunction
with pinning of the DRUJ can restore stability.
Ulnar-sided salvage procedures
Salvage procedures of the ulnar side of the
wrist include distal ulna resection (Darrach pro-
cedure), hemiresection of the distal ulna with
tendon interposition (Bower’s procedure), and
distal radioulnar joint fusion with creation of an
ulnar pseudarthrosis (Sauve-Kapandji procedure).
In general, these procedures are performed in
conjunction with addressing the radial deformity,
either with an osteotomy or with a radiocarpal
fusion. In the setting of mild-to-moderate radial
deformity, however, an isolated distal ulnar pro-
cedure may be indicated. The authors’ preferred
procedure in older patients is the distal ulnar
resection (Darrach procedure). When performed
properly, with resection of the ulna at the prox-
imal edge of the sigmoid notch, we have not
encountered problems with instability of the distal
stump [63]. For younger patients, we prefer to
treat DRUJ problems with a Sauve-Kapandji
procedure, in order to prevent ulnar translation
of the carpus (Fig. 12). George and coworkers [64]
compared the Sauve-Kapandji and Darrach pro-
cedures in two similar groups of patients, con-
cluding that the procedures yielded comparable
and unpredictable results with respect to both
subjective and objective parameters. The authors
have had limited experience with the hemiresec-
tion arthroplasty; however, Fernandez [43] used
this technique as his treatment of choice in
conjunction with radial osteotomy for patients
Fig. 10. Volar shortening osteotomy combined with ulnar shortening. A 40-year-old woman underwent dorsal
osteotomy and iliac crest bone grafting to address distal radial malunion. Patient developed pain 5 months
postoperatively and had radiographic graft resorbtion. Repeat bone grafting was performed and failed. The dorsal
plate was removed, and a volar shortening osteotomy combined with ulnar shortening to restore congruity of the distal
radioulnar joint was performed. (A) Preoperative PA. (B) Preoperative lateral. (C,D) PA and lateral after graft
resorbtion despite repeat bone grafting. (E,F) PA and lateral after volar radial shortening osteotomy combined with
ulnar shortening osteotomy.
 EXTRA-ARTICULAR DISTAL RADIAL FRACTURE MALUNION 483

Fig. 11. Correction of radial malunion combined with ulnar shortening. A 45-year-old man presented with radial
fracture nonunion associated with significant shortening. Shortening of the radius combined with stable internal fixation
corrected the radial deformity. Resection of the distal ulna was used to address the ulnar side of the wrist. (A,B)
Preoperative PA and lateral radiographs. (C) Postoperative PA radiograph. (D) Postoperative volar flexion. (E)
Postoperative dorsiflexion.

who had radial malunion and predominant distal
radioulnar symptoms and limitation of forearm
rotation.
Results
There have been several reports on outcomes
following osteotomy for malunited distal radius
fractures. Presenting a comprehensive picture of
these outcomes is complicated by several stud-
ies that include a mixed population of malunions,
including volar, dorsal, and intra-articular mal-
unions. Outcome parameters are assessed differ-
ently by different authors, with some emphasizing
radiographic correction and other studies reporting
functional improvement and pain relief [43,45,46,
48,49,51–57,59,65–70]. Outcome assessment rating
outcomes from poor to fair are somewhat confus-
ing, with one author [67] reporting good-to-excel-
lent results in 36 of 39 patients, although on
radiographic analysis 9 patients had radiographic
instability of the DRUJ, even though 6 of those 9
had undergone additional stabilization procedures.
Overall, it can be clearly stated that most
patients undergoing distal radial osteotomy for
radial malunion experience improvement in range
of motion, particularly in the flexion-extension arc
and in pronosupination. Grip strength is improved
484 SHARPE & STEVANOVIC

Fig. 12. Distal radial osteotomy combined with Sauve-Kapandji procedure to correct chronic DRUJ subluxation. (A)
Lateral radiograph showing chronic volar subluxation of the ulna. (B,C) Postoperative PA and lateral radiographs
following distal radial osteotomy combined with fusion of the distal radioulnar joint and creation of an ulnar
pseudarthrosis.

