Distal Radius Fractures

Atlas of the Hand Clinics
Copyright © 2006 Saunders, An Imprint of Elsevier
Volume 11, Issue 2 (September 2006)

Issue Contents: (Pages vii-250)
vii-vii
1 Foreword
Osterman AL
ix-x
2 Preface
Dantuluri PK
137-148
3 Volar Plating of Distal Radius Fractures
Badia A
149-161
Fragment-Specific Fixation of Distal Radius Fractures Using the 2.4 mm
4 Synthes Locking System--A Rationale for Treatment
Rikli D
163-174
5 Fragment-Specific Fixation of Distal Radius Fractures
Medoff RJ
175-185
6 Closed Reduction and Percutaneous Pinning for Distal Radius Fractures
Glickel SZ
187-196
7 Distal Radius Fractures: External Fixation and Supplemental K-Wires
Raskin KB
197-205
Nonbridging External Fixation of the Distal Radius
8 McQueen MM
207-219
9 Intramedullary Fixation of Fractures of the Distal Radius
Dantuluri PK
221-230
Considerations in Dorsal Plating of Distal Radius Fractures
10 Dudley TE
231-241
Arthroscopy in the Treatment of Distal Radial Fractures with Assessment and
11 Treatment of Associated Injuries
Osterman A
243-250
Bone Grafts and Bone Graft Substitutes in Distal Radius Fractures
12 Yao J
Atlas Hand Clin 11 (2006) vii
Foreword
A. Lee Osterman, MD
Consulting Editor
The last few years have seen a radical shift in the treatment of distal radius fractures, from
traditional casting and external fixation to open reduction. Dr. Dantuluri has edited an issue
that reflects that sea change.
He has challenged each of his authors to provide state-of-the-art approaches to this complex
fracture, which involves two joints, the radiocarpal and distal radioulnar, and multiple ligament
injuries. The issue covers the concepts of the columnar approach and of fragment-specific
fixation, and his authors provide the technical pearls to such procedures. The fixation devices
have multiplied: volar plates, dorsal plates, fragment-specific plates, wireforms, external
fixators, and intramedullary nails. Each device has an author to champion its use. The excellent
article on bone graft substitutes organizes this complex subject and guides their practical use. In
summary, this issue has accomplished its goal. It gives the reader the understanding, the
techniques, and the versatility to treat the distal radius fracture despite its complexity. Kudos to
Dr. Dantuluri and his dedicated authors.
This is the final issue of The Atlas of the Hand Clinics, because it is essentially flowing back
into its roots, The Hand Clinics. As the lead editor, I would like to thank all of the authors
whose efforts have made this series so successful. We all owe a debt of gratitude to Deb Della-
pena, who as in-house editor has managed to cajole and guide each issue to publication. Like
this issue on the distal radius fracture, each Atlas has become a classic treatise on its topic.
A. Lee Osterman, MD
The Philadelphia Hand Center
834 Chestnut Street
Philadelphia, PA 19107, USA
E-mail address: Loster51@bellatlantic.net
1082-3131/06/$ - see front matter Ó 2006 Elsevier Inc. All rights reserved.
doi:10.1016/j.ahc.2006.10.002 handatlas.theclinics.com
Atlas Hand Clin 11 (2006) ix–x
Preface
Phani K. Dantuluri, MD
Guest Editor
Distal radius fractures are among the most common injuries that occur in the upper extremity
and continue to challenge treating physicians in the new millennium. There has been an
evolution of treatment as continued advances are made, resulting in a greater understanding of
these often complex injuries. Improved biomaterials and implant design have led to differing
forms of treatment for these injuries, resulting in the need for a systematic approach in the
analysis of these often troublesome fractures. It is our hope that this issue of the Atlas of the
Hand Clinics on distal radius fractures will provide a new perspective on these injuries and a bet-
ter appreciation of these fascinating fractures.
Many pioneering surgeons have made monumental contributions to our improved un-
derstanding of distal radius fractures. However, rarely are many of those perspectives found in
one volume. This issue of the Atlas of the Hand Clinics includes articles by many of these vision-
aries in orthopedics, who have pushed through the barriers of convention and provided us
wonderful insights into an often underappreciated injury.
This issue explores the surgical options available for the treatment of distal radius fractures
and begins with the treatment option most commonly chosen todaydvolar plating. Next are
two articles, covering the concept of fragment-specific fixation using differing types of surgical
implants, by two of the pioneers of column-specific fixation. Closed reduction and percutaneous
pinning is then reexamined, followed by two different methods of external fixation for distal
radius fractures. A newer concept of fixation, intramedullary fixation of the distal radius, is then
discussed, followed by a discussion of dorsal plating of fractures of the distal radius. A
contemporary article on the role of arthroscopy in the surgical management of these fractures
follows, and the issue ends with a pertinent article on bone grafts and bone graft substitutes.
As our understanding of distal radius fractures continues to evolve, our surgical treatment
continues to evolve as well. It is our hope that this issue will provide the reader with a current
perspective on the treatment of these injuries and perhaps an insight into future directions. I
would like to personally thank Dr. Lee Osterman for the wonderful opportunity to organize this
issue. I would like to recognize individually each of the experts who have contributed their
precious time, energy, and knowledge toward making this issue a success. It has been an
incredible honor to have worked with these caring, intelligent, and prescient physicians and
surgeons, many of whom have been mentors to me.
Finally, I would like to thank all the editorial staff at Elsevier, including Deb Dellapena and
Catherine Bewick, for their support, guidance, and patience in bringing this issue to press. Their
ceaseless energy, focus, and direction have made the publication of this issue a pleasure and an
x PREFACE
honor. I would also like to thank my family and my wonderful wife for their support and
understanding during this endeavor.
The Philadelphia Hand Center, PC
834 Chestnut Street, G114
Philadelphia, PA 19106, USA
E-mail address: pallagummi@yahoo.com
Atlas Hand Clin 11 (2006) 137–148
Volar Plating of Distal Radius Fractures

Alejandro Badia, MD*, Amel Touhami, MD
Miami Hand Center, 8905 Southwest 87 Avenue, Suite 100, Miami, FL 33176, USA
Ever since the AO/ASIF group established the principles of safe and stable internal fixation
for distal radius fractures, this method has evolved continuously, albeit slowly. Despite ad-
vances in internal fixation, external fixators continued to play a major role in treatment until
studies demonstrated their adverse effects [1–3]. Early experience with conventional buttress
dorsal plating of dorsally displaced distal radius fractures resulted in failure of fixation, partic-
ularly in the presence of comminution or poor bone quality. Soft tissue complications such as
extensor tendon adherence, inflammation, or occasional rupture often were observed. Gesens-
way and colleagues [4] were the first to advocate subchondral bone support by designing
a fixed-angle dorsal plate for dorsally displaced fractures. Subsequently, AO introduced low-
profile dorsal locking plates to prevent loss of reduction, but high rates of implant related prob-
lems still were reported [5–7]. These complications rarely were observed with volarly placed
plates, which initially were designed only for volar fracture patterns. Taking advantage of the
volar distal radius anatomical features, volar fixed-angle fixation of dorsally displaced distal ra-
dius fractures was initiated [8–10]. The extended flexor carpi radialis (FCR) approach provided
the advantages of better visualization of the fracture site, enhanced soft tissue coverage, and ad-
equate blood supply preservation with a low complication rate, while the subchondral support
of the articular surface proved to prevent fracture redisplacement of comminuted or osteopo-
rotic distal radius fractures, allowing early rehabilitation. This combination permitted the con-
current restoration of wrist anatomy and function. Moreover, applications were broadened to
include complex fractures patterns. This article outlines the advantages and reviews the litera-
ture relevant to volar plating for treating distal radius fractures.
Biomechanics
As rigid internal fixators, fixed-angle plates no longer rely on frictional force between the
plate and bone to achieve fixation, but transfer load stress from the fixed distal fragment to the
intact radial shaft, thus enhancing peg–plate–bone construct stability [11]. Several biomechan-
ical studies demonstrated that volar fixed-angle plate systems are stronger than dorsal implants
[12–15]. Furthermore, laboratory studies have shown that optimal restoration of normal volar
tilt of the distal radius is crucial to prevent increased contact forces in the radiocarpal and radio-
ulnar joints [16,17]. Therefore, the ideal volar implant required a different design based on the
particular shape of the volar articular surface and the intended dorsal fixation aim. This implant
would provide concomitant angular and axial stability, thereby minimizing the risk of primary
loss of reduction. The distal part of the implant described herein, the distal volar plate (DVR
TM, Hand Innovations-Depuy Orthopedics. Miami, Florida), has two parallel rows with the
orientation planes of their respective pegs specifically matching the complex three-dimensional
shape of the articular surface. The primary or proximal row pegs are directed obliquely from
proximal to distal to support the dorsal aspect of the articular surface. They are angled
* Corresponding author.
E-mail address: alex@surgical.net (A. Badia).
138 BADIA & TOUHAMI
accurately to improve support for the radial styloid and the dorsoulnar fragments also. These
pegs are most effective in supporting the dorsal aspect of the subchondral plate to neutralize
the redisplacement of dorsally displaced fractures. Concurrently, their action induces a volar
force that tends to displace the distal fragments in a volar direction, an effect that must be op-
posed by a properly configured volar buttressing surface. To enhance fracture fixation in cases
of severe comminution, volar instability, or osteoporosis, an additional row of pegs originating
from a more distal position on the plate and having an opposite inclination to the proximal row
was conceived. This distal row is directed in a relatively proximal direction and crosses the prox-
imal row at its midline. It is intended to support the more central and volar aspect of the sub-
chondral bone. It prevents the dorsal rotation of a volar marginal fragment [18] and volar
rotation of severely osteoporotic or unstable distal fragments with central articular comminu-
tion, thus neutralizing volar displacing forces. Based on the authors’ experience, volar plating,
by virtue of precise peg distribution, allows a single fixed-angle plate to provide the same dorsal
stability as with multiple dorsal implants.
Technique
Implant description
The technique uses a fixed-angle plate (DVR; Hand Innovations-Depuy Orthopedics) [19].
Distal fixation is provided by fixed-angle locking pegs that fan out underneath the subchondral
bone, while 3.5 mm unicortical locking screws are used for proximal fixation to compress the
body of the implant against the endosteal surface, producing a very stable interface. Plates of
different widths and lengths have been developed, including plates specifically for patients
with proximal fracture extensions from high-speed trauma.
Surgical technique
This procedure usually is performed in the outpatient setting, using fluoroscopy and under
regional anesthesia with intravenous sedation. The patient is placed in the supine position with
the arm extended on the hand table. A simple fracture less than 7 days old can be managed
through a standard flexor carpi radialis (FRC) approach. On the other hand, complex fractures
such as significant intra-articular fractures, nascent malunions, and 2- to 3-week-old fractures
will require an extensive exposure, namely the extended FCR approach. This exposure allows an
intrafocal reduction by using the fracture plane and rotating the proximal fragment into
pronation [10]. First, the FCR sheath is released. Then a thorough exposure of the volar surface
of the radius, including the volar rim of the lunate fossa, is performed. Next, the radial septum
(distal FCR tendon sheath, intermuscular septum, first extensor compartment, and brachiora-
dialis) is released to allow proper reduction. Specifically, the sheath of the first dorsal compart-
ment is opened on its proximal aspect to retract the abductor pollicis longus (APL), and the
insertion of the brachioradialis into the radial styloid is identified. This eliminates the major de-
forming force on the radial column. The tendon’s subsequent repair is facilitated by a step-cut
tenotomy. An anchoring point for subsequent suturing of the pronator quadratus muscle over
the plate thus is created. Alternatively, the brachioradialis can be released subperiosteally. At
this point, the proximal radius is elevated and then pronated out of the field to access the dorsal
and articular aspect of the fracture. This allows debridement of the fracture hematoma or callus
and therefore reduction of complex articular injuries. The watershed line then is located prop-
erly. The volar exposure is obtained best by elevating all soft tissue proximal to the watershed
line including the dissection of the transient fibrous zone (TFZ) flap and pronator quadratus
(PQ) muscle. Dorsally displaced fractures frequently present with a rupture of the PQ muscle
located through its most distal fibers proximal to the TFZ. The plate is positioned suitably
2 mm proximal to the watershed line. The first shaft screw is placed through the oblong hole
of the plate before the fixed angle K-wire is applied to the most ulnar hole of the proximal
peg row of the plate anticipating the final position of its pegs. The K-wire subchondral position
is checked under fluoroscopy before drilling the holes of the proximal peg row. Subsequently the
VOLAR PLATING 139
holes of the distal peg row also are drilled, and pegs are applied. After completion of osteosyn-
thesis and fluoroscopic confirmation, the TFZ flap is repositioned, covering the distal edge of
the plate. Next, the brachioradialis is repaired, and the muscular part of the PQ is anchored
to it. Wound closure is performed subsequently.
