!

ASPECTS OF CURRENT MANAGEMENT

A revolution in the management of fractures of the distal radius?

N. D. Downing, A. Karantana
From Queens Medical Centre Campus, Nottingham, England
The recent development of locking-plate technology has led to a potential revolution in the management of fractures of the distal radius. This review examines the evidence for pursuing anatomical restoration of the distal radius and the possible advantages and pitfalls of using volar locking plates to achieve this goal. The available evidence for adopting volar locking plates is presented and a number of important and, as yet unanswered, questions are highlighted.

! N. D. Downing, FRCS (Trauma & Orth), Consultant Hand and Orthopaedic Surgeon ! A. Karantana, MRCS, Specialist Registrar Nottingham University Hospitals NHS Trust, Queens Medical Centre Campus, Nottingham NG7 2UH, UK. Correspondence should be sent to Mr N. D. Downing; e-mail: nicholas.downing@nuh.nhs.uk 2008 British Editorial Society of Bone and Joint Surgery doi:10.1302/0301-620X.90B10. 21293 $2.00 J Bone Joint Surg [Br] 2008;90-B:1271-5.

Fractures of the distal radius are common and account for a considerable proportion of all attendances at fracture clinics. Despite this, their management remains a matter for debate. Although fractures of the distal radius have been the subject of much research, the absence of large, prospective outcome trials of the different methods of treatment is surprising given the number of patients available for study. Recently, the development of locking-plate technology has changed the way in which many fractures are managed. A locking plate has a number of theoretical advantages over the conventional non-locking implant, not least of which is improved fixation in osteoporotic bone.1 No other area of fracture management has been affected as much by the emergence of technology as the treatment of fracture of the distal radius. This has generated renewed interest in the treatment of these fractures and an increase in the production of a variety of specific locking devices. This abundance of implants is driven by the manufacturers who envisage a huge new market, however, there is little evidence-based research to guide our use of these devices.

Is anatomical restoration of the distal radius necessary to achieve good longterm function? This fundamental question has been debated2 but as yet remains unanswered. The assumption that outcome is improved by the restoration of the normal anatomy underpins the growing enthusiasm for volar plating of fractures of the distal radius. For many other intra- and juxta-articular fractures, the principle of stable anatomical

fixation and early mobilisation is wellestablished and universally accepted. Why this philosophy has developed more slowly for the distal radius is unclear, but perhaps the difficulty in restoring the anatomy of this complex joint has dissuaded surgeons from pursuing an anatomical reduction. Since the earliest descriptions of fractures of the distal radius, the assumption has been made that a good result will be achieved whatever the appearance of the reduction.3 This may still be the case in most fractures which occur in elderly, lowdemand and osteoporotic patients,4 but there is a clear distinction between this group and those with higher demands, bearing in mind that these may not necessarily be younger.5 A number of clinical6-8 and biomechanical9-11 studies have demonstrated the advantages of restoring normal anatomy, but the number of studies which have used validated patientderived outcome measures has been few12 and there are no long-term prospective comparative studies of alternative methods of treatment to guide our management. Fldhazy et al13 recently reported the nine- to 13-year followup of fractures of the distal radius which had been treated without surgery. They concluded that a number of patients continued to experience some impairment of hand and wrist function. The patients perception of this impairment was not recorded and whether the outcome could have been improved upon by surgical intervention is not known. The threshold for acceptable extra-articular malunion has not been defined. Malunion with radial shortening has been reported most commonly to be associated with a poor outcome7,14,15 as defined by surgeon-based
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outcome measures such as those of Gartland and Werley.16 The influence of moderate (0 mm to 8 mm) radial shortening has been questioned. Barton, Chambers and Bannister17 found no correlation between moderate shortening and outcome, as assessed by the Patient Related Wrist Evaluation18 at a mean follow-up of 29 months. It is generally accepted that persistent irregularity of the articular surface predisposes to the development of radiologically-identified degenerative changes,6,19,20 but the relevance of such changes is debated. There does not appear to be a clear correlation between radiological degenerative change and a poor clinical outcome, at least in the medium term.20,22 A series of patients studied by Catalano et al20 with a mean follow-up of seven years was re-evaluated at 15 years.22 Although the arthritic change as assessed by radiography and CT had progressed, the only correlation with arthritic change was an insignificant reduction in wrist flexion. Furthermore, a study recently published by Forward, Davis and Sithole,23 in which 106 young adults under 40 years of age were retrospectively reviewed at a mean of 38 years, showed no difference in the Disabilities of the Arm, Shoulder and Hand (DASH)24 scores from population norms and minor (less than 10%) functional impairment as measured by the patient evaluation measure.25 They also found no measure of extra-articular malunion which was related to either the patient evaluation measure or DASH24 score, and were unable to identify any thresholds of malunion beyond which function was clearly worse.23 Despite the growing enthusiasm for the anatomical reduction of fractures of the distal radius, there remains some doubt as to whether patients will be better served, or more satisfied, with this approach in the long term. Anecdotally, despite the large numbers of patients with a fracture of the distal radius, those requiring intervention for long-term unsatisfactory results is small.

