Archives of Orthopaedic and Trauma Surgery

https://doi.org/10.1007/s00402-020-03365-y

HANDSURGERY

Indications, surgical approach, reduction, and stabilization techniques

of distal radius fractures
M. Leixnering1 · R. Rosenauer1,2,3 · Ch. Pezzei1 · J. Jurkowitsch1 · T. Beer1 · T. Keuchel1 · D. Simon1 · T. Hausner1,2,3,4 ·
S. Quadlbauer1,2,3 

Received: 3 February 2020

© Springer-Verlag GmbH Germany, part of Springer Nature 2020

Abstract
Distal Radius fractures (DRF) are one of the most common injuries in the upper extremity and incidence is expected to rise
due to a growing elderly population. The complex decision to treat patients operatively or conservatively depends on a large
variety of parameters which have to be considered. No unanimous consensus has been reached yet, which operative approach
and fixation technique would produce the best postoperative functional results with lowest complication rates. This article
addresses the available evidence for indications, approaches, reduction, and fixation techniques in treating DRF.

Keywords  Distal radius fracture · Outcome · Indication · Approach · Dorsal plating · Volar plating · Fixation technique ·
Complication

Introduction in terms of early functional outcome and lower complication

Distal radius fractures (DRF) are very common and have two
peaks of incidence [1–10]. First, young patients who typi-
cally sustain high-energy trauma and second elderly patients
with low-energy trauma, like falls. In the past, DRFs were
treated conservatively by casting, K-wire stabilization, or
external fixator [11–19]. Due to the introduction of palmar
angular stable plate systems, a fixation of dorsally displaced
DRF became possible from the palmar aspect of the distal
radius. Palmar fixation ensures sufficient stability to allow
early active wrist mobilization without immobilization/
splinting [13, 20–24].
Literature has still found no consensus which fixation
technique is the most advantageous. A recent network meta-
analysis concluded that plate fixation offers the best results
* S. Quadlbauer
stefan.quadlbauer@auva.at
1
AUVA Trauma Hospital Lorenz Böhler - European Hand
Trauma Center, Donaueschingenstrasse 13, 1200 Vienna,
Austria
2
Ludwig Boltzmann Institute for Experimental und Clinical
Traumatology, AUVA Research Center, 1200 Vienna, Austria
3
Austrian Cluster for Tissue Regeneration, 1200 Vienna,
Austria
4
Department for Orthopedic Surgery and Traumatology,
Paracelsus Medical University, 5020 Salzburg, Austria
rate. The long-term outcomes, however, show no stabilizing
technique to be superior to any other [2, 3, 9, 14, 25–28].
This article reviews the current evidence with respect to
indications for surgery, surgical approaches, and reduction
and fixation techniques.
Indications for surgery
The choice of conservative or surgical treatment might be
difficult as there are several variables that need to be con-
sidered. These include age, gender, occupation, dominant
hand, bone quality, co-morbidities, medication, and func-
tional and mental health. In combination with many different
fracture types, the decision process for the best treatment
for each individual is very complex [29]. The most com-
mon form of treatment for DRF is closed reduction and cast
immobilization [30–32]. Unfortunately, the risk for re-dis-
placement is about 64% in conservative treatment [31, 33].
The majority of treating surgeons consider a dorsal angula-
tion > 15°, radial shortening > 3 mm, or an intra-articular
step-off > 2 mm as an indication for surgery [34].
Surgical treatment should be recommended to patients
with a high-risk for re-displacement. However, identifica-
tion of these patients, who are prone to loss of reduction
under conservative treatment, is challenging [29]. In 1989,