The same technique is used in cases of osteoporotic bone, while malunions or nonunions
require a modified technique that incorporates a dorsal opening wedge osteotomy, but by means
of the volar approach [20]. In these cases, it is imperative to use the extended FCR approach to
expose the dorsal aspect of the distal radius allowing release of the dorsal periosteum and soft tis-
sues, obtaining the necessary correction, and applying a cancellous autograft. Alternatively, the
strength of fixation allows one to use synthetic bone graft substitute as per surgeon preference.
The fixed-angle plate is secured first to the proximal fragment, and the distal fragment is reduced
to it with traction and direct manipulation of the distal fragment. This maneuver facilitates ob-
taining the correct volar tilt. A different strategy is to attach the plate to the distal fragment first
and then lever the distal fragment into correction by relying on the variable angle peg fixation.
Rehabilitation
Active finger motion and forearm rotation are encouraged immediately after surgery, and
a short-arm postoperative splint dressing is used for an average of 7 days. After the first
postoperative visit, a custom-made removable short-arm splint is used for an average of 3
additional weeks. Severe osteoporotic or comminuted fractures can be casted for a total of 4
weeks to allow early bone consolidation. Rehabilitation is adjusted to the patient’s clinical
course. Patients are instructed to remove this splint three times a day for active ROM exercises.
Functional use of the hand for light daily activities is encouraged, and a weight limit of 5 lbs is
recommended for the injured hand until union is obtained. Patients are expected to recover full
digital motion at the first postoperative visit (1 week) and full forearm rotation at the second
visit by the end of the first month. At 6 to 8 weeks, patients should have regained most of their
wrist motion, and frequently are discharged at that time. A modified early rehabilitation
program is used for patients with highly comminuted intra-articular injuries, fractures with
associated injury to the distal radioulnar joint, or intrinsic or extrinsic ligament injuries that
require repair.
Case studies
Case one
Fig. 1 illustrates a classic example of a high-energy fracture caused by significant trauma com-
monly seen in younger patients. This 20-year-old woman was involved as the driver in a motor ve-
hicle accident presumably sustaining a hyperextension injury to the wrist, leading to a markedly
displaced intra-articular fracture. There are several fracture planes extending into the joint, but
the bone is of good quality and allows, with rigid internal fixation, the capability to begin early mo-
tion. These high-energy injuries can be assessed with arthroscopy once internal fixation of major
fragments is performed. This is because the literature has demonstrated the high association of
concomitant soft tissue lesions with intra-articular fractures, particularly with this mechanism.
In this case, the patient had a triangular fibrocartilage complex (TFCC) peripheral tear (Palmer
1B) that was treated simply with debridement, as it was not displaced away from its insertion
site. An arthroscopic synovectomy and debridement also help minimize postoperative wrist swell-
ing and may accelerate recovery. Hence, motion was begun at 4 weeks to allow TFCC healing, de-
spite the rigid fixation of the fracture that would allow earlier motion if necessary.
Range of motion photographs (Fig. 2) at 3 months reveal essentially normal function.
Case two
Although these high-energy, intra-articular fractures do well with this technique, it is perhaps
the most common fracture pattern that most benefits. The extra-articular dorsally comminuted
140 BADIA & TOUHAMI
Fig. 1. Four-part articular fracture fixed by a volar fixed-angle plate. (A, B) Preoperative anterior posterior (AP) and
lateral radiographs show a displaced four-part articular fracture. (C, D) Postoperative AP and lateral radiographs
show fracture fragments fixed by a volar fixed-angle plate.
fracture seen in the elderly requires rigid internal fixation with subchondral support that only
locked-plate fixation can provide. Fig. 3 illustrates the classic silver fork deformity seen on ex-
amination with its accompanying classic radiographic appearance. This fracture through oste-
oporotic bone also has an articular extension into the lunate fossa. This ubiquitous fracture
pattern benefits from avoiding the dorsal fragments, since reduction is nearly impossible using
this soft, amorphous bone, and one wants to avoid compromising the blood supply of this meta-
physeal region, which, ironically, will be the first region to consolidate (Fig. 4). This clinical sce-
nario is the most applicable for volar plating and arguably the easiest to perform.
Case three
Osteotomies comprise another application for volar plating and can encompass a spectrum of
clinical scenarios. Fig. 5 illustrates an example of a nascent malunion in a case where volar plat-
ing was performed inadequately. The patient’s fracture was treated with a volar nonlocking
plate and inadequate reduction. This reduction attempt went on to further displacement, be-
cause too few screws were used distally, as in a buttress application, and they were not locked,
allowing screw loosening and displacement of the large radial styloid component. An extended
FCR approach allows one to remove the early dorsal callus and thickened periosteum, which
permits the reduction by restoring length and the volar tilt (Fig. 6). This particular deformity
VOLAR PLATING 141
Fig. 2. For the same patient shown in Fig. 1, postoperative wrist motions at 3 months.
was difficult because of the extent of articular displacement going on articular malunion. The
extended FCR approach allows intrafocal reduction of this articular step-off in an indirect fash-
ion (Fig. 7). Callus debridement can be performed using arthroscopy (Fig. 8). Once the reduc-
tion is obtained, the radius shaft is pronated back into the wound, and the plate applied. Only
the largest osseous defects require bone grafting, because the locked plate fixation is stable
enough to maintain reduction. At 5 months, wrist range of motion was recovered fully (Fig. 9).
Fig. 3. (A) A classic silver fork deformity in an elderly patient. (B) Preoperative AP radiograph shows an AO type C
distal radius fracture with an articular extension into the lunate fossa. (C) Preoperative lateral radiograph better shows
the dorsal displacement of the fracture.
142 BADIA & TOUHAMI
Fig. 4. For the same patient shown in Fig. 3, (A) peroperative view of the DVR plate in place. (B, C) Wrist motions at 4
months postoperatively. (D, E ) Postoperative lateral and AP radiographs show the fracture fragments well reduced,
aligned with the peg’s position at the subchondral bone level.
Case four
Late malunions are also amenable to osteotomy by means of the volar approach. These cases
often have a large cortical deficit and may require bone grafting. The stable nature of a locked
volar plate, however, allows synthetic bone grafting only in many of these cases. This may prove
particularly desirable in certain patients who might poorly tolerate the pain and potential
disability of an iliac crest graft. Only the larger cortical defects will require a tricortical iliac crest
graft, as seen here. Fig. 10 demonstrates the case of an articular deformity caused by premature
physeal closure presumably due to growth plate trauma in an adolescent. The osteotomy re-
quired elongation of the metaphysis predominantly in the volar/ulnar aspect.
These diverse clinical cases demonstrate how there are very few indications for dorsal plating.
Volar fixation solves the clinical dilemma and with virtually no complications. The indirect
reduction and frequent complications of external fixation also relegate this technique to only
select indications, namely severe associated soft tissue deficits.
Discussion
A paradigm shift in the management of complex dorsally displaced distal radius fractures or
their malunions occurred when a new modified surgical approach, the extended FCR volar
VOLAR PLATING 143
Fig. 5. Example of a nascent malunion in a case where volar plating was performed inadequately. The patient’s fracture
was treated with a volar nonlocking plate and inadequate reduction. (A) Preoperative AP radiograph shows screw loos-
ening and displacement of the large radial styloid component. (B) Preoperative lateral radiograph further shows the dis-
placement. (C) Postoperative AP radiograph shows all the major articular fragments fixed by a volar fixed-angle plate
including the radial styloid.
approach, was implemented, and newly designed volar fixed-angle plates were introduced to
surgeons. The frequent reports on the high incidence of dorsal plate-related complications,
coupled with the absence of those problems in volar fixation, spurred this revolution.
From an anatomical stand point, the lack of flexor tendon bone intimacy on the volar aspect
of the distal radius, which is concave in the sagittal plane (the pronator fossa) and limited
distally by a ridge called the watershed line, proved to be attractive features for the proper
placement of the implant. Consequently, the burdensome dissection of extensor tendon sheaths
became unnecessary, and the devascularization of dorsal fragments was avoided. This
anatomical advantage would have been fruitless, however, if concepts such as fixed angle
plating, columnar fixation [21], fragment-specific fixation [22,23], and subchondral bone support
had not been incorporated as important elements in the design of the new volar implants. This
new surgical strategy permitted standard volar management of dorsally unstable fractures. Sev-
eral investigators then began reporting on its effectiveness. They demonstrated that the combi-
nation of the new approach with a stronger volar plate and enhanced peg distribution resulted in
early return of wrist function, optimized final motion, demonstrated lack of extensor or flexor
tendon injuries, and virtual elimination later plate removal [24–30]. Moreover, multiple case se-
ries demonstrated that function could be restored reliably from a volar approach using simple
volar locking plates, even with complex intra-articular or osteoporotic fractures [31–33]. None-
theless, this method would not be used in those patients with skeletally immature bone and open
epiphysis, and in patients with simple fracture patterns or severe medical illness.
Fig. 6. For the same patient shown in Fig. 5, (A) intraoperative view of the loose volar nonlocking plate. (B) Rotating
the proximal fragment into pronation provides the access needed for fracture debridement and articular reduction.
144 BADIA & TOUHAMI
Fig. 7. For the same patient shown in Fig. 5, (A, B) fluoroscopic views show the pronated proximal fragment and the
intrafocal reduction of the articular step-off. (C, D) AP and lateral fluoroscopic views show the articular realignment
following the use of a volar fixed-angle plate.
Fig. 8. For the same patient shown in Fig. 5, (A, B) arthroscopic views show articular step-off and debridement. (C)
Arthroscopic-assisted reduction demonstrated diminishing step-off. (D) Final reduction demonstrated arthroscopically
with less than 1 mm articular incongruity.
VOLAR PLATING 145
Fig. 9. For the same patient shown in Fig. 5, postoperative wrist motions at 5 months.
Subsequent experience led to approach and implant refinements to manage more complex
dorsally unstable fractures in a reproducible fashion such as intra-articular comminuted distal
radius fractures [34]. In this case, the improvement of wrist joint stability can be achieved by
proper volar buttressing of the volar marginal fragment and an adequate subchondral support
to the central aspect of the articular surface by means of a secondary more distal peg row, re-
spectively. In addition, provisional fixation with fixed-angle K-wires allows the surgeon to assess
the inclination of the distal locking screws and to move the plate distally to optimize subchon-
dral bone support or proximally to avoid intra-articular screw placement while anticipating the
final and optimal position of its proximal peg row. Plates were designed to project their pegs
underneath the entire span of the dorsal subchondral plate, requiring the placement of each in-
dividual peg on a unique nonparallel axis. Threaded pegs also were introduced to aid fixation of
dorsal fragments in the event of comminution through a coronal fracture plane. The subchon-
dral bone support pegs are designed to transfer axial loads across the fracture while achieving
fixation in weak metaphyseal bone. This is meant to allow early motion despite comminution,
and, because of the fixed angle construct, this eliminates the need for bone grafting of com-
pacted metaphyseal bone. Careful placement immediately below the subchondral bone must
be emphasized, however, to avoid any possibility of settling of the articular fragments, especially
in patients with osteoporosis. Indeed, distal radius fractures in the elderly or infirmed popula-
tions are common and continue to occur more frequently as the population ages and remains
more active [35].Volar fixed-angle fixation has proven to be an adequate treatment method
for this patient population that requires a quick rehabilitation [31]. The volar approach is tol-
erated well under regional anesthesia, and the technique can be performed quickly, as it relies on
the only substantial bone remaining in advanced osteoporosis: the subchondral plate.
Complications encountered with volar fixed-angle fixation are rare, and, when seen, they
generally attributable to the learning curve. An inappropriate surgical exposure would lead to
an inadequate anatomic reduction (ie, failure to use the extended FCR approach to debride the
callus or release the brachioradialis). A fracture older than 2 weeks or a severe articular
comminution will worsen this scenario, because reduction by indirect means becomes
unfeasible. Flexor tendon impingement can occur in case of a secondary dorsal displacement
where the plate can encroach on the flexor tendons easily. Extensor tendon injury still can occur
if pegs of unwarranted length project through the dorsal cortex. Loss of fixation is uncommon
146 BADIA & TOUHAMI
Fig. 10. Case of an articular deformity in an adolescent caused by (A) premature physeal closure, presumably because of
growth plate trauma. (B) Intraoperative view shows the DVR plate and a tricortical iliac crest graft in place. (C, D) Post-
operative AP and lateral radiographs show all the major articular fragments fixed by a volar fixed-angle plate including
the radial styloid.
but can occur, especially in complex fractures, if unsuitably sized plates are used, thus failing to
support all the fragments, or if pegs are placed too proximal to the subchondral bone. This must
be reoperated early to prevent flexor tendon injury. Delayed healing often is seen after
osteotomy, particularly when using bone allograft or a synthetic bone substitute. This can be
prevented by the judicious use of bone autograft and by preserving bone perfusion. Stiffness and
reflex sympathetic dystrophy (RSD) are rare with this technique but must be detected and
managed aggressively in their early stages. An early rehabilitation program is a crucial
preventive method in these cases. Implant breakage is unusual, but, as for any implant, it can
occur if fracture healing is hindered and fatigue failure takes place. 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 most encouraging. Its main advantage is its reproducibility,
regardless of the fracture pattern, which makes it a prevailing technique that has evolved rapidly
to become the standard of care.