to suggest that arthroscopy of the wrist may help in the management of intra-articular fractures.29 The options for open reduction and internal fixation include dorsal or volar fixation (or both) and the use of locking or non-locking implants, but without a clear evidence base to guide the choice of technique. A Cochrane Review30 concluded that the 48 randomised trials of treatment choices available in early 2003 do not provide robust evidence for most of the decisions necessary in the management of these (distal radius) fractures. Furthermore, the authors concluded that: it is also unclear whether surgical intervention of most fracture types will produce consistently better longterm outcomes.30 More recent Cochrane30 reviews which investigate the evidence for external fixation31 and percutaneous pinning32 were also inconclusive. If one accepts the premise that anatomical restoration is desirable, the development of the volar locking plate has added a new implant with which to pursue this goal. They are now widely used, both to stabilise fractures which could be reduced in a closed manner and therefore would be amenable to a combination of K-wires, plaster, and external fixation, as well as those fractures which could not be reduced by closed techniques and would have required treatment using other methods of internal fixation.

Decisions on treatment Undisplaced fractures are usually stable and may be adequately treated in a plaster cast. Most fresh displaced fractures can be reduced satisfactorily using the principles of ligamentotaxis.26 It is more difficult to predict the likelihood of re-displacement, and therefore the need for stable fixation. Lafontaine, Hardy and Delince27 identified five predictors of instability: a patient over 60, an intraarticular fracture, dorsal comminution, dorsal angulation of more than 20 and an associated ulnar fracture. Mackenney, McQueen and Elton28 have recently developed formulae for predicting the radiological outcome and have produced a prospective method for quantifying the risk of instability, although this remains unvalidated and too complex for use in clinical practice. There are several options for the operative treatment of unstable fractures. These include the use of Kirschner (K)wires with a plaster cast, external fixation (bridging or nonbridging, with or without additional K-wires) and open reduction and internal fixation. There is also some evidence