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Lafontaine et al. [35] determined five predictors for instabil-
ity: dorsal angulation > 20° at presentation, dorsal comminu-
tion, intra-articular fractures, associated ulnar fracture, and
age over 60 years. If three of these five predictors exist, the
fracture is considered to be potentially unstable and, there-
fore, surgical treatment is advisable. Since then, several stud-
ies have confirmed these five predictors as risk factors for a
loss of reduction under conservative treatment [36]. Recently,
Walenkamp et al. [37] pooled the published data in a system-
atic review and meta-analysis. They observed that only dorsal
comminution, females, and patients over 60 years have an
increased risk for secondary re-displacement. There is uni-
form consensus that palmarly displaced (Smiths fracture)
or palmar/dorsal shear fractures (Barton’s, reverse Barton’s
fractures) are unstable and require surgery [38].
To complicate matters further, strong evidence exists that
patients over 60 years of age might not even benefit from
operative treatment [39]. Arora et al. [30] and Ergo et al.
[40] compared conservative treatment with palmar locking
plate fixation in patients over 65 years of age, and found
no significant differences in range of motion (ROM), pain,
or patient-reported outcome measurements 12 months after
surgery. Although the surgically treated group showed a sig-
nificantly better radiological result than the conservatively
treated group. Chen et al. [41] performed a systematic review
and meta-analysis and demonstrated similar findings, but no
significant differences in functional outcome or higher risk
for complications. Apart from age, another recent meta-anal-
ysis has shown that surgical treatment does provide a better
radiological outcome, but no significant differences in func-
tional outcome or complication rates between the operative
and conservative treatment methods were demonstrated [42].
Ultimately, no unanimous solution exists, for treat-
ing DRF. The primary concern of the patients’ needs and
demands of everyday living will determine the choice of
treatment. Restoring the distal radius to an acceptable
radiological alignment (dorsal tilt ≤ 10°, radial shorten-
ing < 2 mm, and intra-articular step-off < 2 mm) is both
mandatory and critical in young and active patients [29].
Preoperative planning
Preoperative planning for surgery of the DRF includes an
exact anamnesis and clinical examination of the patient.
Evaluation of ROM, circulation, and neurology is essen-
tial. Every patient with a DRF must also be evaluated for
CTS. An acute CTS has to be treated intraoperatively by
immediate carpal tunnel release. As CTS is very common
in elderly patients, and particularly elderly female patients
have a higher DRF rate, a latent, pre-existing CTS has to be
excluded [43]. In these cases, the latent CTS should also
be released whilst treating the DRF. Although there is no
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Archives of Orthopaedic and Trauma Surgery
general recommendation in the literature, the high postoper-
ative complication rate of CTS [44] supports this approach.
Standard wrist radiographs for diagnosing a DRF include
images in both planes (anterior–posterior and lateral view)
[45, 46]. The standard radiographs of DRF in all intra-artic-
ular and displaced fractures should be augmented by a CT-
scan to evaluate the complexity, comminution, dislocation,
and involvement of the joint [47]. Cole et al. [48] confirmed
the improved diagnostics of articular congruity compared to
plain radiographs. Identification of an articular involvement
or step-off is critical, as post-traumatic osteoarthritis occurs
in 91% of cases with any degree of incongruity and 100%
where the articular step-off is over 2 mm [49]. In addition,
a 3D reconstruction of the wrist can be helpful for further
surgical planning and confirming a decision [50, 51]. In most
cases, the indication for surgical treatment of a DRF should
be based on the CT-scan. The axial CT images allow the
identification of key fragments and the appropriate surgical
approach can be planned.
The significance of the axial CT-scan and the different
types of “key fragments” is discussed by Hintringer et al. in
the article “Biomechanical Considerations on a CT based
treatment-oriented classification in radius fractures” [52].
Surgical approaches
Surgical approach for palmar plating
The most common approaches to the distal radius are the