usually to within 80% of the contralateral wrist.
Pain is decreased. Although some mild ache can
persist, it often diminishes with time. Compressive
neuropathy, most commonly of the median nerve,
has been reported to resolve with osteotomy alone
[34]; however, the authors’ preference is to perform
a surgical decompression of the nerve with a carpal
tunnel release or release of Guyon’s canal. Most
patients are satisfied with the surgical outcome,
and the cosmetic and functional gains. Despite the
overall improvement, one of the most difficult
problems to correct remains the distal radioulnar
joint. When DRUJ arthrosis or deformity is
identified preoperatively, many authors recom-
mend simultaneous procedures to address the
ulnar side of the wrist; however, ulnar sided wrist
pain or instability may not be evident initially, but
may be a process which evolves over time.
Complications
Several complications have been reported by
different authors. Complications associated with
osteotomy include loss of correction, persistent
deformity, nonunion, symptomatic hardware,
hardware failure, extensor tendon rupture
associated with dorsal plates, flexor tendon rup-
ture associated with volar plating, extensor ten-
don adhesions, and superficial radial nerve
transection or neuritis. Ulnar-sided complications
include instability of the distal radioulnar joint or
instability of the distal ulna following Darrach or
Sauve-Kapandji procedures. Injury to the dorsal
cutaneous branch of the ulnar nerve, nonunion of
the radioulnar synostosis, symptomatic ulnar-
sided hardware, pin-track infection, painful click
at the wrist with rotation, and carpal transloca-
tion have been associated with the ulnar sided
procedures. Donor site complications include
wound infection and dehiscence. Iliac wing frac-
tures have been reported by two separate authors
[8,15,43,45,46,57,64,66–68,70–73].
Fernandez [43] reported that patients under-
going simultaneous radial osteotomy and distal
ulna procedure had a longer period of postoper-
ative pain and edema. Restoration of finger range
of motion was frequently delayed in this group of
patients.
Complex regional pain syndrome (CRPS) can
occur in any setting. Radial osteotomy often
causes significant soft-tissue swelling, which can
mimic CRPS. Aggressive therapy to maintain
 EXTRA-ARTICULAR DISTAL RADIAL FRACTURE MALUNION
finger range of motion and reduce edema and pain
should be instituted at an early stage.
Summary
With the increase in surgical options for the
treatment of distal radius fractures, the authors
anticipate that distal radial fracture malunions will
be a less frequently seen problem. Nevertheless,
they will still occur. Although patient selection has
been weighted toward the younger patient, we
believe that surgery should be based on patient
activity level, functional needs, and disability re-
lated to the malunion. With advances in biotech-
nology and improved anesthetics, surgical
intervention even in the older and osteopenic
population is now more promising. Surgical in-
tervention still requires appropriate patient selec-
tion, careful preoperative planning, and meticulous
surgical technique. The appropriate surgical pro-
cedure should be tailored to the patient’s symp-
toms, age, needs, and radiographic findings.
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 Hand Clin 21 (2005) 489–498
Salvage of Post-Traumatic Arthritis Following
Distal Radius Fracture
Ladislav Nagy, MD, PD
Hand Surgery, Department of Orthopaedics, University of Zurich, Balgrist, 8008 Zürich,
Forchstrasse 340, Switzerland
Over the last 10 years, there has been enor-
mous progress in the knowledge, technique, and
sophistication of treating fractures of the distal
radius. Nevertheless, there are still a considerable
number of patients with unsatisfactory outcome
[1,2]. These usually young and active individuals
are faced with a humble selection of reconstruc-
tive procedures that has remained virtually un-
changed over the last decade. Historically, total
wrist arthrodesis has been the sole resort for these
patients, but with the advent of alternative meth-
ods, it is questionable whether it still represents
the ‘‘gold standard’’ of all wrist salvage proce-
dures [3–6]. There is a large need to evaluate
alternative procedures, not just for the radio-
carpal joint but also for the distal radioulnar joint
that has also suffered from a simplistic approach.
Arthritis is one of the problems potentially
arising from fractures of the distal radius. Accord-
ing to the pattern of the fracture, arthritis may
affect the facet of the radiocarpal joint or the
distal radioulnar joint. Arthritis most often results
from frank incongruity of the joint surfaces. Post-
traumatic chondromalacia, however, can be
caused by other irreversible insults such as mere
compression of the cartilage or avascularity. In
addition, chronic overload due to excentric com-
pressive stress in maloriented or unstable joints
may cause cartilage degeneration over times, even
in initially healthy joints.
It is logical to address these conditions by
correcting the mechanics of the relative joint.
Whereas the technique of intra-articular osteoto-
mies of the distal radius has been sufficiently
E-mail address: ladislav.nagy@balgrist.ch
0749-0712/05/$ - see front matter Ó 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.hcl.2005.03.005
described [7,8], data are lacking on the outcome,
especially with regard to arthritic changes with
delayed timing. Fractures of the distal radius
entail not only frank intra-articular cartilage
damage but also often a component of overall
malalignment of the distal metaphysis. Thus, the
already irreversibly compromised cartilage under-
goes undue overload that may be significantly
reduced to normal values by extra-articular cor-
rective osteotomy. So far, it is unclear how long
these reconstructive methods may be successful
and at what point salvage (partial or complete
arthrodesis) is appropriate.
In addition to the well-visible and evident radio-
carpal joint derangement, there usually is a con-
comitant suffering of the distal radioulnar joint.
This joint may display not only any aforementioned
element of post-traumatic pathologydfrank artic-
ular steps and subsequent arthritisdbut also a great
variety of instability patterns, with their origin
being ligament dysfunction or intra-articular or
extra-articular deformity [9,10]. In the presence of
two potential pain sources, it is of utmost impor-
tance to clearly establish the treatment priority
(if present) or to treat the coexistent pathologies
simultaneously.
The goal of this article is to make recommen-
dations and simplify the decision between the
different treatment options based on the author’s
experience and data and evidence from the
literature. This article is not only retrospective
but also includes a clear bias; however, better or
more scientific evidence has not been found.
Wrist denervation
Wilhelm [11] described in detail the sensory
supply of the wrist originating from branches of
hand.theclinics.com
490
the forearm nerves and the technique for denerva-
tion (ie, the operative interruption of these distinct
branches resulting in a pain-free wrist). The extent
of wrist denervation that is necessary and sufficient
for clinical pain relief is not clear [12–17]. First,
new nerve branches beyond Wilhelm’s description
have been described [15,18]. This overflow of
sensory innervation maybe the reason why, even
in the cases of so-called ‘‘complete denervation,’’
not a single case of neuropathic joint deterioration
(Charcot’s joint) has so far been observed. Second,