Why volar locking implants? Most fractures of the distal radius are dorsally-angulated and displaced, which makes the dorsal surface the most appropriate for buttress plating as it counteracts the deforming forces. It is also subcutaneous and easy to access surgically. However, the dorsal aspect of the distal radius is not the ideal site for a plate. There is little soft-tissue cover and the bone is covered by the extensor tendons and their sheaths. Since the dorsal radius is convex, the tendons rub against any implant. Comminution of the dorsal cortex adds to the complexity of the operation and dorsal scars are less well-tolerated by the patients.33 Consequently, while studies of dorsal plating showed excellent results in terms of reduction of the fracture.34,35 Irritation of the extensor tendons leading to tenosynovitis and attrition rupture was a widely reported problem, particularly with the more bulky implants or those which required intra-operative cutting to fit.34,36,37 Loss of palmar flexion due to dorsal scarring was also a problem.38 Early removal of the metalwork did not necessarily prevent such complications.39 The design of dorsal plates has since been improved; the profiles of the plates are pre-contoured to reduce the need for cutting or shaping; the screws fit flush to the plate and locking technology has imparted angular stability. The use of modern dorsal plates improved the clinical results and reduced the number of complications.40 Simic et al41 reported no problems with the extensor tendons in a series of 50 cases in which such plates were used. The volar buttress plate has long been established as the standard treatment for fractures with volar angulation. The development of locking plates allows fixation of fractures
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with any direction of displacement through a volar approach, and the implant is placed on the tension side of the fracture. There are several theoretical advantages to approaching and fixing the radius through a volar approach;42 more space is available, the flexor tendons are further from the bone and pronator quadratus is interposed. The volar cortex is typically less comminuted, which makes reduction of the fracture easier. Volar scars are better tolerated as they are less obvious and the blood supply to the radius is less likely to be disturbed. In addition, implants with angular stability make it easier to reduce the fracture by fixing it to the distal fragment first, before fixation to the more proximal fragment.

gresses and the fracture haematoma becomes organised that the fracture becomes increasingly difficult to reduce. Orbay33 popularised the extended flexor carpi radialis approach, in which the brachioradialis is released and the radial shaft pronated away from the distal fracture fragments. This allows debridement of the haematoma from within the fracture, before reduction and fixation.

Use of volar locking plates More than 30 designs of volar locking plate are now available. There are generally two main principles of design: fixed-angle and polyaxial locking. With fixed-angle locking, the screws or pegs are inserted into the plate at a fixed angle, usually by a threaded screw head which engages a thread in a screw hole in the plate. Typically this type of plate must be applied in a specific position on the radius, and the angles of the fixed pegs or screws are designed to provide subchondral support and stabilisation of the specific fragments of the fracture. The concept of the watershed line has guided the design of the fixed-angle plate.42 The distal edge of the concave surface of the volar distal radius is marked by a transverse ridge or watershed line. Distal to this line the bone slopes dorsally and gives rise to the attachment of the volar wrist capsule and volar carpal ligaments. The plate must not project beyond this line to avoid coming into contact with, and injuring, the flexor tendons. Polyaxial locking plates allow variation in the angle of insertion of each screw, which allows the surgeon to respond to any variation in the normal bony anatomy and to target specific bone fragments. Furthermore, the position of the polyaxial plate does not have to be fixed. Some plates have a single row of screws/pegs, while others have two or more intersecting rows. The role and relative merits of using pegs or screws has not been clearly defined. Pegs have a larger core diameter and are likely to resist bending stress better than screws, however, screws may provide better grip on individual bone fragments. Partially-threaded screws can theoretically stabilise coronal fracture fragments. The biomechanics of the different volar locking implants have been studied in fracture and osteotomy models.43,44 Koh et al43 cyclically loaded ten different designs of volar locking plate and concluded that all had sufficient stability to allow early mobilisation. However, there is little available clinical research on which to base a decision regarding the choice of design, and typically this decision is based on the preference and familiarity of the surgeon, the cost of the implant and the extent of marketing by manufacturers. Typically, acute, even displaced, intra-articular fractures can be reduced indirectly. It is as the healing process proVOL. 90-B, No. 10, OCTOBER 2008