Summary
The extended FCR approach to the distal radius for dorsally displaced fractures affords
excellent exposure of the joint surface, thus expanding the indications to most fracture patterns
regardless of the bone quality to restore wrist anatomy. Stable fixed-angle subchondral support
VOLAR PLATING 147
offers excellent fracture stability, prevents settling, negates the need for bone grafting, and
allows early active wrist motion. Use of this technique is particularly advantageous for elderly
osteopenic patients and for high-energy comminuted fractures or malunions requiring
osteotomy. Further randomized prospective studies are needed to validate this newer technique.
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angle plate in a model of dorsally unstable distal radius fractures. J Orthop Trauma 2005;19(3):187–91.
[15] Trease C, McIff T, Toby EB. Locking versus nonlocking T plates for dorsal and volar fixation of dorsally commi-
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[21] Rikli DA, Regazzoni P. Fractures of the distal end of the radius treated by internal fixation and early function.
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[28] Sakhaii M, Groenewold U, Klonz A, et al. Results after palmar plate-osteosynthesis with angularly stable T plate in
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148 BADIA & TOUHAMI
[30] Arora R, Lutz M, Fritz D, et al. Palmar locking plate for treatment of unstable dorsal dislocated distal radius frac-
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[33] Krimmer H, Pessenlehner C, Hasselbacher K, et al. Palmar fixed-angle plating systems for unstable distal radius
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[35] US Census Bureau. Statistical abstracts of the United States. Washington (DC): US Census Bureau; 1999.
Atlas Hand Clin 11 (2006) 149–161
Fragment-Specific Fixation of Distal Radius

Fractures Using the 2.4 mm Synthes
Locking SystemdA
Rationale for Treatment
Daniel Rikli, MDa, Jesse B. Jupiter, MDb,c,*
a
Chirurgie A, Kantonspital Luzern, Spitalstrasse 600, Luzern, Switzerland
b
Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
c
Hand and Upper Extremity Service, Department of Orthopaedic Surgery,
Massachusetts General Hospital, 2100 Yawkey Building, 55 Parkman Street, Boston, MA 02114, USA
The past decade has witnessed a dramatic change in the management of fractures of the distal
radius. Despite a lack of many evidence-based studies supporting the efficacy of internal
fixation, this has become the preferred method of treatment for all but the most minimally
displaced fractures [1–11].
What, then, has contributed to this striking change in the management of these common but
often vexing fractures? Along with technological advances in implant design and metallurgy, has
come a much clearer understanding of the biomechanical aspects of the distal radius fracture.
One of the most important concepts has been the three-column theory developed independently
by Rikli and Regazzoni in Basel, Switzerland and Medoff in Hawaii (oral communication, 2005)
[1] (Fig. 1). Anatomically and biomechanically, the distal radius and ulna can be divided into:
• The radial column, composed of the radial styloid and scaphoid facet of the distal radius
• The intermediate column, which includes the lunate facet and sigmoid notch
• The ulnar column, comprised of the distal ulna and triangular fibrocartilage complex
The relevance of this three-column concept becomes more apparent when one analyzes the
normal axial forces transmitted through the carpus onto these three structural columns. Using
various techniques, numerous investigators have suggested that the greater axial load will be
located across the radial column [12]. In contrast, Rikli, using a dynamic intra-articular pressure
measurement technique in vivo in normal volunteers, identified more forces transmitted through
the intermediate and ulnar column than previously thought (Rikki D, MD, unpublished data,
2001) (Fig. 2). Furthermore, few if any forces were seen being transmitted through the radial
styloid. With this understanding, the biomechanics of the distal radius and ulna can be viewed
as the following:
• The radial column’s function is that of stability providing a bony buttress for the carpus ra-
dially and serving as the origin of the important intracapsular stabilizing ligaments.
• The intermediate column is of importance in load transmission, which explains why articular
compression injuries so often involve the lunate facet.
• The ulnar column serves for load transmission and for stabilizing the carpus representing the
ulnar pivot point (Fig. 3).
E-mail address: jjupiter1@partners.org (J.B. Jupiter).
1082-3131/06/$ - see front matter 2006 Elsevier Inc. All rights reserved.
150 RIKLI & JUPITER
Fig. 1. The three-column concept of the structural anatomy of the distal radius and ulna.
Fig. 2. Rikli and colleagues used a dynamic intra-articular pressure measurement technique in normal volunteers to
study normal forces in vivo. (A) The location of the pressure measurement sensor extending from radial column onto
the TFCC. (B) Multiple pressure points could be registered in all positions of the hand and wrist.
The stability provided by the ulnar column can be appreciated more clearly when evaluating
distal radius fractures associated with unstable ulnar neck fractures or with Galeazzi-type
injuries with large ulnar styloid fractures. Load transmission on the ulnar column recognized
even with minor length changes after distal radius fracture may be tolerated poorly.
A second important development has been a greater appreciation of the pathomechanics of
the various patterns of distal radius fracture and the association with intercarpal ligament and
distal radioulnar joint lesions. In a cadaver model, Pechlaner and colleagues were able to
reproduce numerous fracture patterns by loading the wrists in hyperextension [13]. In 28 of 40
specimens, additional lesions were seen, including scapholunate ligament disruptions in 10, lu-
natotriquetral ligament disruptions in six, and ulnar styloid fractures in 13. Others also have
identified intercarpal ligament disruptions using arthroscopic control intraoperatively.
The third major impact influencing the widespread interest in internal fixation has been the
development of anatomically shaped implants, which provide angular stability especially
effective in osteoporotic bone [14]. Conventional screw plate fixation depends upon the screws
generating a compressive force between the plate and bone. The ability to create such a force is
dependent upon the quality of the underlying bone. By having the screws lock into the plate,
there is less dependence upon the quality of the underlying bone.
Fig. 3. Proposed theory of load transmission across wrist based upon three-column concept.
FIXATION OF DISTAL FRACTURES 151
Fig. 4. The basic 2.4 mm Synthes fragment-specific locking plate system.
Fig. 5. The volar plate for dorsally displaced extra-articular or simple articular fractures. The distal rim locked screws
extend distally and angulate radially and ulnarward.
The development of the 2.4 mm plate system of Synthes (Synthes Ltd, Paoli, Pennsylvania)
was designed to specifically address the biomechanical aspects of fractures of the distal radius.
The implants have a low plate and screw profile, polished surface, and tapered design with
rounded edges, all designed to minimize tendon and soft tissue irritation. The plates have an
elongated hole to facilitate plate positioning and combination holes to allow locked angular sta-
ble screws or regular screws. They are available in numerous anatomically shaped designs and
lengths (Fig. 4).
There are two volar plate designs. One is specific for extra-articular and uncomplicated intra-
articular fractures (Fig. 5), while the other extends onto the volar distal rim of the radius, which
is applicable for more complex articular fractures (Fig. 6).
A straight plate contoured to fit the radial column has a notched tip, which is useful to
facilitate placement of the plate after a temporary Kirschner wire (K-wire) is placed into the
Fig. 6. The volar plate designed for distal complex articular fractures has the distal 2.4 mm screws directed proximally
akin to a rake.
152 RIKLI & JUPITER
Fig. 7. The radial column plate is contoured with undercuts to facilitate bending without deforming locked screw holes.
A notch at the distal tip helps place the plate against a temporary Kirschner wire placed into the radial styloid.
Fig. 8. Various plates are available for either dorsal or even volar fragment fixation.
radial styloid (Fig. 7). This implant can be applied from a volar or dorsal approach. The dorsal
plate system includes a right and left L-, oblique L-, and T-shaped implants (Fig. 8). These, too,
are applicable for dorsal and volar fragment fixation.
Treatmentdoverview
Numerous factors are involved in the decision making regarding treatment of fractures of the
distal radius. Among these include the energy of injury, the vector of the applied force, the
quality of the involved bone, and associated injuries. The pathomechanics of general fracture
patterns established by Fernandez are useful in general considerations of treatment (Fig. 9) [15].
Fig. 9. The general categories of fracture patterns based upon mechanism of injury was developed by Fernandez.
Fig. 10. General considerations of treatment can be based upon the injury patterns developed by Fernandez.
The group of bending fractures may respond to ligamentotaxis; shearing fractures will require
buttress support. Impaction fractures necessitate direct realignment; avulsion fractures may re-
quire associated ligament repair, and the complex fracture patterns require skeletal and soft tis-
sue treatment (Fig. 10). As an example, the displaced radial styloid fractures (AO B1) can be the
result of an avulsion force as part of a ligamentous injury, or a compressive force onto the radial
column (Fig. 11).
The fragment-specific approach is based upon the anatomic and biomechanical factors that
comprise the three-column concept. The basic premise is that the fixation of the fracture should
result in the stability of all three columns (Box 1).
Dorsal fragment fixation
The indications for specific dorsal fragment plate fixation include a displaced dorsal lunate
facet fracture, either isolated or as part of a more complex injury; associated carpal fracture or
intercarpal ligament tear, and early (nascent) dorsally angulated malunions. Specifically,
indications for dorsal double plating include:
Fig. 11. Displaced fractures of the radial styloid can be differentiated by the mechanism of injury either an avulsion
radiocarpal or a compressive intra-articular category.
154 RIKLI & JUPITER
Box 1. Basic concept of fragment fixation of distal radius fractures based upon
the three-column concept
Address palmar–ulnar and dorso–ulnar fragments individually
Hyperextended palmar fragment/loss of palmar buttress: address from palmar
Displaced dorso–ulnar fragment that does not respond to ligamentotaxis: address
from dorsal
All three columns must be stable/stabilized.
Radial column: buttress from palmar or dorsal approach
Intermediate column: key to radiocarpal joint
Formal revision: dorsal arthrotomy
• Displaced dorso-ulnar fragment

• Reconstruction of radio-carpal joint
• Associated scaphoid Fx/carpal ligament tear
• Early corrective-OT (Colles)
The surgical approach is through a longitudinal incision between the second and third
extensor compartments. Following elevation of the extensor pollicis longus, the displaced lunate
facet fragment can be exposed by elevation of the fourth extensor compartment or a retinacular
incision between the fourth and fifth extensor compartments. The radial column is exposed
between the first and second extensor compartments (Figs. 12, 13).
Following fragment reduction, a temporary fixation of the radial column is suggested with
a smooth K-wire placed through the radial styloid and similarly through the reduced lunate
facet fragment. The radial column plate has a small notch at the distal-most end, which allows
the plate to be placed up against the wire, helping to identify the position of the implant on the
radial column.
Given the more critical role of the intermediate column, stable plate fixation is begun here.
The use of an L- or T-shaped implant is preferred. By virtue of the undercuts in the plate, the
distal limb of the plate may be contained to extend around the very ulnar aspect of the lunate
fragment, providing additional support against shearing and compressive forces. If necessary,
a dorsal arthrotomy in line with the fibers of the capsule will help confirm the adequacy of the
articular reduction and assure that the distal screws are not in the joint space. The authors’
routinely obtain a lateral radiograph with the beam 20 to the longitudinal axis of the distal
locking screws [16] (Fig. 14).
By virtue of the angular stable fixation provided by the locking screws of the 2.4 mm plate
system, there is little need for autogenous bone graft or bone substitute to help support the
articular realignment.
Fig. 12. The dorsal approach to the radius. (A) The incision lies between the second and third extensor compartments.
(B) The retinaculum is opened to elevate the extensor pollicis longus.
Fig. 13. The exposure of the radial columns. (A) The retinacular exposure is marked (red) between the first and second
extensor compartment. (B) The retinaculum is opened.
Fixation of the radial column plate is facilitated by its precontoured shape. Caution
is expressed in avoiding penetration of the radiocarpal joint with the most distal screws
(Figs. 15–17).
Palmar plate fixation
The indications for palmar plate application include unstable dorsal-bending extra-articular
fractures, rotated palmar lunate facet fractures, volar shearing fractures and volar displaced
extra-articular fractures, some impacted articular fractures, and corrective osteotomies. Specific
indications for palmar plates are:
• Displaced palmar fragment/loss of palmar buttress
• Reconstruction of radio–carpal joint
• Colles-type Fx
• Smith and reverse Barton’s Fx
• Corrective-osteotomy
The rationale for internal fixation of an unstable dorsally displaced fracture with a palmarly
applied implant is based upon numerous factors (Box 2). These include a more anatomic
Fig. 14. The schematic approach to dorsal double plate fixation. (A) Temporary Kirschner wire of the radial styloid. (B)
Initial plate fixation is of the dorsal lunate facet with a screw through the oval hole of the plate. (C) The first 2.4 mm
locking screw is placed using a calibrated drill guide and a 1.8 mm drill bit. The radial column plate is placed using
a screw in the oval hole. (D, E) Distal locking screws are placed. (F) The two plate placements.