many investigators have used partial denervation,
which is the interruption of the terminal branch
of the posterior interosseous nerve alone [13] or
together with the anterior interosseous nerve,
with the same success as the more extensive pro-
cedure [16,17]. There is a definite advantage for this
modification because a single, limited approach
allows interosseous nerves to be severed at the
same time. The approach has to be placed slightly
more proximal to the distal border for access-
ing of the interosseous membrane. Through a split
in the membrane, the anterior neurovascular
bundle can easily be visualized entering the
pronator quadratus. Here, the motor supply of
the muscle is at risk, and the morbidity is not
known.
The success rate of denervation in the literature
is high, 70% on average. Different investigators
[13,14,19] have observed deterioration of the
initial result with time. A true long follow-up
[20], however, did not confirm this deterioration:
the percentage of satisfied patients remained
constant at 66%, even 10 to 23 years after
denervation.
It is unfortunate that published series do not
subdivide the results according to the diagnosis.
The author’s experience clearly shows more re-
duction of radial-sided wrist pain than ulnar-sided
wrist pain. This experience was confirmed by
Schweizer et al [20]: these investigators also had
better results treating scapholunate advanced col-
lapse or scaphoid nonunion advanced collapse and
radiocarpal arthritis than painful disorders of the
distal radioulnar joint. Thus, in the presence of
significant distal radioulnar or ulnocarpal dysfunc-
tion, wrist denervation must be supplemented by an
adjunct ulnar procedure tailored to the individual
case. In the first instance (distal radioulnar joint)
and most frequently, this adjunct procedure is ulnar
shortening [21], with or without triangular fibro-
cartilage complex debridement [22] or reconstruc-
tion [23] and only exceptionally with arthroplasty.
The effect of denervation can be mimicked
NAGY
preoperatively by test anesthesia at the tactic nerve
passage sites. The subjective pain reduction should
also be documented by means of measuring the
patient’s objective performance on a standardized
occupational therapy circuit or on a work simulator
such as the Baltimore, Therapeutic Equipment
(BTE) [13,16,17]. An advantage of wrist denerva-
tion, in addition to its relative ease, is the absence of
complications, especially comparing it with partial
and total wrist fusions. The recovery is fast and
does not necessitate immobilization and unloading.
It is therefore the first choice for the patient with
good range of motion and does not ‘‘burn bridges’’
for further procedures.
Treatment of the radiocarpal joint
Recent advances in the understanding of the
biomechanics of the wrist joint, together with an
increasing sophistication of internal fixation tech-
niques, allow better patient selection for the
individual type of fusion. Due to perfection of
the operative technique, a higher degree of success
can be achieved.
Total wrist arthrodesis
Despite alternative fusion techniques, Arbeits-
gemeinschaft für Osteosynthesefragen (AO) plate
arthrodesis has become the ‘‘gold standard.’’ The
plate offers full versatility for optimal positioning
of the wrist, enables immediate post-treatment
function, and guarantees unmatched fusion rates
[3,4]. A further improvement was achieved with
the introduction of a dedicated wrist fusion plate
(Fig. 1). Its design, with a slim distal end for the
fixation on the third metacarpal in the appropriate
2.7-mm system, reduces the bulk of the implant on
the dorsum of the hand, which formerly was
a frequent site of painful synovitis. The perfect
shape of the precontoured plate speeds up the
operative procedure and leaves less room for
error. Panarthrodesis of the wrist yields predict-
able and lasting pain relief at the expense of wrist
motion but may entail a considerable complica-
tion rate (14%–68%) [24,25]. One source of
morbidity is the harvest site for the bone graft.
Weiss and Hastings [26] demonstrated that
a 100% consolidation rate could be achieved
with local bone graft alone. A further source of
complications may be the unnecessary inclusion of
the third carpometacarpal joint into the fusion
mass [27]. The preparation of the joint decreases
its stability and alters its alignment. Plate fixation
 SALVAGE OF POST-TRAUMATIC ARTHRITIS
Fig. 1. Faced with arthritis of the radiocarpal and the midcarpal joint as after transradial perilunate injury, complete
arthrodesis with the wrist fusion plate is the treatment of choice. (A) Preoperative radiographs. (B) Postoperative
radiographs.
may then lead to inadvertent permanent rotatory
malalignment of the third metacarpal, with sub-
sequent scissoring of the fingers. Although the
new plate was designed to be a permanent im-
plant, this goal has not been reached in any
reported series and removal of the plate is
frequent. Arthrodesis of the third carpometacar-
pal joint has been recommended to avoid painful
hypermobility of the joint, but only one case is
documented in the literature. In contrast to the
radiocarpal and midcarpal joint, fusion rates of
the third carpometacarpal joint are low. With
removal of the implant, the nonunion may be-
come symptomatic, which is the case in up to 20%
of patients. The author therefore strongly advises
to not include the third carpometacarpal joint into
the fusion mass of an AO-wrist arthrodesis unless
the carpometacarpal joint showed pre-existing
pathology and to only bridge it by the plate.
After fusion, it appears logical to remove the
implant and allow physiologic motion of this
joint.
In the literature, most results were reported
without subdividing or adequately analyzing the
outcome according to the underlying pathology.
Thus, the rather large variations among the
different series may well reflect different diagnostic
entities rather than true differences. It is evident
that the best results have been obtained in
rheumatoid patients [5] compared with results
after panarthrodesis for post-traumatic conditions
and avascular necrosis of the lunate. Further
analysis of the patients reported previously [5,28]
491
reveals that within the post-traumatic group, the
patients after fracture of the distal radius had the
worst results (Table 1).
Limited intercarpal fusion
After fractures of the distal radius, usually only
the radiocarpal joint is incongruent, arthritic, and
painful; therefore, limited wrist fusion of the
affected joint may appear to be an appealing in-
between solution, avoiding total arthrodesis. Sev-
eral laboratory studies have been performed to
determine the residual motion of the wrist after
radioscaphoid or radioscapholunate fusions.
These studies have shown that of the original
range of motion, 36% to 41% of flexion–exten-
sion and 47% to 59% of radial–ular deviation will
be preserved [29–31], enough for most functional
needs [32]. Although theses values have never
been reached in vivo due to scarring, the clinical
studies have demonstrated residual range of
motion values of 47
to 55
for flexion–extension
and 21
to 33
for radial–ular deviation. These
values were between 64% and 107% of the
preoperative values [28,33–38]. The residual plane
of motion, however, appears awkward, not linear
as reported [35], but still severely restricted when
the motion sector is observed (Fig. 2). Recent
reports have demonstrated promising improve-
ment of the motion when the distal pole of the
scaphoid is resected. In laboratory experiments,
the range of motion values could be increased to
86
and 53% of normal for flexion–extension and
492 NAGY