Henry approach and modified Henry approach, also known
as trans-FCR approach. The difference between them is that
the latter is through the FCR tendon sheath, whereas the
classic one is between the FCR tendon and the radial artery,
without opening the FCR tendon sheath [53].
An approximately 7  cm longitudinal skin incision is
made, beginning at the wrist crease and extends over the
tendon of the flexor carpi radialis muscle. If necessary, the
incision can be extended distally towards the scaphoid’s
tubercle (Fig. 1). After coagulation of small subcutane-
ous vessels, sharp preparation up to the FCR tendon takes
place. Then, the forearm fascia is released. The FCR tendon
sheath should only be opened distally, when there is a need
to access to ulnar part of the distal radius, like in ulnar pal-
mar rime factures and incised on the radial side to prevent
damage to the nearby cutaneous branch of the median nerve.
The flexor muscles are bluntly divided and held to the
ulnar side using blunt hooks, thus protecting the median
nerve. The pronator quadratus muscle is visualized, incised
lengthwise on the radial side, and pushed away from the
radius with a blunt rasp. Thus, direct access and reduction
of the fracture are possible (Fig. 2) [54–58].
Archives of Orthopaedic and Trauma Surgery
Fig. 1  Palmar approach to the distal radius. An approximately 7  cm
longitudinal skin incision is made over the tendon of the flexor carpi
radialis muscle. If necessary, the incision can be extended distally or
proximally
Fig. 2  Deep palmar preparation to the distal radius. After releasing
the forearm fascia, the flexor muscles are bluntly divided and held to
the ulnar side. The pronator quadratus muscle is visualized, incised
lengthwise on the radial side, and pushed away from the radius
To position the plate on the fracture site, the pronator
quadratus muscle needs to be detached and released, from
its distal–radial aspect [59]. The conventional approach
involves a routine repair of the muscle, but it still remains
debatable in the literature. Some surgeons postulate that a
repair restores pronation strength and protects the flexor
tendons by covering the hardware [5, 60, 61]. However, in
a systematic review by Mulders et al. [61], no significant
benefit in the functional outcome for repairing the pronator
quadratus muscle was found. Even in minimal invasive plate
osteosynthesis (with preservation of the pronator quadratus
muscle), no significant differences in wrist function was
observed when compared to the conventional palmar plating.
Surgical approach for dorsal plating
Dorsal approach
If a dorsal plate position is necessary, a longitudinal skin
incision is made ulnar and proximal to the Lister’s tubercle
(Fig. 3). After coagulation of smaller subcutaneous vessels,
dissection down to the extensor retinaculum takes place and
full skin flaps with subcutaneous tissue are raised to prevent
injury of the dorsal branches of the ulnar nerve as well as the
superficial branch of the radial nerve [55, 62, 63]. The fore-
arm fascia and the third extensor tendon compartment are
opened to radially retract the extensor pollicis longus ten-
don. The fourth extensor tendon compartment is mobilized
subperiosteally in an ulnar direction [9]. If necessary, it can
also be opened like a door wing (Figs. 4, 5). The posterior
interosseous nerve lies under the fourth extensor tendon,
which can be neurectomized proximally if a dorsal wrist
capsule denervation should be necessary [55, 63].
Dorsal–ulnar approach
For the dorsal–ulnar approach the radioulnar joint is pal-
pated and a longitudinal incision is made accordingly. The
fifth extensor tendon compartment is then opened, and the
underlying radioulnar joint can be accessed [55, 63].
Approach to distal radioulnar joint and treatment of insta-
bility is discussed in the article by Spies et al. “Distal radi-
oulnar joint instability – current concepts of treatment” [64].
Fig. 3  Dorsal approach to the distal radius. The dorsal aspect of the
distal radius is accessed by 7  cm longitudinal skin incision ulnar to
the tuberculum lister
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Fig. 4  Opening of the extensor tendon sheets. The fourth extensor
tendon sheet is opened like a door wing
Fig. 5  Dorsal approach axial view. Temporary shift of the extensor
pollicis longus tendon to the radial side. If necessary, the extensor
carpi radialis tendons can be mobilized subperiosteal radially
Palmar or dorsal fixation of distal radius fractures?