Clinical experience and outcomes Several uncontrolled case series all report good to excellent results with a variety of volar locking plates.45-49 Chung et al47 prospectively assessed 87 patients and found that their Michigan Hand Outcomes Questionnaire50 scores approached normal after six months and had improved little more by one year. There are few comparative studies, and these suffer from being retrospective, having short follow-up or a small numbers of cases. Therefore definitive information is not yet available.51-53 From the existing literature it is clear that volar locking plates can be used successfully to stabilise both intraarticular and extra-articular fractures and to allow early mobilisation. However, the use of locking plates is not without complications.46,54,55 Arora et al54 reported an overall rate of complications of 27% in 114 patients and Rampoldi and Marsico55 reported a rate of 8% in 90 patients. Some complications can be attributed to the inevitable learning curve encountered with a new implant, while others are implant-specific.56 The extensor tendons are not immune from injury by volar plates57,58 and irritation and rupture of the extensors form a significant proportion of the reported complications. For example, they comprised 20% of the complications reported by Arora et al.54 This is most likely to be a result of failure to appreciate the trapezoidal shape of the distal radius, so that screws which appear to be within the bone on the lateral view may be penetrating the cortex dorsally and injuring the extensors. The flexor tendons are also at risk from volar plating and formed 29% of the complications in the series reported by Arora et al.54 Most complications involving the flexor tendons can be attributed to incorrect placement of the plate, in failure to appreciate the watershed line and to anatomically abnormal tendons. Despite this, Klug, Press and Gonzalez59 reported a case of rupture of flexor pollicis longus in a patient with normal anatomy and a correctly positioned implant. Because the distal articular surface of the radius cannot be seen from the volar approach without disrupting the volar radiocarpal ligaments, placement of screws and pegs into the subchondral bone outside the joint depends on a clear knowledge of the three-dimensional anatomy of the articular surface of the distal radius and careful intraoperative imaging. The use of fixed-angle locking plates may increase the risk of inadvertent penetration of the joint. If the plate is placed too distally or if the fracture is not reduced anatomically, the predetermined direction of the screws will inevitably result in penetration of the joint.

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Placement of intra-articular screws after volar plating of the distal radius has been reported.54