Table 1
Comparison of the results after complete wrist fusion according to diagnosis
All post-traumatic Only radius fractures Kienböck’s disease Inflammatory arthritis
n 64 23 11 19
Follow-up (y) 1.8 1.9 2.3 0.6
Pronation (
) 75 72 72 71
Supination (
) 69 65 69 67
Pain (0–4) 0.7 0.8 1.0 0.18*
Work (%) 75 61* 75 33*
Grip strength 60 49* 52 186*
(% of contralateral)
Excellent/good (%) 60 38* 88 75
Distal radioulnar 14 47 0 100
joint arthroplasty (%)
* P ! 0.05.

radial–ular deviation, respectively [39]. This find-
ing was observed by the author [28] in the case of
a nonunited scaphoid fracture after established
radioscapholunate fusion: after simple resection
of the distal fragment, the range motion for
flection and radial deviation improved. Thus,
resection of the distal third of the scaphoid has
become the standard when performing radiosca-
pholunate arthrodesis. In addition to the positive
effect on range of motion, resection of the distal
third of the scaphoid also decreases the torque
that acts on the scaphoid and may help avoid the
most frequent complications of radioscapholunate
arthrodeses: scaphoid fracture and nonunion of
the radioscaphoid interface [28]. The author’s
experience and one preliminary report [40] have
so far been optimistic. For patients with
Fig. 2. Presentation of the motion sector after radio-
scapholunate fusion (left panel) compared with the
healthy side (right panel). The light-emitting diode was
photographed while the patient moved his wrists along
the outer border of the field of motion.
incongruence or arthritis in the lunate fossa of
the radius alone, such as after an ulnar die-punch
fracture, radiolunate arthrodesis may be the
appropriate limited wrist fusion (Fig. 3). This
treatment has been well described and docu-
mented for the rheumatoid patient [41], but
sufficient data are not available on the post-
traumatic patient. It is surprising that the afore-
mentioned biomechanical motion analyses did not
consider radiolunate fusion or its variants. It is
especially interesting whether the overall wrist
motion could be increased by sectioning the
scapholunate ligament or by resecting the distal
pole of the scaphoid.
The value of subtotal wrist fusions was cor-
roborated by long-term follow-up reports. These
reports have clearly demonstrated that the clinical
and radiographic result is unlikely to change after
2 years [28,42]. Until the 2-year follow-up is
reached, however, a potentially difficult phase
must be mastered. From the reports on partial
intercarpal fusions [43,44], a high rate of intra-
and postoperative complications is expected
(50%–72%). Rapid residual joint deterioration
and disappointing short-term results will necessi-
tate further salvage in up to 38% [28]. In contrast
to panarthrodesis, radiocarpal fusion has been
accomplished in technically different ways, espe-
cially with regard to the method of postoperative
bone fixation. The author prefers a modular
fixation with two separate plates: one for the
radioscaphoid interval, the other for the radio-
lunate joint. Plates that offer angular stability
therefore seem to have the best rigidity in the
metaphyseal soft bone (Fig. 4), which allows for
resection of the distal pole of the scaphoid and
immediate postoperative mobilization.
 SALVAGE OF POST-TRAUMATIC ARTHRITIS
Fig. 3. When only the lunate facet is arthritic, radiocarpal arthrodesis implies only the radiolunate junction. In this
young patient, a Sauvé-Kapandji operation was chosen, with tenodesis of the ulnar stump (cf, drill holes). (A)
Preoperative radiographs. (B) One-year postoperative radiographs.
Wrist prostheses
Although wrist prostheses have been used for
treating post-traumatic arthritis of the wrist, the
reported cases are extremely infrequent. It must be
concluded that the enormous progress in total
arthroplasty in the rheumatoid wrist [45,46] has
not yet been transferred to post-traumatic prob-
lems. The revision rates of up to 6% to 22% [47] in
the long-term series, however, are not higher than
the complication rates of wrist arthrodeses or the
conversion rates from partial to total arthrodesis.
Distal radioulnar joint
Some of the patients undergoing one of the
aforementioned procedures may still have
a healthy and asymptomatic distal radioulnar
joint. It is therefore of paramount importance to
leave this joint undisturbed during these proce-
dures. One potential derangement can result from
the preparation of the joint surfaces for radio-
carpal arthrodesis. The resection of residual
cartilage and subchondral sclerotic inevitably
decreases the distance between the ulnar head
and the proximal carpal row and causes ulnocar-
pal impaction. Solid or morcellized bone graft
should therefore be introduced into the radio-
lunate gap to keep the carpus at sufficient distance
to avoid an ulnocarpal conflict (see Fig. 4).
Most patients, however, have a coexisting pa-
thology of the distal radioulnar joint. According to
the pattern of the initial injury, this coexisting
pathology may be one of the following:
493
 Shortening of the radius causes relative over-
length of the ulna, leading to ulnocarpal
impaction and axial dislocation of the distal
radioulnar joint. The latter can be reduced only
by a shortening osteotomy of the ulna [21],
which may also improve some ulnocarpal
instability, whereas impaction alone can be
handled equally by a wafer procedure [48].
 Malalignment of the distal radial epiphysis
causes incongruity and subluxation of the distal
radioulnar joint. This pathology should be
handled by corrective osteotomy of the distal
radius (Fig. 5), whereas true ligamentous in-
stability is treated more reliably with triangular
fibrocartilage reconstruction than with simple
repair [23].
 Most difficult is the treatment of distal radio-
ulnar joint arthritis. In addition to the well-
known, traditional types of ulnar head resections
(Darrach [49], Bowers’s hemirection [9],
Watson et al’s matched arthroplasty [50])
and distal radioulnar joint arthrodeses (distal:
Sauvé-Kapandji procedure [51]; complete: one-
bone forearm [52]), prosthetic ulnar head re-
placement was introduced 8 years ago [53].
Except for cases with chronic instability and
insufficient soft tissue stabilizers of the ulnar
head, prosthetic replacement is a promising
treatment option that has stood the test of
time. In contrast to the other options, prosthetic
replacement appears to reliably avoid radio-
ulnar convergence [54]. The author’s experience
suggests that patients with a rigid wrist joint
tend to have worse results after ulnar head
494 NAGY