156 RIKLI & JUPITER
Fig. 15. (A, B) The fracture radiographs and CT scan of an impacted dorsally displaced articular fracture. (C, D) In-
ternal fixation with dorsal plates and functional follow-up.
Fig. 16. An impacted fracture involving the radial column and dorsal lunate facet in an active 75-year-old man treated
with double plating.
Fig. 17. A nascent malunion seen 4 weeks after injury is realigned and stabilized with double dorsal plating in an elderly
woman. No autogenous bone graft was required.
restoration of radial length and rotation caused by the stronger palmar cortex fracture lines be-
ing more easily interdigitated, especially in the older aged patient. Palmar plating will permit an
earlier return to independent upper extremity function, less swelling, and less risk of a complex
pain syndrome, especially in the older patient. These observations have been supported by nu-
merous studies.
For the most part, the radially based distal limb of the Henry approach will provide adequate
exposure for most fractures [5]. The pronator quadratus muscle is elevated in an L fashion to
facilitate subsequent closure over the plate. It is useful to place a needle into the radiocarpal
joint to help identify the most distal rim of the end of the radius. This is particularly important
when faced with small volarly displaced articular rim fractures [17]. The reasons for this are
based upon the fact that the very distal rim is covered by the attachment of the volar wrist cap-
sule and not directly visible. Furthermore, the radial styloid and lunate facet are situated more
volar than that of the scaphoid facet and may not be supported readily by one single plate. One
advantage of the 2.4 mm Synthes system is the ability to use two small dorsal plates in these
situations (Fig. 18).
The 2.4 mm system provides two forms of volar T plates. One is designed specifically for
dorsally displaced bending fractures and simple dorsally displaced articular fractures (Fig. 19).
This implant features the distal 2.4 mm locking screws directed distally and into the radial sty-
loid and lunate facet regions, while the alternative volar plate, designed more for complex ar-
ticular rim fractures, will sit more distally with its distal 2.4 mm locking screws directed
proximally to avoid penetration into the radiocarpal joint (Fig. 20). Because of the undercuts
on the distal limb of the plate, the distal limb may be contoured to sit more closely on the spe-
cific aspect of the very distal radius.
Box 2. Rationale for palmer plating in simple Colles Fx

Anatomic restoration of radial length
• Most critical outcome factor
• Strong palmar cortex
Early function
• Less algodystrophy
• Earlier return of function
Less radiologic and clinical controls
• May equal costs of plate
Outcome more predictable
• Less corrective osteotomes and ulnar shortening
158 RIKLI & JUPITER
Fig. 18. A complex fracture involving articular impaction and displacement of the intermediate column is fixed with two
plates, one oblique L and one L on the palmar surface.
For more simple dorsally displaced fractures, once reduction is assured, two options existd
either maintain the reduction manually with a temporary K-wire, or, alternatively, apply the
plate distally with the distal fragment still displaced and use the implant to help restore
alignment (Fig. 21).
The design of both volar plates includes an oval hole in the proximal straight limb, into which
a 2.4 mm or 2.7 mm central screw can be placed. This will help facilitate plate positioning, which
in all instances must be controlled using intraoperative fluoroscopy.
Internal fixation of volar shearing fractures or radiocarpal impaction fractures may require
more strategic placement of implants (Fig. 22). In these instances, the use of two smaller L or T
plates may support the specific components of the articular injury more effectively.
Combined palmar and dorsal fixation
The indications for approaching the distal radius fracture from both the volar and dorsal
sides include a rotated displaced lunate facet fragment with impacted articular fragments,
Fig. 19. A dorsally displaced Colles-type fracture secured with 2.4 mm volar locking plate.
Fig. 20. A Colles-type fracture fixed with the volar locking plate designed to sit more distally with the 2.4 mm distal
locking screws directed proximally.
Fig. 21. Schematic representation of dorsal fracture reduction using the volar plate to facilitate realignment by attaching
the 2.4 mm locking screws into the distal fragment before final reduction.
Fig. 22. A volar shearing fracture fixed with a 2.4 mm volar locking plate with excellent functional outcome.
160 RIKLI & JUPITER
Fig. 23. A complex intra-articular fracture in a 55-year-old man. (A) The preoperative anteroposterior and lateral ra-
diographs. (B) The sagittal and coronal CT images showing impaction and dorsal and volar displacement of the lunate
facets. (C) Radiographs postoperatively and at 13 months follow-up. (D) Clinical follow-up at 13 months.
rotated volar and dorsal lunate facet fragments, displaced volar fracture fragments associated
with intercarpal ligament injury, and high-energy complex injury. Specific indications for
a combined palmar and dorsal approach are:
• Displaced palmar fragment/loss of palmar buttress and impacted articular fragments
• Displaced palmar fragment/loss of palmar buttress and dorso-ulnar fragment
• Displaced palmar fragment/loss of palmar buttress and associated carpal ligament tear
The authors prefer to obtain preoperative CT scans for most of these complex fractures to
better understand the specific components of the injury. In general, the volar fracture
component is exposed and stabilized first. The radial column buttress plate also can be applied
from the volar surface. Once this is accomplished, careful intraoperative imaging will define
whether further realignment and fixation will be required through a dorsal approach. If the
dorsal lunate facet fragment alone requires realignment and fixation, this may be approached
through a small exposure between the fourth and fifth extensor compartments. Fixation can be
achieved with a small L or T plate (Fig. 23).
Pitfalls
As with any approach to internal fixation of fractures of the distal radius, there will exist
identifiable pitfalls. These include inadequate reduction, loss of fixation, tendon irritation or
rupture, and post-traumatic arthrosis.
Attention to detail, careful preoperative assessment of the fracture fragments, and adequate
surgical exposure will help to minimize these risks.
References
[1] Rikli D, Regazzoni P. Fractures of the distal end of the radius treated by internal fixation and early function. J Bone
Joint Surg 1996;78B:588–92.
[2] 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(3):340–4.
[3] Rikli D, Regazzoni P. The double plating technique for distal radius fractures. Tech Hand Up Extrem Surg 2000;
4(2):107–14.
[4] Ring D, Prommersberger K, Jupiter JB. Combined dorsal and volar plate fixation of complex fractures of the distal
part of the radius. J Bone Joint Surg 2005;86(A):1646–52.
[5] Jupiter JB, Ring D. AO manual of fracture managementdhand and wrist. New York: Thieme; 2005.
[6] Musgrave D, Idler R. Volar fixation of dorsally displaced distal radius fractures using the 2.4-mm locking compres-
sion plates. J Hand Surg 2005;30(A):743–9.
[7] Orbay JL. The treatment of unstable distal radius fractures with volar fixation. J Hand Surg 2000;5:103–12.
[8] Constantine KJ, Clawson MC, Stern PJ. Volar neutralization plate fixation of dorsally displaced distal radius frac-
tures. Orthopedics 2002;25(2):125–8.
J Hand Surg 2002;27(A):205–15.
[10] Drobetz H, Kutscha-Lissberg E. Osteosynthesis of distal radial fractures with a volar locking screw plate system. Int
Orthop 2003;27(1):1–6.
[11] Orbay JL, Fernandez DL. Volar fixed-angle plate fixation for unstable distal radius fractures in the elderly patient.
J Hand Surg 2004;29(A):96–102.
[12] Viegas SF, Tencer A, Cantrell J, et al. Load transfer characteristics of the wrist. J Hand Surg 1987;2(A):971–7.
[13] Pechlaner S, Kathrein A, Gabl M, et al. Distale Radiusfrakturen und Begleitverletzungen: experimentelle Untersu-
chungen zum Pathomechanismus. Handchir Mikrochir Plast Chir 2002;34:150–7.
[14] Peine R, Rikli RD, Hoffman R, et al. Comparison of three different plating techniques for the dorsum of the distal
radius: a biomechanical study. J Hand Surg [Am] 2000;25(1):29–33.
[15] Fernandez DL, Jupiter JB. Fractures of the distal radius. A practical approach to management. New York: Springer
Verlag; 1996.
[16] Smith DW, Henry MH. The 45 pronated oblique view for volar fixed-angle plating of distal radius fractures.
J Hand Surg 2004;29(A):703–6.
[17] Harness NG, Jupiter JB, Orbay JL, et al. Loss of fixation of the volar lunate facet fragment in fractures of the distal
part of the radius. J Bone Joint Surg 2004;86(A):1900–8.
Atlas Hand Clin 11 (2006) 163–174
Fragment-Specific Fixation of Distal Radius Fractures

Robert J. Medoff, MD
John A. Burns School of Medicine, University of Hawaii, 30 Aulike St., #506, Kailua, Hawaii 96734, USA
Distal radius fractures are not all alike. Differences in the direction and magnitudes of
applied force, the position of the hand and forearm at the time of injury, and the underlying
quality of bone are important factors that influence the character and extent of injury. Factors
such as the degree and extent of articular disruption, association of distal radioulnar joint
injury, and type and direction of fracture displacements are some of the parameters that may
affect the natural history of the injury and the effectiveness of a specific treatment. Because the
term distal radius fracture includes several different groups of injury patterns, no single method
of treatment is uniformly effective for every distal radius fracture.
Fractures of the distal radius tend to occur in set patterns, however, with each specific
pattern with its own fracture personality that characterizes features of that group (Fig. 1).
For instance, extra-articular fractures are typically osseous failures generated by a bending
moment applied to the wrist. Extra-articular fractures with dorsal displacement are caused
by a dorsal bending moment and are unstable only when enough dorsal and metaphyseal
comminution is present to compromise support of the articular surface. In contrast, extra-
articular fractures with volar displacement have a different personality and natural history.
Injuries in this direction are almost always unstable, because volar displacement of the distal
fragment causes the articular surface to migrate into the palmar soft tissue where there is no
osseous support to resist the strong pull of the flexor tendons. At first glance, these two in-
juries may seem quite similar, and numerous studies and classification systems continue to
group them together as equivalent injuries [1–3]. This difference in the direction of displace-
ment, however, significantly changes the natural history, anatomy, and biomechanics of the
fracture and suggest that volar and dorsal displacement patterns should be considered as
separate injuries. Similarly, different patterns of intra-articular fractures retain their own
unique personalities, such that each warrants its own specific approach to treatment.
In 1994, the author devised the term fragment-specific fixation to describe an approach for
distal radius fractures characterized by analysis of the specific fracture pattern combined with
rigid anatomic restoration of the articular surface based on individual fixation of each major
fracture component. In essence, each implant is designed to optimize the mechanical and
biological requirements of each fracture element rather than forcing a variable combination of
fracture elements to fit a single plate. As a result, fragment specific fixation is not one technique
or implant but rather a set of approaches and implants customized to the specific fracture
configuration. Although fragment-specific fixation shares similarities to pin fixation in that
fixation can be directed to each major fracture component, fragment-specific fixation achieves
multi-planar fixation of the distal articular surface. As a result, this approach results in a load-
sharing composite that allows immediate motion of the wrist and accelerated rehabilitation,
even for fractures with extensive articular comminution.
E-mail address: rmedoff@lava.net
164 MEDOFF
Fig. 1. Fracture personalities. Note that volarly displaced fractures have different characteristics from dorsally displaced
fractures. In addition to the distal radius fracture pattern, treatment decisions may be affected because of associated in-
juries to the distal radioulnar joint, distal ulna, carpus, and syndesmosis.
Evaluation
Fragment specific fixation starts with a complete evaluation of the injury, including
assessment of the patient, the fracture personality, and the specific fragmentation pattern.
Recently described radiographic landmarks and parameters can provide a wealth of information
from standard radiographs about the mechanism of injury, the type and number of fracture
elements, and the presence of articular disruption [4]. In addition, evaluation for associated in-
juries to the carpus, distal radioulnar joint, radioulnar syndesmosis, and distal ulna is important
and can affect the approach to treatment.
The evaluation of the injury typically begins with the patient. The age and activity level of the
patient are important, not only to determine the functional and cosmetic expectations of the
patient, but also to provide information about the quality of the osseous and soft tissue
structures. Elderly patients who are marginal community ambulators often are willing to accept
greater loss of motion and cosmetic deformity than an individual who is socially and
recreationally active. Treatment of fractures that occur in the context of severe senile
osteoporosis and atrophic skin may be jeopardized by methods of fixation that would otherwise
be reliable in healthier bone. Although the fracture pattern and personality are important for
selecting a specific approach to treatment, the type of patient still remains an important factor
that has an impact on treatment decisions.
Evaluation of the radiographs is an essential part of fracture assessment. Injury and
postreduction radiographs provide a wealth of information that often is overlooked relating to
the pattern and mechanism of the injury. Most fractures generate a fragmentation pattern that is
a subset of five main cortical elements: radial column, volar rim, ulnar corner, dorsal wall, and
free articular fragments (Fig. 2). Fractures that extend through the articular surface contain two
or more of these fracture elements. In addition, central compression of the metaphyseal bone
can result in a void after the reduction of the articular surface, and it often is considered a sixth
fracture element.