A recent network meta-analysis concluded that plate fixation
offers the best results in terms of early functional outcome
and minimizing fracture healing complications [25, 26]. As
yet, none of the fixation methods have shown their superior-
ity and which approach is preferable is still open to debate
[62].
Not only the direction of the fragment displacement will
influence the decision for palmar or dorsal fixation, but also
the surgeon’s experience/preference [65]. An advantage of
dorsal plating is the direct visibility of the fragments and
articular surface. In addition, the plate can act as a buttress
against dorsal collapse [66, 67]. Since the introduction of
palmar locking plate systems, not only palmar displaced
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Archives of Orthopaedic and Trauma Surgery
fractures can be fixed successfully. However, the locking
screws also prevent dorsal collapse of the fracture. Due to
the span between the palmar cortex and flexor tendons, pal-
mar plate fixation reduces the risk of tendon irritation.[65].
Wei et al. [68] compared complications of dorsally and
palmarly stabilized DRF in a meta-analysis. No significant
differences in the overall complication rate could be deter-
mined, but a dorsal fixation showed higher rates of tendon
irritation and a palmar one, a higher risk for carpal tun-
nel syndrome, and neuropathy. As earlier meta-analyses
included not only studies using low-profile plates, the more
recent research found no significant differences in functional
outcome and complication rate between palmar and dorsally
stabilized DRF [65, 69, 70].
The fracture type and surgeon’s experience should deter-
mine the optimal approach, fixation technique, and plate
type. In our opinion, indications for dorsal plating are lim-
ited to dorsal shear fractures or severe dorsally comminuted
fractures, where palmar plating does not ensure adequate
stability.
Reduction techniques for distal radius
fractures
When treating a DRF, a basic distinction must be made
between dorsal or palmar dislocation, central impression,
comminution zone, or combination of them all.
Strongly dissociated fractures are generally treated with
the extension technique. In a supine position, the arm is
placed on the hand table and traction of 2–3 kg is attached
to the thumb, index, and ring finger using Chinese finger
traps (Fig. 6). Thereby, the same principle as the conserva-
tive reduction of DRF is applied, except along the horizontal
axis. After the extension is attached, and traction in direction
of dislocation applied, reduction of the fracture fragments in
their anatomical position can be performed.
Fig. 6  Horizontal traction using Chinese finger traps. Presents the
patient lying in a supine position with the affected arm positioned on
the operating hand table. Sterilized Chinese finger traps are used to
generate horizontal traction of 2–3 kg. Thereby, reduction of the frac-
ture is facilitated
Archives of Orthopaedic and Trauma Surgery
Arthroscopic fracture reduction and treatment of concom-
itant injuries of DRF is discussed in detail by Kastenberger
et al. [71]
Dorsal dislocation
Large dorsally dislocated fragments can be reduced by
closed reduction under traction. If the reduction is unstable,
intramedullary k-wires, 1.4–1.6 mm in diameter, are inserted
from the dorsal and radial aspect into the fracture site
according to the technique of Kapandji (Fig. 7) [72]. A small
incision is made to insert the blunt end of the K-wire into
the bone; thereby, avoiding possible injury to the extensor
tendons or sensory nerve branches. Intramedullary K-wires
can also be inserted from the radial side to reduce radial
dislocation of the distal fragment and maintain reduction.
Another useful trick is to use the K-wires as dorsal joysticks
to manipulate the fracture element and stabilize the reduc-
tion. To lower the tension on the radial styloid and facilitate
anatomical reduction, the tendon of the M. brachioradialis
can be released distally [73].
Fig. 7  Kapandji reduction
technique. Seventy-nine-year-
old female patient with a
dorsally displaced distal radius
fracture (a). Closed reduction
was achieved using intramedul-
lary K-wires from the dorsal
and radial aspect according to
Kapandji (b)
Fig. 8  Palmar dislocation. Fifty-one-year-old male patient with a pal-
mar dislocated distal radius fracture (a). Tension using Chinese finger
traps was applied to the thumb, index, and ring finger. Thereafter, the
Palmar dislocation
A palmar dislocation can be manually reduced under lon-