Fig. 4. Current/standard technique of radioscapholunate fusion using two separate plates to provide angular stability.
The distal radioulnar joint is intact; therefore, a corticocancellous graft is interposed to maintain the ulnocarpal
clearance. The distal pole of the scaphoid is resected primarily. (A) Preoperative radiographs. (B) Intraoperative
presentation. (C) Postoperative radiographs.

replacement than patients with a still-mobile
wrist when treated with the same implant.
Nevertheless, the outcomes of limited total
wrist fusion have shown no influence of the
treatment type or the presence of still-mobile
wrists.
Comparison
To compare the different treatment options,
the author’s data, previously collected and
partially published elsewhere [5,28], has been
restricted to the treatment of arthritis following
distal radius fractures. Only patients treated with
total wrist denervation have been added (Table 2).
The patients treated with total wrist denervation
not only display a much shorter follow-up but
there also is a considerable selection bias, as in
any retrospective analysis. Nevertheless, some
conclusions may still be valid. There is a complete
absence of complications and need for secondary
arthrodesis in the denervation group, whereas
20% to 40% of patients treated with fusions
 SALVAGE OF POST-TRAUMATIC ARTHRITIS 495

Fig. 5. Cases with concomitant dia-metaphyseal malunion have to be addressed by osteotomy to realign the distal
radioulnar joint. In this case, an ulnar head prosthesis was used that permits adjustment of the length. Thus, no graft was
interposed at the radiocarpal arthrodesis site. At plate removal, the radioscaphoid interval proved mobile and underwent
repeat arthrodesis. (A) Preoperative radiographs. (B) Postoperative radiographs. (C) Radiographs after plate removal
and repeat arthrodesis of the radioscaphoid joint.

were affected. The outcome parameters were also Summary

similar between the various treatment groups
There are practical recommendations that can
when comparing primary and secondary complete
be drawn from the aforementioned results. Due to
arthrodeses. The highest pain level was observed
the minimal morbidity of the wrist denervation,
after radioscapholunate fusions, even after exclu-
patients with good but painful wrist motion
sion of the revised cases.
496 NAGY

Table 2
Comparison of the results after different salvage procedures folowing distal fractures of the radius
1st
2nd
Radioscapholunate
Panarthrodesisa Panarthrodesisb fusion Denervation
n 17 5 8 (þ5) 8
Follow-up (y) 1.9 7.1 7.9 0.6
Pronation (
) 72 80 69 51
Supination (
) 66 71 73 79
Flexion (
) 0 0 17 47
Extension (
) 0 0 33 49
Radial deviation (
) 0 0 4 18
Ulnar deviation (
) 0 0 23 34
Pain (0–4) 0.9 1.4 1.9* 1.1
Work capacity (%) 59 58 76 91*
Grip strength 44* 61 60 74*
(% of contralateral)
Satisfied (%) 82 60 75 75
Changed job (%) 29 60 38 25
Excellent/good (%) 71 80 88 75
Complications (%) 41 40 25 0
Distal radioulnar 41 60 50 0
joint arthroplasty (%)
a
Primary panarthrodesis: complete wrist arthrodesis as initial salvage procedure.
b
Secondary arthrodesis: complete wrist arthrodesis as secondary salvage after failed radioscapholunate athrodesis.
* P ! 0.05.