References
1. Larson AN, Rizzo M. Locking plate technology and its applications in upper extremity fracture care. Hand Clin 2007;23:269-78. 2. Fernandex DL. Should anatomic reduction be pursued in distal radial fractures? J Hand Surg [Br] 2000;25:523-7. 3. Colles A. On the fracture of the carpal extremity of the radius. Edinb Med Surg J 1914;10;181.Clin Orthop 2006;445:5-7. 4. Jaremko JL, Lambert RG, Rowe BH, Johnson JA, Majumdar SR. Do radiographic indices of distal radius fracture reduction predict outcomes in older adults receiving conservative treatment? Clin Radiol 2007;62:65-72. 5. Young BT, Rayan GM. Outcome following nonoperative treatment of displaced distal radius fractures in low-demand patients older than 60 years. J Hand Surg [Am] 2000;25:19-28. 6. Knirk JL, Jupiter JB. Intra-articular fractures of the distal end of the radius in young adults. J Bone Joint Surg [Am] 1986;68-A:647-59. 7. McQueen M, Caspers J. Colles fracture: does the anatomical result affect the final function? J Bone Joint Surg [Br] 1988;70-B:649-51. 8. Trumble TE, Schmitt SR, Vedder NB. Factors affecting functional outcome of displaced intra-articular distal radius fractures. J Hand Surg [Am] 1994;19:325-40. 9. Pogue DJ, Viegas SF, Patterson RM, et al. Effects of distal radius fracture malunion on wrist joint mechanics. J Hand Surg [Am] 1990;15:721-7. 10. Kazuki K, Kusunoki M, Yamada J, Yasuda M, Shimazu A. Cineradiographic study of wrist motion after fracture of the distal radius. J Hand Surg [Am] 1993;18:41-6. 11. Short WH, Palmer AK, Werner FW, Murphy DJ. A biomechanical study of distal radial fractures. J Hand Surg [Am] 1987;12:529-34. 12. Wilcke MK, Abbaszadegan H, Adolphson PY. Patient-perceived outcome after displaced distal radius fractures: a comparison between radiological parameters, objective physical variables, and the DASH score. J Hand Ther 2007;20:290-8. 13. Fldhazy Z, Trnkvist H, Elmstedt E, et al. Long-term outcome of nonsurgically treated distal radius fractures. J Hand Surg [Am] 2007;32:1374-84. 14. Stewart HD, Innes AR, Burke FD. Factors affecting the outcome of Colles fracture: an anatomical and functional study. Injury 1985;16:289-95. 15. Jenkins NH, Mintowt-Czyz WJ. Mal-union and dysfunction in Colles fracture. J Hand Surg [Br] 1988;13:291-3. 16. Gartland JJ Jr, Werley CW. Evaluation of healed Colles fractures. J Bone Joint Surg [Am] 1951;33-A:895-907. 17. Barton T, Chambers C, Bannister G. A comparison between subjective outcome score and moderate radial shortening following a fractured distal radius in patients of mean age 69 years. J Hand Surg Eur Vol 2007;32:165-9. 18. MacDermid JC. Development of scale for patient rating of wrist pain and disability. J Hand Ther 1996;9:178-83. 19. Baratz ME, Des Jardins J, Anderson DD, Imbriglia JE. Displaced intra-articular fractures of the distal radius: the effect of fracture displacement on contact stresses in a cadaver model. J Hand Surg [Am] 1996;21:183-8. 20. Catalano LW 3rd, Cole RJ, Gelberman RH, et al. Displaced intra-articular fractures of the distal aspect of the radius: long-term results in young adults after open reduction and internal fixation. J Bone Joint Surg [Am] 1997;79-A:1290-302. 21. Young CF, Nanu AM, Checketts RG. Seven-year outcome following Colles type distal radial fracture: a comparison of two treatment methods. J Hand Surg [Br] 2003;28:422-6. 22. Goldfarb CA, Rudzki JR, Catalano LW, Hughes M, Norrelli J Jr. Fifteen-year outcome of displaced intra-articular fractures of the distal radius. J Hand Surg [Am] 2006;31:633-9. 23. Forward DP, Davis TR, Sithole JS. Do young patients with malunited fractures of the distal radius inevitably develop symptomatic post-traumatic osteoarthritis? J Bone Joint Surg [Br] 2008;90-B:629-37. 24. Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand). Am J Ind Med 1996;29:602-8. 25. Macey AC, Burke FD, Abbott K, et al. Outcomes of hand surgery. British Society for Surgery of the Hand. J Hand Surg [Br] 1995;20:841-55. 26. Agee JM. Distal radius fractures: multiplanar ligamentotaxis. Hand Clin 1993;9:577-85. 27. Lafontaine M, Hardy D, Delince P. Stability assessment of distal radius fractures. Injury 1989;20:208-10. 28. Mackenney PJ, McQueen MM, Elton R. Prediction of instability in distal radial fractures. J Bone Joint Surg [Am] 2006;88-A:1944-51. 29. Varitimidis SE, Basdekis GK, Dailiana ZH, et al. Treatment of intra-articular fractures of the distal radius: fluoroscopic or arthroscopic reduction? J Bone Joint Surg [Br] 2008;90-B:778-85. 30. Handoll HH, Madhok R. Surgical interventional for treating distal radial fractures in adults. Cochrane Database Syst Rev 2003;3:CD003209.
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Are locking plates a revolution? Since the first reports of volar locking plates,60 the wave of enthusiasm for these devices has continued unabated. Many case series have shown that they are effective devices for fixation of the fracture. There has been much interest in the volar approach to the distal radius and as a result the standard approach to the distal radius through the bed of flexor carpi radialis has been refined.61 Subchondral placement of implants has focused attention on accurate imaging and improved the understanding of the three-dimensional shape of the distal radius.62,63 The locking plate appears to have the advantage of reliable fixation in osteoporotic bone which facilitates early mobilisation. The volar approach allows anatomical reduction of intra-articular and extra-articular fractures and a locking plate enables this reduction to be maintained. Other advantages include ease of reconstruction of the comminuted irreducible intra-articular fracture, and in delayed reconstruction of intra- and extra-articular fractures. However, as with all new implants, natural enthusiasm can lead to the extension of their use into areas which are less obviously justifiable. Early fixation of minimally-displaced or undisplaced fractures, even in elderly patients, may be warranted on the grounds of a potential earlier return to self-care, work and sport. This has to be balanced against the potential hazards of the procedure and the considerable cost of the implants. There is a risk that essential skills in the non-operative management of fractures of the distal radius will be lost. The economic impact of volar locking plates is likely to be significant but has yet to be assessed. What questions remain? There are a number of important unanswered questions which should temper any enthusiasm for fixing fractures of the distal radius with volar locking plates. Do these plates offer any definite advantage over traditional methods in terms of the long-term outcome? Does the early mobilisation allowed by volar locking plates improve outcome? What is the cost of the procedure and does the cost of the surgery and the implant balance any earlier return to normal function? Is there a place for fixing simple, even undisplaced, fractures in elderly patients to allow a more rapid return to full function? On-line clinical trials registries such as ClinicalTrials.gov64 and www.who.int/trialsearch65 reveal several current and planned studies which may answer some of these questions in the future. The fundamental debate about the long-term relevance of intra- and extraarticular malunion is, however, unlikely to be resolved.
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