New landmarks and parameters have been described recently that can be used to define the
fragmentation pattern and the direction of fragment displacements from the anteroposterior
(AP), lateral, and 10 lateral radiograph [4]. Identification of the carpal facet horizon with cor-
relation to the lateral radiograph can determine whether it is the dorsal or volar corner of the
lunate facet that is involved, and how much shortening of this element has occurred. Widening
of the distal radioulnar joint may imply disruption of the distal radioulnar ligaments or syndes-
mosis. Observation of the central rotational axis of the capitate to the dorsal or volar side from
its normal alignment with the volar cortex of the radial shaft may indicate subluxation of the
carpus. The 10 lateral radiograph enables more accurate assessment of the articular surface,
improving the visualization of the ulnar two thirds of the radialcarpal joint to assess step-off
or separation. In addition, significant depression of the teardrop angle is helpful to indicate
FRAGMENT-SPECIFIC FIXATION 165
Fig. 2. Fragment components. Most fractures consist of a subset of these fracture elements.
rotational deformities of the volar rim and dorsiflexion deformities of this fracture element.
Widening of the AP interval suggests sagittal discontinuity across the lunate facet with articular
disruption of the sigmoid notch. If necessary, axial or three-dimensional CT scans may be used
to provide additional information about the scope and the extent of the injury.
Fragment-specific implants
Fragment-specific implants are designed to stabilize a particular fracture element (Fig. 3). As
a general rule, they are low profile distally to avoid irritation with tendons that overlie the peri-
articular portion of the bone [5]. In addition, most fragment-specific implants stabilize distal
fragments without the need for direct screw purchase distally, thereby avoiding the risk of
additional iatrogenic comminution from large screw holes in a small distal fragment. Typically,
fragment-specific implants are anchored to the proximal cortex of the ipsilateral shaft. In addi-
tion, the fragment-specific approach uses fixation in more than one plane, creating a load-shar-
ing composite that is more effective than single plane fixation in resisting the multiple axes of
motion inherent to the wrist and forearm [6].
Fragment-specific implants fall into three general classes: pin or columnar plates, wire forms,
and buttress plates [7]. Pin plates are designed to augment fixation of an interfragmentary K-
wire that has purchased the far cortex of the proximal shaft by adding a second point of
constraint to the pin at the surface of the unstable distal fragment. Wire forms combine the ad-
vantages of an ultra-low profile implant with a buttressing effect. For most applications, the
wire form is designed so that the mechanical load on the implant is aligned with its longitudinal
Fig. 3. Fragment-specific implants. Fragment-specific implants are designed to optimally stabilize a particular fracture
element, based on anatomic and mechanical parameters characteristic of that specific fragment. Note the two points of
constraint (1, 2) of K-wires by the pin plate and proximal fragment.
166 MEDOFF
axis to optimize its rigidity. Buttress plates are used to buttress the surface of a bone fragment,
or pegs are used to provide subchondral support behind the articular surface. Because fragment-
specific implants are matched to the configuration of the fracture pattern, the result is an ex-
tremely versatile approach that can be customized to the needs of each specific pattern of injury.
Radial column fixation is important for several reasons. First, rigid fixation of a free radial
column fragment can add significant stability to the final fixation, particularly with compression
of the radial column fragment in a load-sharing construct with the other distal fragments.
Second, restoration of radial length brings the carpus out to length, unloading the ulnar side of
the articular surface. By correcting the collapse of the proximal carpal row into the lunate facet,
obstructions to articular reduction are removed, and the likelihood of late collapse is reduced.
Third, the position of a radial column plate along the radial border is mechanically
advantageous for resisting flexion and extension movements of the wrist, resulting in a stable
reconstruction that allows immediate motion of the wrist postoperatively. Finally, radial
column plates having elastic properties such as the Radial Pin Plate (TriMed Incorporated,
Valencia, California) serve to act as a leaf spring, flattening as they are fixed proximally, and
producing a force in the ulnar direction. This secondary ulnar compression across the distal
fragments locks peri-articular fragments in place and improves distal radioulnar joint (DRUJ)
stability by seating the ulnar head within the curved sigmoid notch.
The Radial Pin Plate (TriMed Incorporated, Valencia, California) is a fragment-specific
implant designed for stabilization of the radial column; it shares many of the principles of simple
trans-styloid pin fixation [8,9]. Unlike simple pinning that only constrains the pin at the far cor-
tex, however, application of a Radial Pin Plate adds a second point of constraint to the pin
where it penetrates the surface of the radial column. As a result, fixation of the radial column
is triangulated to both the ipsilateral and contralateral cortex of the proximal fragment, result-
ing in significant improvement in pin stiffness and resistance to displacement.
The Ulnar Pin Plate (TriMed Incorporated) is designed for stabilization of the dorsal ulnar
corner fragment. Like the Radial Pin Plate, the Ulnar Pin Plate provides two-point fixation of
an interfragmentary pin that is placed across the ulnar corner fragment into the volar cortex of
the shaft. In practice, because the ulnar border of the distal radius supinates about 15 as it
courses proximally from the distal surface, fragment-specific plates in this region should be
contoured to match the curve of this surface geometry. In addition, a slight amount of
dorsiflexion usually is added to the distal end of the plate to allow close apposition to the bone.
In addition to the ulnar corner fragment, the Ulnar Pin Plate may be used for fixation of
fractures of the base of the ulnar styloid and distal portion of the ulnar head. When used in this
manner, the tip of the Ulnar Pin plate first is bent to an 80 angle, slid over a pin placed through
this fragment, and fixed proximally with one or two bone screws.
The Buttress Pin (TriMed Incorporated) is a dorsal wire form for fixation of the ulnar corner
or dorsal wall. In one technique, the legs of the implant penetrate and purchase the distal
fragment directly, and the implant is then secured proximally to the shaft with one or two bone
screws and washers. When used in this way, the device functions distally like a staple. In
addition to an extremely low distal profile, this has the advantage of using the implant like
a joystick, allowing direct manipulation of the distal fragment to restore length and reduce the
articular surface. In addition, the dorsal Buttress Pin can be used to stabilize free articular
fragments, providing a direct buttress from the legs of the implant behind subchondral bone to
sandwich articular fragments against the proximal carpal row. Other wire-form implants that
provide stabilization of dorsal wall and free articular fragments include the Small Fragment
Clamp (TriMed Incorporated), which locks the dorsal wall in place, grabbing it from both the
endosteal and periosteal surfaces, and the Small Fragment Clamp/Buttress Pin (TriMed
Incorporated), which combines the subchondral support of a Buttress Pin with the dorsal wall
fixation of the Small Fragment Clamp.
The Volar Buttress Pin (TriMed Incorporated) is a simple wire form that has a unique ability
to secure marginal volar rim fragments and volar rim fragments with a depressed teardrop angle
that have displaced into dorsiflexion. Like the dorsal Buttress Pin, the Volar Buttress Pin secures
the distal fragment with two legs that are placed to penetrate the fragment in the center of the
teardrop; the implant then is used like a joystick to reduce the fragment into position before
securing it proximally with two screws and washers. Because the mechanical axis of the carpus
on the lateral projection aligns with the volar shaft of the radius, the Volar Buttress Pin is loaded
along the central axis of the wire form proximally, resulting in mechanically effective
stabilization of even small distal fragments.
Volar or subchondral fixation also may be approached with various volar plates. In some
situations, particularly in the context of simple volar translation of a volar rim fragment, simple
buttress plates may be all that is required. Subchondral support also may be provided with
a fixed-angle volar plate. Newer volar polyaxial locking plates such as the TriMed Bearing Plate
(TriMed Incorporated) have the additional advantage of individualizing subchondral support
by allowing an independent trajectory to each of the distal fixation pegs, which then are locked
to match the specific fracture geometry. Although these plates are not, by definition, fragment-
specific fixation, they may be used in conjunction with fragment-specific implants as composite
fixation to address fragments that are not secured by these plates.
Fragment-specific techniques
Three-part articular fracture
Three-part articular fractures are the result of combined axial loading and bending forces,
resulting in a large combined radial column and volar rim fragment, a secondary dorsal ulnar
corner fragment with the insertion of the dorsal DRUJ ligaments and the dorsal portion of the
sigmoid notch, and a proximal shaft fragment. Initially described as the die punch fragment by
Sheck, the ulnar corner fragment is the result of impaction of the lunate into the dorsal portion
of the lunate facet; often, secondary fragmentation of the dorsal wall also may be present [10]. In
some injuries, the ulnar corner fragment displaces dorsally, producing widening of the AP dis-
tance on the lateral radiograph. In others, the ulnar corner fragment can displace dorsally and
shorten proximally, resulting in malalignment of the DRUJ that may interfere with supination.
Three-part articular fractures have several options for treatment. One direct approach is
fixation of the ulnar corner fragment dorsally with an Ulnar Pin Plate combined with fixation of
the radial column fragment with a Radial Pin Plate (Fig. 4). If significant compression of the
metaphyseal bone has occurred, bone grafting of the metaphyseal void may be inserted through
the dorsal or radial defects. This combination of implants has the advantage of two-plane fix-
ation of the distal articular surface with limited dorsal and volar incisions. Alternatively, this
combination of implants may be applied through a single dorsal incision.
Another option for the treatment of three-part fractures is to combine a dorsal Buttress Pin
to the ulnar corner fragment and a Radial Pin Plate to the radial column (Fig. 5). This simple
approach achieves rigid fixation and allows independent correction of the two primary articular
fragments. The Buttress Pin should only be used for fixation when the ulnar corner fragment has
sufficient size to allow purchase by the legs of the implant. One advantage to this technique is
the ability to use the Buttress Pin as a joystick to restore length to the ulnar corner fragment.
With this technique, the Buttress Pin initially is held loosely with a single screw and washer cen-
trally, and then the wire form is slid distally to bring the ulnar corner fragment out to length.
The screw and washer are then tightened fully, locking the fragment in position. If needed, a sec-
ond screw and washer, or a blocking screw and washer behind the proximal loop of the wire
form, can be used to augment fixation.
Simple three-part articular fractures also can be treated from a volar approach with a fixed
angle volar plate. This technique can restore articular congruity and reduce the ulnar corner
fragment by direct reduction and fixation by a subchondral support peg, or by indirect
reduction from the soft tissue attachments on the ulnar corner fragment. A polyaxial locking
plate is particularly useful to allow an independent peg to be directed into the ulnar corner
fragment from the volar approach. Treatment of three-part articular fractures from the volar
approach, however, is not always a reliable method of fixation for this pattern. Failure to
initially obtain reduction or subsequently maintain reduction because of tenuous fixation may
lead to late collapse and should be recognized and addressed. In these situations, it is reasonable
to combine volar plate fixation with secondary fragment-specific fixation of the ulnar corner,
either with an Ulnar Pin Plate or dorsal Buttress Pin.
168 MEDOFF
Fig. 4. Three-part fracture in a 25-year-old woman treated with Radial Pin Plate (TriMed Incorporated, Valencia,
California) and Ulnar Pin Plate (TriMed Incorporated). (A) Injury radiographs. (B) Postoperative radiographs. Motion
allowed immediately after surgery.
Volar shear fractures
Volar shear fractures are caused from shearing injuries that drive the carpus into the volar
rim. In the classic volar shear fracture, the radial column and dorsal structures remain
unaffected with the osseous failure limited to the volar rim of the lunate facet. Often,
comminution of the volar rim is present. Displacement of the fragment with translation into the
palmar soft tissues and significant shortening is typical; usually, there is no dorsal rotation of the
fragment. Because the carpus migrates with the displaced volar rim fragment, volar shear
fractures are extremely unstable injuries that require operative stabilization.
Treatment of volar shear fractures is directed at anatomic restoration of the volar rim, and
this often is accomplished by placing an implant to buttress the fragment from the volar surface
(Fig. 6). A simple buttress plate, small fragment fixation plate, or Volar Buttress Pin are effec-
tive methods of treatment. Fixed-angle volar plates should be used with caution in this pattern,
however. Especially in the case of small distal fragments, treatment with a fixed-angle volar
plate may fail from inadequate support of the volar rim, particularly if the plate has been
positioned too far proximally in order to avoid penetration of the joint by the distal pegs
[11]. For extremely distal fragments, a Volar Buttress Pin may be more effective and can be
used without reflection of the volar wrist capsule by directly penetrating the distal fragment
with the legs of the implant through the volar ligaments. Treatment of volar shear fractures
should result in restoration of carpal alignment to its normal position.
Dorsal shear fractures
Shearing fractures of the dorsal rim of the distal radius are relatively uncommon. They
typically are approached through a dorsal exposure, and can be stabilized directly with a small
peri-articular plate, dorsal Buttress Pin, or Ulnar Pin Plate. Because of the proximity of the
extensor tendons, a low-profile implant should be used. If necessary, a portion of the extensor
retinaculum may be reflected and sutured over the implant to place a layer of soft tissue between
the implant and the overlying tendons.
Fig. 5. Three-part fracture in a 38-year-old woman treated with a Radial Pin Plate and a dorsal Buttress Pin (TriMed
Incorporated). (A) Injury radiographs. (B) Postoperative radiographs. Motion allowed immediately after surgery.