following fracture of the distal radius should first
be evaluated for wrist denervation unless formal
resection of the dorsal interosseous nerve has
clearly been included in the previous treatment.
The evaluation is performed in a standardized
manner before and after test infiltration of both
interosseous nerves. This evaluation includes as-
sessment of pain, strength, and working capacity.
Whereas the grip strength often does not (cannot)
increase more than 10% to 20%, the subjective
pain relief can be remarkable, leading to higher
repetition counts and increased dexterity. In
patients with insufficient response to the anes-
thetic nerve blocks, other pain sources must be
sought, especially on the ulnar side of the wrist.
Patients with less than functional range [32] are
candidates for complete arthrodesis. A way for
further evaluation with regard to the potential of
partial and complete wrist arthrodesis is trial
immobilization of the wrist in a light cast or
a firm reinforced brace. Trial immobilization also
allows anticipating the functional deficit from loss
of range of wrist motion. Due to the still-
unrestricted pronation and supination, ulnar-sid-
ed wrist pain may persist and will need adequate
follow-up adjunct treatment. Patients who have
good pain relief but are not willing to completely
lose their wrist motion should be evaluated
fluoroscopically or receive lateral radiographs in
full flexion and extension to measure their mid-
carpal joint mobility and anticipate the potential
residual motion after radiocarpal fusion. Patients
without pain relief from test anesthesia, trial
immobilization, and no apparent distal radioulnar
joint pathology are poor candidates for further
operative treatment.
In evaluating different salvage procedures,
among all diagnoses, painful arthritis following
fracture of the distal radius is the most difficult to
treat and yields the poorest results. Emphasis
must therefore be on better initial fracture treat-
ment and earlier secondary reconstructive inter-
ventions. The current salvage procedures must
allow further improvement or alternatives must be
developed. Prosthetic replacement merits serious
consideration, especially when it can be adapted
to the specific post-traumatic setting. This situa-
tion is not worse than rheumatoid arthritis
because the clinician is dealing with healthy and
strong intact bone stock, tendons, and ligaments,
and most important, complete absence of a pro-
gressive disease [55].
 SALVAGE OF POST-TRAUMATIC ARTHRITIS
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 Hand Clin 21 (2005) 499

Erratum

In the February 2003 Hand Clinics issue Pagensteert, and James W. May Jr, MD, please
‘‘Mutilating Hand Injuries,’’ chapter ‘‘Replan- note the correct spelling of Geert I. Pagenstert,
tation in the Mutilated Hand,’’ by Bradon MD. We apologize for the error and inconve-
Wilhelmi, MD, W.P. Andrew Lee, MD, Geert I. nience.

0749-0712/05/$ - see front matter Ó 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.hcl.2005.01.003 hand.theclinics.com
 Hand Clin 21 (2005) 501–505

Index
Note: Page numbers of article titles are in boldface type.

A C
Antibiotics, following distal radius fracture
treatment, 295, 296
Arthritis, following malunion of distal radius
fractures, 470, 471
of distal radioulnar joint, 493–494
post-traumatic, salvage of, following distal
radius fracture, 489–498, 494–495, 496
Arthrodesis, of wrist, in nonunion of distal radius,
444, 445
total, in treatment of radiocarpal joint,
490–491
Arthroscopic fixation, and open reduction, in
four-part distal radius fractures, 412–413, 414,
415
Arthroscopy, in central perforations in articular
disc in distal radius fractures, 419–421
in intra-articular distal radial fractures,
407–416
in reduction of radial styloid fractures, 410,
411
in reduction of ulnar styloid fractures, 413–415
Arthrosis, following malunion of distal radius
fractures, 470
B cast immobilization in, 310–313, 314, 315
Bone graft substitutes, allograft, 450–451
bioactive glass, 452
calcium sulfate (plaster of Paris), 452
composite grafts, 452
demineralized bone matrix, 451
growth factors, 452–453
ideal, properties of, 449
in distal radius fractures, indications for,
449–450
injectable cements, 452
mineral grafts, 451–452
Bone grafts, autogenous. See Bone graft
substitutes.
0749-0712/05/$ - see front matter Ó 2005 Elsevier Inc. All rights reserved.
doi:10.1016/S0749-0712(05)00066-1
Carpal instability, classification of, 408–409
Carpal tunnel syndrome, distal radius fractures
and, 295–296
Cast(s), immobilization using, in distal radial
fractures, 310–313, 314, 315
Colles’ fracture(s), and scaphoid fracture, 436–438
immobilization of, 311, 312
Combiholes, and locking plate stems, for plate
fixation of distal radial fractures, 334–336
Compartment syndrome, following internal
fixation of distal radial fracture, 296, 302
Computed tomography, in malunion of
extra-articular distal radius fractures, 474
Corticotomy, distraction, of radius, 479
D
Distal radius fracture(s), acceptable reduction
of, 292
and intracarpal lesions, 290
and predictors of osteoarthritis, 289–290
and predictors of residual disability, 290–291
bone graft substitutes and bioactive materials
in treatment of, 449–454
central perforations in articular disc in,
arthroscopy in, 419–421
closed manipulation and casting of, 307–316
closed reduction of, and cast treatment of,
complications of, 297–299
longitudinal traction, 310, 311, 312
manual, 310
combined internal and external fixation of,
395–406
bone grafting in, 398
goal of, 398
patient selection for, 399–400
technique for, 400–403
comminuted, ligamentataxis in, 368–369
hand.theclinics.com
502 INDEX