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31. Handoll HH, Huntley JS, Madhok R. External fixation versus conservative treatment for distal radial fractures in adults. Cochrane Database Syst Rev 2007;3:CD006194. 32. Handoll HH, Vaghela MV, Madhok R. Percutaneous pinning for treating distal radial fractures in adults. Cochrane Database Syst Rev 2007;3:CD006080. 33. Orbay J. Volar plate fixation of distal radius fractures. Hand Clin 2005;21:347-54. 34. Ring D, Jupiter JB, Brennwald J, Bchler U, Hastings H 2nd. Prospective multicenter trial of a plate for dorsal fixation of distal radius fractures. J Hand Surg [Am] 1997;22:777-84. 35. Campbell DA. Open reduction and internal fixation of intra articular and unstable fractures of the distal radius using the AO distal radius plate. J Hand Surg [Br] 2000;25:528-34. 36. Carter PR, Frederick HA, Laseter GF. Open reduction 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. 37. Jakob M, Rikli DA, Regazzoni P. Fractures of the distal radius treated by internal fixation and early function: a prospective study of 73 consecutive patients. J Bone Joint Surg [Br] 2000;82-B:340-4. 38. Bassett RL. Displaced intraarticular fractures of the distal radius. Clin Orthop 1987;214:148-52. 39. Fitoussi F, Ip WY, Chow SP. Treatment of displaced intra-articular fractures of the distal end of the radius with plates. J Bone Joint Surg [Am] 1997;79-A:1303-12. 40. Kamath AF, Zurakowski D, Day CS. Low-profile dorsal plating for dorsally angulated distal radius fractures: an outcomes study. J Hand Surg [Am] 2006;31:1061-7. 41. Simic PM, Robison J, Gardner MJ, et al. Treatment of distal radius fractures with a low-profile dorsal plating system: an outcomes assessment. J Hand Surg [Am] 2006;31:382-6. 42. Orbay JL, Touhami A. Current concepts in volar fixed-angle of unstable distal radius fractures. Clin Orthop 2006;445:58-67. 43. Koh S, Morris RP, Petterson RM, et al. Volar fixation for dorsally angulated extraarticular fractures of the distal radius: a biomechanical study. J Hand Surg [Am] 2006;31:771-9. 44. McCall TA, Conrad B, Badman B, Wright T. Volar versus dorsal fixed-angle fixation of dorsally unstable extra-articular distal radius fractures: a biomechanic study. J Hand Surg [Am] 2007;32:806-12. 45. Orbay JL, Fernandez DL. Volar fixation for dorsally displaced fractures of the distal radius: a preliminary report. J Hand Surg [Am] 2002;27:205-15. 46. Rozenthal TD, Blazar PE. Functional outcome and complications after volar plating for dorsally displaced, unstable fractures of the distal radius. J Hand Surg [Am] 2006;31:359-65. 47. Chung KC, Watt AJ, Kotsis SV, et al. Treatment of unstable distal radial fractures with the volar locking plating system. J Bone Joint Surg [Am] 2006;88-A:2687-94. 48. Orbay JL, Fernandex DL. Volar fixed-angle plate fixation for unstable distal radius fractures in the elderly patient. J Hand Surg [Am] 2004;29:96-102.