Comminuted articular fractures
Comminuted articular fractures of the distal radius with multiple articular fragments can be
technically challenging, but often have the most to gain from anatomic reconstruction of the
articular surface. Although some fractures are simply too comminuted for internal fixation,
many are amenable to stable, anatomic fixation of the articular surface followed by immediate
motion with fragment specific techniques. Involvement of the radial column, ulnar corner, and
dorsal wall are common with most of these patterns. Additional involvement of the volar rim
and free intra-articular fragments may complicate articular disruption further. Ligamentous
injury of the distal radio–ulnar joint, with or without fractures of the distal ulna, can add
significant instability to an already complex injury.
In most cases, the radial column remains intact as a large independent fragment. In this
situation, the reconstruction is started by reduction of the radial column out to length and
provisional fixation with a trans-styloid K-wire, restoring the carpus to its normal spatial
relationship. This simplifies reduction of the lunate facet by removing the compressive loads
caused by shortening and impaction of the proximal carpal row. If volar rim fragments are
present, they are reduced and fixed with a Volar Buttress Pin or volar plate, depending the size
and position of the fragment and the experience of the surgeon. The ulnar corner then is reduced
and secured with a dorsal Buttress Pin or an Ulnar Pin Plate. Elevation of dorsal wall fragments
allows access to the metaphyseal cavity, and free articular fragments are reduced using the
proximal carpal row as a template. If needed, bone graft can be applied through the metaphyseal
defect and a wire form used dorsally. Finally, fixation is completed with a Radial Pin Plate,
securing the radial column fragment and sandwiching the remaining distal fragments by
compression of the distal end of the radius against the ulnar head.
Comminuted articular fractures with volar rim instability
Comminuted articular fractures with volar rim instability can be particularly complex
injuries, and are often associated with additional comminution of the radial column. In one
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Fig. 6. Volar shearing fracture treated with a small volar buttress plate. (A) Injury radiographs. (B) Postoperative
radiographs.
pattern, the carpus is driven into the distal articular surface from an axial loading injury,
causing a pattern that creates discontinuity between the dorsal and volar portion of the lunate
facet and drives the volar rim into dorsiflexion, with secondary subluxation of the carpus
dorsally. This fracture personality is characterized by marked depression of the teardrop angle,
typically below 45 on the lateral radiograph, and widening of the AP interval. Often, dorsal
subluxation of the center of the capitate from a line extending from the volar cortex of the radial
shaft also is noted. In some cases, the volar rim fragment is too distal to allow support with
a volar plate [11]. Even when the fragment extends proximally enough to be buttressed by a volar
plate, the fragment still can be too distal for fixed-angle pegs to correct the dorsal rotation
(Fig. 7).
Fig. 7. Inadequate reduction of volar rim with fixed angle volar plate. (A) Intraoperative radiograph showing volar plate
applied, with exaggeration of dorsiflexion of volar rim (depressed teardrop angle a) and an incongruent articular inter-
val. Also note inadequate support of volar rim by trajectory of intended peg (large arrow), and displacement of dorsal
corner (widened AP interval). (B) Intraoperative radiograph after conversion to a Volar Buttress Pin (TriMed Incorpo-
rated). Note the correction of the teardrop angle and restoration of a congruent articular interval between the distal ra-
dius and the lunate. In this case, additional fixation was applied to the radial column and ulnar corner to complete
fixation. Motion started immediately after surgery.
One option for correcting dorsiflexion of the volar rim with depression of the teardrop angle
is to use a Volar Buttress Pin. The legs of the implant are cut to length and inserted centrally
within the teardrop to purchase the volar rim fragment; this allows correction of the dorsal
rotation by alignment of the base of the implant to the radial shaft. Because the legs of the Volar
Buttress Pin are at an angle of 70 to the base of the implant, proximal fixation of the implant
restores the normal anatomic relationship between the volar rim of the lunate facet and the
remaining articular surface (Fig. 8).
In a second pattern of articular comminution with volar rim instability, the volar rim
fragment translates and shortens in the palmar soft tissue, carrying the carpus with it. If this
fragment is large enough, a volar buttress plate or Volar Buttress Pin can be used to restore the
volar rim to its anatomic position. In cases in which this fragment is extremely distal, the Volar
Buttress Pin may be the only option capable of providing stability to this fragment.
Comminuted articular fractures with volar rim instability often are associated with
subluxation of the carpus, either dorsally or volarly from its normal alignment, which can
cause difficulties with reduction of radial column, ulnar corner, and articular fragments. In these
situations, it is often helpful to start internal fixation with correction of the translational and
rotational deformities of the volar rim, to return the carpus to its normal position in space. This
removes deforming forces on the remaining articular fragments and allows reduction and
internal fixation of the remaining fragments.
Extra-articular fractures
Although extra-articular fractures by definition do not extend through the articular surface
of the distal radius, internal fixation with fragment-specific techniques can advantageous,
achieving rigid fixation with a limited incision approach. In general, fixation of these injuries
combines stabilization of the radial column with either volar or dorsal fixation. The result is
Fig. 8. Comminuted articular fracture with dorsiflexion of the volar rim in a 28-year-old man. (A) Injury radiographs.
Note the comminution of the articular surface, the widened DRUJ interval, and dorsiflexion of an extremely distal volar
rim fracture, with depression of the teardrop angle (a). (B) Postoperative radiographs, after fixation with a Radial Pin
Plate, dorsal Buttress Pin, Volar Buttress Pin, and repair of the dorsal DRUJ ligaments. Because of the extent of the
ligamentous injury, motion was delayed until 2 weeks postoperatively.
172 MEDOFF
fixation in two planes, a construct that has been shown to be stiffer than either a single volar or
dorsal plate [6].
Two types of fragment-specific approaches can be used for dorsally displaced extra-articular
fractures. The first option is to combine radial column fixation with a Radial Pin Plate with
a fragment-specific implant dorsally, using either an Ulnar Pin Plate or a dorsal Buttress Pin.
This combination can be placed through either a single incision dorsally, or with limited volar
and dorsal approaches. A second option is to combine radial column fixation using a Radial Pin
Plate with volar fixation using a Volar Buttress Pin (Fig. 9). This combination can be applied
through a single limited volar approach, to achieve biplanar fixation of the distal fragment. If
necessary, bone graft can be inserted through the radial column defect with the single-incision
volar approach.
Extra-articular fractures of the distal radius with volar displacement are more unstable
injuries than those that displace dorsally, because the carpus displaces with the distal fragment
into the unsupported volar soft tissues. These fractures are often unstable to closed methods of
treatment. In addition, because the direction of instability occurs with palmar flexion of the
wrist, the distal fragment tends to displace away from the subchondral support pegs of a fixed-
angle volar plate. If the distal fragment is extremely distal, this may compromise fixation with
a volar plate. Alternatively, a Volar Buttress Pin and Radial Pin Plate may be used as another
option to secure volarly displaced extra-articular fractures, particularly for very distal fractures.
Postoperative care
The goal of fragment-specific fixation is an anatomic reduction of the articular surface that is
stable enough to start immediate motion of the wrist after surgery. The stability of fixation is
confirmed by observing the fracture as the wrist and forearm are placed through a full range of
motion before the skin is closed. The arm is placed into a removable volar splint, and the patient
Fig. 9. Extra-articular fracture in a 57-year-old woman. (A) Injury radiographs. (B) Postoperative radiographs after fix-
ation with a Radial Pin Plate and Volar Buttress Pin through a single limited incision. In this case, bone allograft chips
were packed through the radial defect. Immediate motion allowed after surgery.
is instructed to start gentle range of motion of the wrist, fingers, and forearm out of the brace
twice daily, starting the first day postoperatively. In particular, pronation/supination, wrist
flexion/extension, and finger flexion/extension are stressed. The patient is cautioned to avoid
any resistive loading across the wrist, including lifting moderate-to-heavy objects, impact-type
activities, and use of the arm to push up out of a bed or chair. On the other hand, daily activities
that do not place resistance across the wrist are encouraged, including writing, typing on
a keyboard, eating, and brushing teeth. When signs of radiographic healing are noted, typically
by postoperative week 4, resistive exercises are started. If less than 60% of motion is present at 4
weeks, the patient is started on occupational therapy.
Complications
Complications associated with fragment specific fixation are not common. Dorsal tendon
irritation or rupture is unusual and most commonly associated with a pin that has backed out
dorsally or a plate that has not been contoured to fit the dorsal surface. Tendon irritation from
any of the wire forms is extremely rare. Tendon irritation over the radial column or soft tissue
irritation from prominent hardware can occur but is uncommon. Neuromas or neuropraxia of
the sensory nerves to the base of the thumb may be related to careless exposure or compression
of a nerve by a trans-styloid pin during the operative fixation. Usually, these symptoms resolve
spontaneously.
Loss of reduction can occur with fragment-specific fixation. One cause of this can be failure
to recognize the presence of a particular fragment component or instability pattern, resulting in
an unstable fracture element that has not been addressed. In addition, pins that are improperly
placed and not directed into the proximal fragment defeat the mechanical basis of pin plate
fixation, and will result in loss of reduction. Patient noncompliance in restricting loading of the
extremity until signs of radiographic healing is another potential cause of failure. Fractures that
are severely osteoporotic may drift proximally during healing, particularly if bone graft has not
been applied, resulting in loss of radial length.
Biomechanics of fragment specific fixation
Dodds and colleagues compared the mechanical stability of fragment-specific fixation with
external fixation with pins in a cadaver model [12]. They showed that the two methods have
comparable stability in a three-part fracture model, but that fragment-specific fixation had bet-
ter stability than external fixation and pins in their four-part model, even despite movement of
the joint with fragment-specific fixation. Peine and colleagues compared the stability of two
plane fixation of distal radius fractures with single-plane fixation with either a dorsal or volar
plate. They determined that the two-plane method of fixation had superior stiffness to either sin-
gle volar or dorsal plate fixation but had equivalent resistance to bending and bone gap to
failure [6].
Clinical results
There are several clinical series on fragment-specific fixation for distal radius fractures.
Konrath and colleagues reported on TriMed fragment-specific fixation of the distal radius in 27
patients with a minimum 2-year follow-up using pin plates and wire forms [13]. Patient satisfac-
tion was high, and only a single fracture lost reduction. The average clinical outcome score at
follow-up showed a Disabilities of the Arm, Shoulder, and Hand score of 17 and a Patient
Rated Wrist Evaluation score of 19. There were no major complications including tendon rup-
ture. In three cases, hardware was removed. Jakob and colleagues reported on 74 patients
treated with radial column and dorsal ulnar corner fixation using 2 mm plates [14]. This series
included 20 extra-articular fractures and 40 complex articular fractures, with good and excellent
results in 98% of patients. Complications of extensor tendinitis in four patients and extensor
174 MEDOFF
tendon rupture in five patients were noted, but were associated with cutting of the 2 mm plate,
with the recommendation that this practice be avoided.
Summary
Distal radius fractures are not a single, homogeneous type of injury but rather a group of
several different types of fracture patterns. Each pattern is characterized by its own personality
that is defined by the mechanism of injury, the fragmentation pattern and the type and direction
of articular disruption. Complete evaluation of the fracture components, mechanism of
instability, and relative age and activity level of the patient is essential before considering any
type of treatment algorithm.
Although plate fixation is appropriate for certain types of fracture configurations, not every
fracture pattern can be fit to the static geometry and shape of a particular plate, and not all
fracture patterns can be stabilized with a plate. Although newer polyaxial locking plate designs
provide additional flexibility by allowing independent peg trajectories as determined by the
fragmentation pattern, in some situations they lack a comprehensive method of addressing each
fracture component. In contrast, fragment-specific fixation is an extremely flexible approach
that provides a set of implants specifically designed for each fracture component, allowing the
surgeon to mix and match implants to the particular characteristics of the fracture [15]. As a re-
sult, fragment-specific fixation is not a single technique of internal fixation but rather a powerful
set of tools that have the versatility to cover a range of fracture personalities, providing a range
of fixation possibilities that extend from simple extra-articular patterns to some of the most
complex articular injuries of the wrist.
References
[1] Musgrave D, Idler R. Volar fixation of dorsally displaced distal radius fractures using the 2.4 mm locking compres-
sion plates. J Hand Surg 2005;30(4):743–9.
[2] Gradl G, Jupiter J, Gierer P, et al. Fractures of the distal radius treated with a nonbridging external fixation tech-
nique using multi-planar k wires. J Hand Surg 2005;30(5):960–8.
[3] Muller M, Nazarian S, Koch P, et al. The comprehensive classification of fractures of long bones. Berlin: Springer-
Verlag; 1990.
[4] Medoff R. Essential radiographic evaluation for distal radius fractures. Hand Clin 2005;21(3):279–88.
[5] Shumer E, Leslie B. Fragment-specific fixation of distal radius fractures using the TriMed device. Tech Hand Up
Extrem Surg 2005;9(2):74–83.
[6] Peine R, Rikli D, Hoffmann R, et al. Comparison of three different plating techniques for the dorsum of the distal
radius: a biomechanical study. J Hand Surg 2000;25(1):29–33.