Distal radius fracture(s) (continued ) surgery in, evaluation for, 471–473

complications of, 295–296 goals of, 474
avoidance and treatment of, 295–305 indications for, 471–474
conservative management of, indications for, osteotomies, 474–479
308 procedures in, 474–483
displaced, conservative management of, results of, 483–484
309–310 ulnar variance in, 473
dorsal plating for, 341–346 plate fixation of, biomechanics and biology
column theory of, 342 of, 329–339
complications of, 343 distal radius T-plate for, 331
contemporary implants and techniques in, low profile, low contact plates for,
343–344 331–332
distal radius specific implants in, 342–343 plate biomechanics and, 331
early experiences with, 341 surgical treatment of, complications of,
technique of, 344–346 325–326
external fixation of, 284, 395–397 indications for, 321–322
augmentation of, 367–368 radiographic evaluation for, 322
biologic advantage of, 397 technique of, 322–325
biomechanical considerations for, 381–383 University of Washington/Harborview
biomechanics and biology of, 363–373 Medical Center experience with,
bone healing with, 369–370 326
complications of, 395 four-part, open reduction and arthroscopic
definitive, 364 fixation in, 412–413, 414, 415
dynamic, 368 fragment-specific classification of, 285–287
mechanics of external fixator for, 364–367 fragment-specific internal fixation of, 355–362
non-spanning, 375–380 biomechanical studies on, 357–358
anatomy of distal radius and, 375 complications of, 360
contraindications to, 376 hardware removal following, 360–361
distal radial osteotomy in, 377–378 historical perspective on, 355–357
in unstable fracture, 376–377 indications for, 358
indications for, 375–376 results of, 359–360
potential pitfalls of, 378 surgical technique for, 358–359
results of, 378–379 grip strength loss following, 291
surgical technique for, 376–377 initial evaluation in, 295–297
pin-bone interface and, biology of, 370–371 instability of, predictors of, 289
static, 367 internal fixation of, 397–398
temporary, 363–364 complications of, 301–303
extra-articular, external fixation of, 320 intra-articular, arthroscopy in, 407–416
goal of treatment of, 321 displaced, 407
intrafocal pin fixation of, 318–319 interosseous ligament injury in, 408
in older patients, 320 nonbridging external fixation of, 381–394
with cast or external fixation, 320 biomechanical testing for, 385–387
malunion of, 469–487 case report of, 390–392
carpal malalignment in, 473 contraindications to, 392
complications of, 484–485 materials and methods for, 383–387
computed tomography in, 474 osteotomy for, 385
osteotomies in, 474–479 pin configurations for, 385
radial inclination in, 471, 472 results of, 387–388
radial shift in, 473 soft tissue injuries in, 408
radial shortening in, 472 intrafocal (Kapandji) pinning and
radial tilt in, 472 supplemental skeletal stabilization in,
radiographic parameters of, 459–470 317–328
sequelae of, 470 malunion of, 292
 INDEX 503