49. Musgrave DS, Idler RS. Volar fixation of dorsally displaced distal radius fractures using the 2.4-mm locking compression plates. J Hand Surg [Am] 2005;30:743-9. 50. Chung KC, Pillsbury MS, Walters MR, Hayward RA. Reliability and validity testing of the Michigan Hand Outcomes Questionnaire. J Hand Surg [Am] 1998;23:575-87. 51. Wright TW, Horodyski M, Smith DW. Functional outcome of unstable distal radius fractures: ORIF with a volar fixed-angle time plate versus external fixation. J Hand Surg [Am] 2005;30:289-99. 52. Rein S, Schikore H, Schneiders W, Amlang M, Zwipp H. Results of dorsal or volar plate fixation of AO type C3 distal radius fractures: a retrospective study. J Hand Surg [Am] 2007;32:954-61. 53. Oshige T, Sakai A, Zenke Y, Moritani S, Nakamura T. A comparative study of clinical and radiological outcomes of dorsally angulated, unstable distal radius fractures in elderly patients: intrafocal pinning versus volar locking plating. J Hand Surg [Am] 2007;32:1385-92. 54. Arora R, Lutz M, Hennerbichler A, et al. Complications following internal fixation of unstable distal radius fracture with a palmar locking-plate. J Orthop Trauma 2007;21:316-22. 55. Rampoldi M, Marsico S. Complications of volar plating of distal radius fractures. Acta Orthop Belg 2007;73:714-19. 56. Bhattacharyya T, Wagaonkar AD. Inadvertent retention of angled drill guides after volar locking plate fixation of distal radial fractures: a report of three cases. J Bone Joint Surg [Am] 2008;90-A:401-3. 57. Benson EC, DeCarvalho A, Mikola EA, Veitch JM, Moneim MS. Two potential causes of EPL rupture after distal radius volar plate fixation. Clin Orthop 2006;451:21822. 58. Al-Rashid M, Theivendran K, Craigen MA. Delayed ruptures of the extensor tendon secondary to the use of volar locking compression plates for distal radial fractures. J Bone Joint Surg [Br] 2006;88-B:1610-12. 59. Klug RA, Press CM, Gonzalez MH. Rupture of the flexor pollicis longus tendon after volar fixed-angle plating of a distal radius fracture: a case report. J Hand Surg [Am] 2007;32:984-8. 60. Orbay JL. The treatment of unstable distal radius fractures with volar fixation. Hand Surg 2000;5:103-12. 61. Orbay JL, Badia A, Indriago IR, et al. The extended flexor carpi radialis approach: a new perspective for the distal radius fracture. Tech Hand Up Extrem Surg 2001;5:204-11. 62. Smith DW, Henry MH. The 45 degrees pronated oblique view for volar fixed-angle plating of distal radius fractures. J Hand Surg [Am] 2004;29:703-6. 63. Boyer MI, Korcek KJ, Gelberman RH, et al. Anatomic tilt x-rays of the distal radius: an ex vivo analysis of surgical fixation. J Hand Surg [Am] 2004;29:116-22. 64. No authors listed. ClinicalTrials.gov. http://www.clinicaltrials.gov/ (date last accessed 12 August 2008). 65. No authors listed. International clinical trials registry platform search portal. http:// www.who.int/trialsearch/ (date last accessed 12 August 2008).

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