gitudinal traction and applying palmar pressure with the
surgeon’s thumb. Conservative reduction uses a similar
technique. But as a rule, surgery is necessary to stabilize
a palmar dislocation. To visualize and directly reduce the
fracture, a palmar approach has to be used (Fig. 8). In these
cases, a secondary dislocation is very unlikely due to the
immediate support of the palmar plate. However, it is impor-
tant to identify smaller palmar edge fragments, which can
usually be reduced directly, but require a very far distal plate
positioning or special plates for permanent stabilization. The
hook, lunate facet, or rim plates are options to stabilize these
specific fracture types. In very distal fractures, which require
plate positioning distally to the watershed line, irritation or
rupture of the FPL tendon can occur in the long-term due to
pressure of the plate on the tendon. Therefore, in these cases,
an early plate removal should be planed. To protect the FPL
tendon and prevent these complications, special plates were
designed [8, 13, 74].
fracture was directly reduced using the palmar approach and a plate
was applied (b). One year after surgery, the X-ray shows an anatomi-
cally aligned healed fracture of the articular surface (c)
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Central depression
A central depression zone cannot be reduced by a closed
approach. Using a palmar approach, the radius is dissected.
Depressions of the articular surface can then be lifted with
an intramedullary k-wire (Fig. 9) before or after the plate
is applied. If there is a pronounced dorsal comminution
zone, the impression can also be elevated using a combined
approach (Fig. 10) and then stabilized by palmar plating.
Temporary fixation with K-wires distal to the plate directly
on the palmar rim provides temporary stability.
Comminuted fracture
When treating a comminuted fracture, a combination of
the above-mentioned procedures is usually necessary.
First, the extension is attached to the hand as previously
described. The larger dorsally dislocated elements can then
be stabilized temporarily by medullary k-wires according to
Kapandji. The fracture elements are presented via a palmar
approach, reduction can then be maintained directly or by
the plate. If palmar stabilization is not sufficient, an addi-
tional dorsal plate is recommended.
Tips and tricks for DRF reduction
After using these tricks for indirect reduction, there are
also different helpful tricks to assist direct reduction of the
fracture.
Fig. 9  Small depression of the articular surface, reduction over the
plate. A distal radius fracture in a 71-year-old female patient with a
central depression zone (a). The plate was applied with the palmar
approach, and reduction was achieved using an intramedullary K-wire
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Archives of Orthopaedic and Trauma Surgery
K‑wires as joysticks distal to the plate (Fig. 11)
The plate is positioned palmary under image intensification
and fixed onto the distal radius using the gliding hole. In
case of a persistent step-off of the articular surface, k-wires
can be inserted into specific fracture fragments distal to the
plate. Using this method, fracture elements can be manipu-
lated and positioned directly using the k-wires. Thus, mal-
rotation of these parts, which could occur during drilling
or screw insertion, can be avoided. Care has to be taken for
precise subchondral positioning of the K-wires. After reduc-
tion of the fragments, the angular stable screws are inserted
and the K-wires removed.
K‑wire reduction through the distal holes
of the plate (Fig. 12)
Smaller as well as larger fracture fragments can be reduced
and stabilized with temporary K-wire fixation, through the
distal plate holes. This method prevents malrotation during
drilling or screw insertion.
Additional screw fixation with headless
compression screws (HCS) (Fig. 13)
The smaller fracture elements that cannot be grasped by the
available screws of the plate need separate stabilization with
HCS that can be inserted before or after applying the plate.
This method can fix smaller fragments to larger units, which
in turn are stabilized with the plate. If additional screws are
used, the guide wires can be used as joysticks for temporary
through a plate hole. The reduction was temporarily stabilized with
multiple K-wires, and finally, the screws were inserted (b). c Radio-
logical outcome 6 months after surgery
Archives of Orthopaedic and Trauma Surgery