nondisplaced, conservative management of, E

308–309 Edema, of hand, inflammatory, 456–457
osteoarthritis following, 292 management of, 457
osteoporosis following, disability and, 291–292 simple, 456
outcome of, factors not invariably predictive
of, 292 Extensor pollicis longus tendon, rupture of,
percutaneous and external fixation of, 438–439
complications of, 299–301 External fixator, for fixation of distal radial
plate fixation of, complications of, 336–337 fracture, anchoring pins for, 364
fixed angle principle for, 333–334 components of, 364
fragment specific fixation in, 332–333 connecting rods and joints for, 364
locking plate stems and combiholes for, frame configurations for, 365
334–336 frame stability of, 365–367
physiology of fracture healing with, 336 mechanics of, 367–368
post-traumatic osteoarthritis after, 290
predicting outcome of, 289–294
predictors of loss of wrist motion following, F
291 Finger trap-traction, in distal radial fractures,
predictors of patient satisfaction following, 310–311, 312
291–292
Fixator, external. See External fixator.
radiographic evaluation for, 279–288
rehabilitation of, 455–468 Fracture(s), distal radius. See Distal radius
and fracture stability, phases of, 458–459 fracture(s).
cast treatment of, 460 healing of, biochemical response to injury and,
combined fixation in, 465 456–457
dorsal plating in, 464 by callus formation, 455–456
external fixation in, 462 factors determining, 455
finger rehabilitation in, 461 fracture site forces and, 456
intrafocal pinning in, 461–462 radial styloid, arthroscopy in reduction of, 410,
plate fixation in, 464 411
procedure-specific treatment for, 460–465 three-part, arthroscopy in reduction of,
South Bay Hand Surgery Center protocol 410–411, 412
for, 459–460
special considerations in, 461
volar plating in, 464–465 G
salvage of post-traumatic arthritis following, Grip strength, loss of, following distal radial
489–498 fractures, 291
comparison of options for, 494–495, 496
treatment algorithm of, 321
treatment failures in, causes of, 465–466 H
treatment of, decisions for, 307 Hand, edema of, inflammatory, 456–457
ulnar fragments in, 417–418 management of, 457
ulnar wrist pain and, 290 simple, 456
volar plate fixation of, 347–354
anatomic considerations for, 347–349
biomechanical aspects of, 349–350 I
clinical experience with, 350–353 Infection(s), following treatment of distal radial
wrist motion following, 292 fracture, 295, 296, 302–303
wrist pain/grip strength following, 291 pin track, pathogenesis of, 370
Distraction corticotomy, of radius, 479 Intercarpal fusion, limited, of radiocarpal joint,
491–492
Dorsal plating, of distal radial fractures,
341–346 Intracarpal lesions, distal radial fractures and, 290
504
Intrafocal (Kapandji) pinning, and supplemental
skeletal stabilization, in distal radial fractures,
317–328
K Radiocarpal joint, treatment of, limited
Kirschner wire, for internal fixation of distal
radial fractures, 398
L Radioscapholunate fusion, technique of, 494
Ligamentotaxis, biologic effects of distraction
and, 369
biomechanics of, 368
limitations of, 397
pitfalls of, 462–464
principles of, 368, 369
Lunate, central axis of, 281–282
M ulno-radial ligaments and, 417, 418
Milch procedure, in malunion of extra-articular
distal radius fracture, 479–480
N articular step-off of, 284, 286
Nerve damage, radial nerve, following
percutaneous and external fixation of distal
radial fracture, 299
O 444–446
Osteoarthritis, following distal radial fractures,
292
post-traumatic, after distal radial fracture,
290
predictors of, distal radial fractures, 289–290
Osteotomy(ies), for nonbridging external fixation
of intra-articular distal radial fractures, 385
in malunion of extra-articular distal radius
fracture, 474–480
P
Pin fixation, intrafocal, of radial distal fractures,
318–320
Pin track infection, pathogenesis of, 370
Pin track problems, in external fixation of radial
fracture, 395–396
Plate fixation, of radial distal fractures,
biomechanics and biology of, 329–339
Plate stems, locking, and combiholes, of distal
radial fractures, 334–336
INDEX
R
Radial nerve, injury of, following percutaneous
and external fixation of distal radial fracture,
299
intercarpal fusion in, 491–492
total wrist arthrodesis in, 490–491
wrist prostheses in, 493
Radioulnar joint, distal, arthritis of, 493–494
dislocation of, 493
functional anatomy of, 417, 418
late problems of, after distal radius fracture,
421
laxity of, in distal radius fracture, 417
malalignment of, 493, 495
pain in, following distal radius fracture
malunion, 480–481
Radius, distal, anatomy of, non-spanning external
fixation and, 375
articular separation of, 284–285, 286
articular surface of, 281
fractures of. See Distal radius fracture(s).
lateral view of, 280–281, 283–284
nonunion of, 443–447
open reduction and internal fixation in,
radial deviation deformity in, 446
surgery in, complications of, 446
rehabilitation following, 446
treatment options in, 443, 444, 445, 446
wrist arthrodesis in, 444, 445
normal radiographic landmarks of,
279–282, 285
patterns of injury to, 285
posteroanterior view of, 279–280, 282–283
radial deviation deformity of, 446
radiocarpal interval and, 282–283
radiographic parameters of, 282–285
radius of curvature of, 281, 282
volar tilt of, 283–284
work-related injury to, injury compensation
in, 291
S
Scaphoid, and distal radius, combined fractures
of, arthroscopy and soft tissue repair in, 432,
433
as challenging, 427
 INDEX
clinical cases of, 436–439
distal radius fracture reduction in, 431,
432
imaging of, 429–430
percutaneous and arthroscopic
techniques in, 427–441
postoperative care in, 435
rigid fixation of distal radius in,
432–433, 434
scaphoid fracture-reduction in, 430–431
screw implantation in, 435, 436
screws for fixation of, 433–435
treatment of, 428–435
materials and methods for, 428–435
results of, 435–436
surgical technique in, 428–435
fracture(s) of, and radial styloid fracture, 436
Colles’ fracture and, 436–438
with distal radius fractures, 297
Skeletal stabilization, supplemental, and
intrafocal (Kapandji) pinning, in distal radial
fractures, 317–328
Smith fractures, immobilization of, 312, 314
Splint(s), types of, 458, 459, 460, 462
Styloid, radial fracture of, and scaphoid fracture,
436
radial fractures of, arthroscopy in reduction of,
410, 411
ulnar fractures of, 421
arthroscopic reduction in, 413–415
with distal radius fractures, 297, 298
Sugar tong splint, in distal radial fractures,
310–311, 312
T ulnar, injuries of, realignment of incongruency
T-plate, distal radius, for fixation of radial distal
fractures, 318–320
Tendon(s), rupture of, in closed cast treatment of
distal radial fractures, 299
Tendon excursion, in hand, 457
Tendon gliding, and tendon repair, 457–460
Tendonitis, following closed cast treatment of
distal radial fractures, 299
Tissue(s), biomechanics of, 458
immobilization of, shortening in, 458
viscoelastic, 458
505
Traction tower, in intra-articular distal radius
fractures, 409, 410, 413
Triangular fibro-cartilage complex injuries, in
distal radius fractures, 418–419
U
Ulnar shortening osteotomy, and volar shortening
osteotomy, 479, 482
arthroscopic, with wafer resection, 480
in malunion of extra-articular distal radius
fracture, 479–480
Ulno-radial ligaments, distal radio-ulnar joint,
417, 418
V
Volar avulsion fractures, with distal radius
fractures, 297
Volar plate fixation, of distal radial fractures,
347–354
Volar shortening osteotomy, ulnar shortening
osteotomy and, 479, 482
W
Wrist, arthrodesis of, in nonunion of distal radius,
444, 445
total, in treatment of radiocarpal joint,
490–491
motion of, following distal radial fractures, 292
overdistraction of, following percutaneous and
external fixation of distal radial fracture,
300
pain in, and grip strength, following distal
radial fractures, 291
in, 418, 419
with distal radius fractures, treatment of,
417–425
pain in, 290
following malunion of radial fractures,
480–481
arthroscopic reduction and pinning
in, 418, 419
triangular fibro-cartilage complex
injuries in, 418–419
posttraumatic, assessment of, 422
salvage procedures in, 481–483
Wrist prostheses, for radiocarpal joint, 493