[7] Swigart C, Wolfe S. Limited incision open techniques for distal radius fracture management. Orthop Clin North Am
2001;30(2):317–27.
[8] Leslie B, Medoff R. Fracture-specific fixation of distal radius fractures. Tech Orthop 2000;15(4):336–52.
[9] Barrie K, Wolfe S. Internal fixation for intra-articular distal radius fractures. Tech Hand Up Extrem Surg 2002;6(1):
10–20.
[10] Scheck M. Long-term follow-up of treatment of comminuted fractures of the distal end of the radius by transfix-
ation with Kirschner wires and cast. J Bone Joint Surg Am 1962;44A:337–51.
[11] Harness N, Jupiter J, Orbay J, et al. Loss of fixation of the volar lunate facet fragment in fractures of the distal part
of the radius. J Bone Joint Surg Am 2004;86A(9):1900–8.
[12] Dodds S, Cornelissen S, Jossan S, et al. A biomechanical comparison of fragment-specific fixation and augmented
external fixation for intra-articular distal radius fractures. J Hand Surg 2002;27(6):953–64 [AM].
[13] Konrath G, Bahler S. Open reduction and internal fixation of unstable distal radius fractures: results using the
TriMed system. J Orthop Trauma 2002;16(8):578–85.
[14] Jakob M, Rikli D, 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(3):340–4.
[15] Bae D, Koris M. Fragment-specific internal fixation of distal radius fractures. Hand Clin 2005;21(3):355–62.
Atlas Hand Clin 11 (2006) 175–185
Closed Reduction and Percutaneous Pinning

for Distal Radius Fractures
Steven Z. Glickel, MDa,b,*, Milan M. Patel, MDb,
Louis W. Catalano III, MDa,b
a
Columbia College of Physicians and Surgeons, 630 W 168th Street, New York, NY 10032, USA
b
C.V. Starr Hand Surgery Center, St. Luke’s–Roosevelt Hospital Center,
1000 Tenth Avenue, 3rd Floor, New York, NY 10019, USA
There are multiple techniques for treating distal radius fractures. Closed reduction and
percutaneous pinning remain a valid and well-accepted method of surgical treatment for
displaced and unstable fractures. Pinning has been described for intra and extra-articular
fractures and represents a relatively simple, minimally invasive, and cost-effective method of
treatment.
Indications and contraindications
The goal of surgical treatment of distal radius fractures is to obtain and maintain anatomic
reduction. Percutaneous pinning can be used for extra-articular (Arbeitsgemeinschaft für
Osteosynthesfragen [AO]/Association for the Study of Internal Fixation [ASIF] type A2 and
A3) and intra-articular fractures, including three- and four-part fractures (AO/ASIF type C1
and C2). Pinning is most effective for fractures that can be closed, reduced by traction, manip-
ulation, and ligamentotaxis. Contraindications for percutaneous pinning alone (without aug-
mentation, [ie, external fixation or open reduction and internal fixationdORIF] include
severe metaphyseal or intra-articular comminution (AO/ASIF type C3), poor bone stock, and
shear fractures (AO/ASIF type B).
History
Several techniques of percutaneous pinning of distal radius fractures have been described.
These techniques include pinning only the radius and pinning both the radius and ulna.
Techniques of pinning the radius alone have included one or multiple pins placed obliquely
through the radial styloid, crossed pinning from the radial styloid and dorsoulnar cortex,
oblique and horizontal pins placed through the radial styloid, and intrafocal pinning within the
distal radius fracture site. In 1907, Lambotte [1] described using a single radial styloid pin as
a method of stabilization, and in 1959, Willenegger and Guggenbuhl [2] further reported on
their experience with this method in 25 patients. Stein and Katz [3] and Clancey [4] described
crossed pinning of the radius, using one or more pins through the radial styloid and another
through the dorsal and ulnar corner of the distal radius. This technique stabilized the dorsoul-
nar radial fragment and provided orthogonal pin configuration, inherently more stable than
pins in one plane. Fernandez and Geissler [5] described another method for stabilizing the
E-mail address: sglickel@msn.com (S.Z. Glickel).
176 GLICKEL et al
dorsoulnar fragment. In addition to two oblique radial styloid pins, they placed transverse
pins in the subchondral bone from the radial styloid to the ulnar fragment, avoiding entering
the distal radioulnar joint. The transverse pin supported the intra-articular fracture fragments,
preventing proximal displacement. In 1976, Kapandji [6] reported a technique of intrafocal
pinning using two pins in the fracture site for reduction and buttress fixation of the fracture
and modified this in 1987, using intrafocal pinning with three pins [7].
The techniques involving both the radius and ulna include pinning from the ulna to the
radius proximal to the distal radioulnar joint, radial styloid pinning with a pin across the
radioulnar joint, and multiple pins from the ulna to the radius, with fixation of the distal
radioulnar joint. DePalma [8] described placing a single threaded wire obliquely from the sub-
cutaneous border of the ulna to the radial styloid. The starting point on the ulna for this method
was about 4 to 4.5 cm proximal to the ulnar styloid. Lortat-Jacob and colleagues [9] and Mort-
ier and colleagues [10] described a technique in which oblique pins in the radial styloid are com-
bined with a transverse pin from the ulna through the distal radioulnar joint to capture the
dorsoulnar radial fragment. Rayhack [11,12] used four to nine 0.045 in pins from the ulna across
the distal radioulnar joint and proximal to it into the radial styloid and radial metaphysis. The
pins are begun from the ulna to radius, transverse distally and then at increasing obliquity more
proximally on the ulna.
Practically, these techniques of closed reduction and percutaneous pinning are used alone or
in combination depending on the particular fracture pattern. The number of pins, size of the
pins, and configuration within the distal radius are adapted to the fracture pattern. In a
biomechanical study, Naidu and colleagues [13] demonstrated that crossed pinning with three
0.062 in diameter K-wires was more rigid than two parallel radial styloid pins alone. Rogge and
colleagues [14] corroborated this finding in their study using mathematical and computer-
generated finite element modeling. The authors’ approach and technique is described.
Technique
A pneumatic tourniquet is placed on the arm, and the hand and arm are prepared and draped
with a stockinet and a prefabricated extremity drape. The procedure is performed using a hand
table to which an outrigger for longitudinal traction can be incorporated. (Carter table,
Innovation Sport, Foothill Ranch, CA). Finger traps on the thumb and index finger are at-
tached to a wire that runs over the pulley of the traction outrigger. Ten pounds of weight are
applied for longitudinal traction, with the limb horizontal on the hand table. The head and
arm of the image intensifier are sterilely draped. The image intensifier is brought into the oper-
ative field, and posterior-anterior (PA) and lateral images of the distal radius are obtained. The
Fig. 1. Preoperative radiographs of an unstable distal radius fracture in a 55-year-old woman.

CLOSED REDUCTION, PERCUTANEOUS PINNING 177
Fig. 2. The fracture is closed reduced with volarly directed manipulation and 10 lbs of finger trap traction.
fracture is manipulated with volarly directed pressure on the dorsum of the distal fracture frag-
ment in an effort to restore length and volar tilt (Figs. 1, 2). In instances where the distal fracture
fragment is translated radially, ulnarly directed pressure on the radial styloid or ulnar transla-
tion of the wrist by ulnar deviation and manual translation of the hand can facilitate reduction.
The reduction is monitored fluoroscopically (Fig. 3). If it is felt that reduction is achievable, the
surgeon proceeds with the planned percutaneous pin fixation. If the fracture is not reducible
closed, open reduction and internal fixation may be required.
The authors’ preference is to place pins from the radial styloid first. The pins are 0.062 in
diameter. The authors place the pins under direct vision to avoid injury to the superficial sensory
branch of the radial nerve or the tendons of the first compartment (Fig. 4). A 1.5 cm longitu-
dinal incision is made extending from the tip of the radial styloid distally. The superficial sensory
branch of the radial nerve is identified and retracted. The pins usually are placed just dorsal to
the first extensor compartment, but they may be placed volar to the compartment depending
upon the pattern of the fracture and the location of the superficial sensory branch of the nerve.
There is frequently some loss of reduction of the fracture once manual pressure on the distal
fracture fragment is released to begin pin placement. Therefore, the first pin is placed in the dis-
tal fracture fragment, not crossing the fracture line. The pin always is placed through a soft tis-
sue protector to avoid wrapping up adjacent soft tissues structures. The first pin is started at the
Fig. 3. Initial closed reduction lateral.

178 GLICKEL et al
Fig. 4. (A) The superficial sensory branch of the radial nerve and the first dorsal extensor compartment are exposed
with a longitudinal incision. The black arrow identifies the superficial sensory branch of the radial nerve. (B) A
0.062 in K-wire is placed from the radial styloid with a tissue protector while retracting the superficial sensory branch
of radial nerve.
tip of the radial styloid and directed at a fairly shallow angle obliquely with the goal of crossing
the fracture line and engaging the ulnar cortex of the radius proximal to the fracture. Once the
pin is driven into the distal fracture fragment with a K-wire driver, the fracture is re-reduced and
the reduction confirmed with PA and lateral radiographs. When the fracture is reduced anatom-
ically, the K-wire is driven across the fracture and the distal radial metaphysis engaging the ul-
nar cortex proximal to the fracture line. Postfixation fluoroscopic images are obtained. Usually,
a second 0.062 in K-wire is placed at a slightly more proximal starting point and at a slightly
different angle than the initial pin, directing it more dorsally or volarly within the medullary ca-
nal and at a slightly different obliquity. Reduction and fixation are confirmed with the image
intensifier (Fig. 5).
For two-part fractures, a second set of pins is placed perpendicular to the radial styloid pins.
Generally, the authors place those pins beginning from the dorsal rim of the distal radius just
distal to Lister’s tubercle (Fig. 6). The pins should be started just distal to the tubercle or slightly
radial to it. Beginning the pin ulnar to that point runs the risk of tethering or otherwise injuring
the extensor pollicis longus (EPL) tendon. The wrist is placed in position to obtain a lateral im-
age, and the starting point of the pin at the dorsal rim of the radius is confirmed. It is important
to start the pin in the fairly dense, solid bone of the dorsal rim of the radius as opposed to more
proximally where it is thinner and may be comminuted from the fracture. The pin is driven
obliquely from dorsal to volar across the fracture line, engaging the volar cortex of the radius
proximal to the fracture. In some patients, a second pin may be placed in a similar manner
Fig. 5. Placement of the radial styloid K-wires is confirmed with imaging.

Fig. 6. A pin is placed at the dorsal rim of the radius distal to Lister’s tubercle to provide orthogonal fixation and avoid
the EPL tendon.
beginning just proximal to the first pin and directed at a slightly different angle to enhance the
fixation.
There are some modifications of this basic pinning technique, which are used in specific
fractures to assist with the reduction or provide fixation for the ulnar fracture fragment in three
part fractures. Fractures treated 2 to 3 weeks after injury may be difficult to reduce simply with
manipulation and manual pressure. In that case, an intrafocal pin may be used to assist in the
reduction. If the fracture is shortened, and the distal articular surface dorsally tilted, an intra-focal
pin is placed into the fracture dorsally at an angle from proximal to distal. The position of the pin
is confirmed fluoroscopically, and it is used to manually advance the distal fracture fragment
distally and volarly by levering the pin distally, changing the obliquity of the pin to distal to
proximal from the original proximal to distal position. Usually, this can be done percutaneously.
The exception is a fracture close to 3 weeks old that is healed enough that a 0.062 in K-wire is not
sufficiently rigid to accomplish the goal of mobilization of the distal fracture fragment. In that
case, a short longitudinal incision is made over the fracture line, and a 3/16 in Steinman pin with
a spatula tip is placed into the fracture and swept from radial to ulnar breaking up some the heal-
ing callus. The pin then is used to push the distal fracture fragment distally and volarly.
A similar technique can be used to assist in translating the distal fracture fragment ulnarly if
it is displaced radially. This should be done under direct vision to avoid injury to the superficial
sensory branch of the radial nerve and the tendons of the first compartment. The incision
described previously for exposure of the radial styloid may be extended proximally or a separate
1 cm incision made to expose the fracture. A 0.062 in K-wire is placed into the fracture at an
angle from proximal to distal. The pin is levered distally, mobilizing the distal fracture fragment
and translating it ulnarly. Once the reduction is felt to be satisfactory, percutaneous pin fixation
is achieved using the technique described previously. The surgeon may opt to leave the intra-
focal pin in place and drive it proximally into the cortex adjacent to the fracture. Alternatively,
the pin is removed once the fracture is fixed.
If the fracture has three parts and there is any proximal subsidence of the lunate fossa
creating a step off, this may be addressed percutaneously also. If there is proximal displacement
of the lunate fossa fragment, it can be advanced distally using an intrafocal pin placed
percutaneously into the dorsum of the fracture as described previously. The pin is angled from
proximal to distal and the fracture fragment advanced distally as the pin is pushed in an arc
from proximal to distal. Fixation of the lunate fossa fragment can be achieved in one of two
ways. Proximal subsidence of the fracture can be prevented by placing a transverse pin from the
radial styloid across the distal radial metaphysis just proximal to the subchondral bone (Fig. 7).