Fig. 10  Severe central depression of the articular surface. A dis- approach, the depression was elevated with an osteotome. Prior to
tal radius fracture in a 53-year-old male patient with a severe cen- screw insertion, the reduction was temporarily stabilized with multi-
tral depression and dorsal comminution zone (a). Using a dorsal ple K-wires (b). c Outcome on X-ray and CT 6 months after surgery

fixation, after which the screw can be threaded over these

K-wires.

Fixation of the styloid with headless compression

screws (Fig. 14)

Especially radial styloid fragments can be stabilized using

HCS, which are inserted through the radial styloid in a
proximal–ulnar direction. To prevent a lesion of the super-
ficial branch of the radial nerve or the tendons in the first
extensor tendon compartment, a mini-open approach is
used. If the distal radioulnar joint is unstable, the ulnar sty-
loid should be fixed. Therefore, an intraoperative instability
check has to be carried out after stabilization of the distal
Fig. 11  Temporary K-wire reduction and fixation. After reducing the
radius [75–77]. Details about the approach and treatment fracture using both dorsal and radial K-wires according to Kapandji
of distal radioulnar joint instability are described by Spies (a), the plate is stabilized on the radius through the gliding hole in
et al. “Distal radioulnar joint instability – current concepts a palmar approach. The articular surface is supported with K-wires
of treatment” [64]. distal to the plate (b). These are used as joysticks for direct manipula-
tion, to realign the anatomic shape of the articular surface

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 Archives of Orthopaedic and Trauma Surgery

Fig. 12  Fracture reduction using the distal holes of the plate. Twenty- ture compression through the plate (c). Multiple K-wires provided
three-year-old male patient with a palmar dislocated distal radius temporary stabilization prior to screw placement, which were then
fracture (a). Reduction was achieved by a palmar approach and frac- removed at the end of surgery (b)

Fig. 13  Additional stabilization using a headless compression screw. larger unit, and the final stabilization was achieved with a long palmar
Thirty eight-year-old female patient with a fracture of the left radius plate. c Radiological outcome after 6 months
(a). Two headless compression screws joined the distal fragment to a

Fig. 14  Fixation of the radial styloid using a headless compression fixed with a headless compression screw using a radial mini-open
screw. Forty-eight-year-old male patient with a fracture of the radial approach, and finally, a palmar plate was placed to stabilize the rim
styloid and a palmar rim fragment (a). The intra-articular step-off fragment (b). c Radiological result 6 months postoperatively
was elevated with a K-wire from palmar, the radial styloid was then

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Archives of Orthopaedic and Trauma Surgery
Fig. 15  Temporary transfixation of the radius  to the lunate. Thirty-
year-old male patient with a high-energy distal radius fracture includ-
ing dorsal subluxation of the carpus and multiple small rim fragments
(a). Traction was applied using Chinese finger traps. Thereafter, a
palmar approach was used to stabilize the small palmar rim fragments
Temporary transfixation of the distal radius
to the lunate (Fig. 15)
In very distal palmar rim fractures, where even special plates
are unable to incorporate the small fragments, or if a high
risk for palmar subluxation of the carpus exists, a temporary
K-wire transfixation can be used. The K-wire is drilled from
the distal radius into the lunate in a dorsal-to-palmar direc-
tion. The K-wire is clipped just under the skin and left in situ
for 5 weeks [43]. Therefore, secondary fragment dislocation
palmary and subluxation of the carpus can be prevented.
Conclusion
Indications of DRFs are dependent on many factors that
influence the choice of surgical treatment. These include co-
morbidities, medication, and functional and mental health.
Especially in elderly patients, with low demands and osteo-
porosis, an operation must be carefully considered.
If surgery is necessary, then the majority of DRF can
be stabilized by a palmar approach. Our center prefers
the Henry approach and the sheath of the FCR tendon
should only be opened if access to the ulnar part of the
radius is necessary. In the surgical standard setting, the
aforementioned traction with Chinese finger traps has
become an established method. Ideally, manual correction
of the dislocation should be performed before the skin
incision. A DRF can be reduced directly or indirectly,
particularly with the aid of k-wires. Persistent instabilities
may require either temporary transfixation of the carpus
or a small hook plate to reinsert bony avulsed ligaments.
Acknowledgements  We thank Rose-Marie Sedlacek for proof reading
this article. Without her help, this English publication would not have
been possible.
Funding  This research received no specific grant from any funding
agency in the public, commercial, or not-for-profit sectors.
with a small hook plate. A second low-profile plate was applied via a
dorsal approach. The dorsal subluxation of the carpus was prevented
by a temporary radio-lunate transfixation using a K-wire (b). The
K-wire was removed 5 weeks after surgery (c). d Radiological result
6 months after the first operation
Compliance with ethical standards 
Conflict of interest The authors, their immediate families, and any
research foundations with which they are affiliated have not received
any financial payments or other benefits from any commercial entity
related to the subject of this article.
Ethical approval  All procedures performed in studies involving human
participants were in accordance with the ethical standards of the insti-
tutional research committee and with the 1964 Helsinki declaration and
its later amendments or comparable ethical standards.
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