The tip of the pin is driven to engage the ulnar cortex of the radius in the area of the sigmoid
notch, but the pin should not extend beyond the cortex into the distal radioulnar joint. An al-
ternative is to fix the lunate fossa fragment with a pin placed percutaneously from the dorsoul-
nar corner of the distal radius, driving it obliquely in a dorsovolar direction to engage the volar
cortex proximal to the fracture line. In general, that pin is started in the interval between the
180 GLICKEL et al
Fig. 7. Placement of a transverse and subchondral K-wire to buttress the lunate fossa fracture fragment is shown on
imaging.
fourth and fifth extensor compartments, and the starting point of the pin is confirmed fluoro-
scopically before advancing the pin.
Once the distal radius fracture is stabilized, the distal radioulnar joint (DRUJ) is examined to
assess stability (Fig. 8). If the joint is unstable, and there is no ulnar styloid fracture, the DRUJ
is stabilized by pinning the ulna to the radius with two 0.062 in Kirschner wires placed trans-
versely proximal to the joint. If the ulnar styloid is fractured at its base, consideration is given
to fixing the fracture, which may be done with a tension band.
The reduction and fixation are assessed with final fluoroscopic images in at least two planes
(Fig. 9). The pins are left superficial to the skin and are bent using pliers to prevent migration.
The radial styloid pins may be left through the incision. If they tent the skin adjacent to the in-
cision, the skin either needs to be released with a secondary incision or the pin can be cut, and,
before bending it, placed through the skin adjacent to the incision, obviating the need for addi-
tional incisions. The radial styloid incision is closed with interrupted absorbable sutures
(Fig. 10). The authors’ current preference is to use 5/0 Vicryl Rapide (Ethicon, Incorporated,
Somerville, New Jersey). They have seen very little skin reaction to that suture, which remains
for a greater duration than plain cat gut suture.
Fig. 8. After fixation of the distal radius, DRUJ stability is tested.

Fig. 9. (A, B) The final K-wire placement and final reduction are shown on imaging.
Postoperative care and rehabilitation
The fracture usually is immobilized for the first 2 weeks postoperatively in a sugar tong
splint. It is the authors’ impression that immobilizing the forearm for 2 weeks is useful to allow
the skin around the pins to begin healing. This may help to prevent irritation of the pin sites.
Alternatively, the wrist can be immobilized in dorsovolar splints. The splints are secured with
Coban (3M, St. Paul, MN) wrapped with no tension (Fig. 11). After the initial 2 weeks of im-
mobilization, the patient is seen back in the office for follow-up radiographs. The wrist then is
immobilized in a short-arm cast if the distal radioulnar joint was stable at surgery, or a long-arm
cast if the distal radioulnar joint was unstable and needed to be pinned during the surgery. Pa-
tients then are seen biweekly to obtain new radiographs. The cast is removed, and the pin sites
are examined only if the patient has complaints, or if there is a concern about pin site infection
or pin migration. Immobilization usually is continued for 5 to 6 weeks postoperatively. The au-
thors never immobilize a fracture of the distal radius for longer than 6 weeks. At that point, the
cast is removed. If the fracture is nontender, and radiographs confirm maintenance of reduction
and healing of the fracture, the Kirschner wires are removed. The patient is referred to the hand
therapist for a prefabricated wrist-resting splint, which is used for support and protection of the
wrist for the 2 weeks after immobilization is discontinued. The patient removes the splint to
work on range-of-motion exercises and scar massage. Range of motion usually can be regained
within 10 to 12 weeks postoperatively. Two weeks after immobilization is discontinued, gentle
strengthening exercise with putty and a hand gripper is started. At 1 month after
Fig. 10. The K-wires are bent, cut, and left superficial to the skin. The incision is closed with 5/0 Vicryl Rapide.
(Ethicon, Incorporated, Somerville, NJ.)
182 GLICKEL et al
Fig. 11. The final dressing and splint are applied. They consist of a sugar tong splint wrapped with coban.
immobilization, light resistive exercises can be started using a 1 to 3 lb dumbbell and progressing
as the patient tolerates. At 3 months after fracture, they can resume most activities with the ex-
ception of contact sports, and at 4 months after fracture they can resume playing contact sports
(Figs. 12–14).
Results and complications
Follow-up studies have shown variable results of percutaneous pinning. Some of these
studies, however, relied on pinning of the fractures solely through the radial styloid and reported
several instances of loss of reduction [15–17]. Several recent prospective studies demonstrated
the effectiveness of closed reduction and percutaneous pinning when the pins were placed per-
pendicular to each other in an orthogonal configuration.
In a prospective randomized study of 40 patients, Rodriguez-Merchan [18] compared plaster
cast immobilization with percutaneous pinning and casting in patients between 46 and 65 years
old. The pins were placed in a crossed pin configuration with two pins from the radial styloid
Fig. 12. Preoperative radiographs of an unstable distal radius fracture with an intra-articular gap.
Fig. 13. Six-week follow-up radiographs are obtained just before K wire removal.
toward the ulna and one pin placed from the ulnar aspect of the radius and driven radially. The
plaster group had a significant loss of position in 75% of the patients, while all of pinning pa-
tients maintained their initial reductions. The best anatomic and functional results were ob-
tained in the percutaneous pinning group. There were two pin tract infections that were
superficial and responded to pin care and antibiotics, and one patient in each group developed
reflex sympathetic pain.
Ludvigsen and colleagues [19] reported on a randomized group of 60 patients who were
treated with external fixation or percutaneous pinning. The patients from both groups had
equally good outcomes, which were not statistically significantly different. The complications
in both groups were similar and included 13 patients who had injury to the superficial radial
nerve. This was persistent in five patients, three from the external fixation group and two in
the pinning group. Reflex sympathetic dystrophy (RSD) occurred in three patients in the exter-
nal fixation group and in one patient in the pinning group. None of the patients required anti-
biotics for any pin-related infections.
Fig. 14. Seven-month follow-up shows a completely healed fracture with excellent alignment.
184 GLICKEL et al
Harley and colleagues [20] prospectively randomized a group of 50 patients under the age of
65 who received augmented external fixation or percutaneous pinning and casting. The percu-
taneous pinning group had at least two pins placed from the radial styloid and directed ulnarly
and one pin from the dorsal surface of the radius directed volarly. Both groups had similar out-
comes in regards to wrist motion, grip strength, disabilities of the arm, shoulder, and hand
(DASH) scores and shortform (SF)-36 scores at 6 and 12 months of follow-up. Four patients
had persistent superficial radial nerve irritation, one in the percutaneous pinning group and
three in the external fixation group. Six patients required antibiotics for pin tract infections,
two in the percutaneous pinning group and four in the external fixation group. All three patients
diagnosed with RSD were treated with external fixation.
In a prospective randomized study with 100 patients, Strohm and colleagues [21] compared
two different procedures for pinning of distal radius fractures. One method of pinning was with
two K-wires inserted at the styloid process as described by Willenegger and Guggenbuhl [2]. The
technique with which it was compared was a modified Kapandji method as described by Fritz
and colleagues [22] using two dorsal intrafocal pins and one radial styloid pin. They found the
functional and radiographic outcomes to be significantly better in the patients who had intra-
focal pinning and attributed the results, in part, to a shorter immobilization period in those pa-
tients. Complications were not significantly different between the groups. In total, 12 patients
had nerve irritations that resolved after pin removal. Eight patients between the groups had
wire migration, but none of the patients had tendon injury or rupture. One patient in each group
developed carpal tunnel syndrome, and one patient in each group developed RSD.
The authors have been very satisfied with their results of closed reduction and percutaneous
pinning for unstable distal radius fractures. The authors’ complication rate for these cases has
been low and comparable to the reported series. Complications have included pin tract irritation
and superficial infection, loss of reduction, and superficial radial nerve irritation. Fortunately,
superficial radial nerve complaints have been minimal and resolve after pin removal. The
authors feel this is related directly to visualization of the nerve during pin placement.
Summary
Closed reduction and percutaneous pinning is a valuable technique for treating displaced and
unstable distal radius fractures. The method is relatively simple, minimally invasive, and
reliable. Good-to-excellent results usually can be achieved when the procedure is performed for
the proper indications, and a biomechanically sound pin configuration is used. Complication
rates have been low and manageable and have included pin tract infections and skin irritation.
These problems usually can be treated effectively with oral antibiotics or pin removal. Injury to
the superficial sensory branch of the radial nerve is also a commonly reported complication that
can be avoided with direct visualization of the nerve. Occasionally, the nerve is irritated by its
proximity to the pins. This generally resolves with pin removal.
Acknowledgments
Special thanks to Benjamin Chia, BS, for his assistance with preparation of the manuscript.
References
[1] Lambotte A. L’Intervention opératoire dans les fractures récentes et anciennes. A. Maloine: Paris; 1907.
[2] Willenegger H, Guggenbuhl A. Operative treatment of certain cases of distal radius fracture. Helv Chir Acta 1959;
26(2):81–94.
[3] Stein AH Jr, Katz SF. Stabilization of comminuted fractures of the distal inch of the radius: percutaneous pinning.
Clin Orthop Relat Res 1975;(108):174–81.
[4] Clancey GJ. Percutaneous Kirschner-wire fixation of Colles fractures. A prospective study of thirty cases. J Bone
Joint Surg Am 1984;66(7):1008–14.
[5] Fernandez DL, Geissler WB. Treatment of displaced articular fractures of the radius. J Hand Surg [Am] 1991;16(3):
375–84.
[6] Kapandji A. Internal fixation by double intrafocal plate. Functional treatment of nonarticular fractures of the lower
end of the radius. Ann Chir 1976;30(11–12):903–8.
[7] Kapandji A. Intrafocal pinning of fractures of the distal end of the radius 10 years later. Ann Chir Main 1987;6(1):
57–63.
[8] DePalma A. Comminuted fractures of the distal end of the radius treated by ulnar pinning. J Bone Joint Surg [Am]
1952;34(3):651–62.
[9] Lortat-Jacob A, Frank A, de Bonduwe A, et al. Y nailing in the treatment of fractures with posterior displacement
of the lower end of the radius. Acta Orthop Belg 1982;48(6):936–46.
[10] Mortier JP, Baux S, Uhl JF, et al. The importance of the posteromedial fragment and its specific pinning in fractures
of the distal radius. Ann Chir Main 1983;2(3):219–29.
[11] Rayhack JM. The history and evolution of percutaneous pinning of displaced distal radius fractures. Orthop Clin
North Am 1993;24(2):287–300.
[12] Rayhack JM, Langworthy JN, Belsole RJ. Transulnar percutaneous pinning of displaced distal radial fractures:
a preliminary report. J Orthop Trauma 1989;3(2):107–14.
[13] Naidu SH, Capo JT, Moulton M, et al. Percutaneous pinning of distal radius fractures: a biomechanical study.
J Hand Surg [Am] 1997;22(2):252–7.
[14] Rogge RD, Adams BD, Goel VK. An analysis of bone stresses and fixation stability using a finite element model of
simulated distal radius fractures. J Hand Surg [Am] 2002;27(1):86–92.
[15] Habernek H, Weinstabl R, Fialka C, et al. Unstable distal radius fractures treated by modified Kirschner wire pin-
ning: anatomic considerations, technique, and results. J Trauma 1994;36(1):83–8.
[16] Mah ET, Atkinson RN. Percutaneous Kirschner wire stabilisation following closed reduction of Colles’ fractures.
J Hand Surg [Br] 1992;17(1):55–62.
[17] Munson GO, Gainor BJ. Percutaneous pinning of distal radius fractures. J Trauma 1981;21(12):1032–5.
[18] Rodriguez-Merchan EC. Plaster cast versus percutaneous pin fixation for comminuted fractures of the distal radius
in patients between 46 and 65 years of age. J Orthop Trauma 1997;11(3):212–7.
[19] Ludvigsen TC, Johansen S, Svenningsen S, et al. External fixation versus percutaneous pinning for unstable Colles’
fracture. Equal outcome in a randomized study of 60 patients. Acta Orthop Scand 1997;68(3):255–8.
[20] Harley BJ, Scharfenberger A, Beaupre LA, et al. Augmented external fixation versus percutaneous pinning and cast-
ing for unstable fractures of the distal radius–a prospective randomized trial. J Hand Surg [Am] 2004;29(5):815–24.
[21] Strohm PC, Muller CA, Boll T, et al. Two procedures for Kirschner wire osteosynthesis of distal radial fractures.
A randomized trial. J Bone Joint Surg Am 2004;86-A(12):2621–8.
[22] Fritz T, Wersching D, Klavora R, et al. Combined Kirschner wire fixation in the treatment of Colles fracture.
A prospective, controlled trial. Arch Orthop Trauma Surg 1999;119(3–4):171–8.
Atlas Hand Clin 11 (2006) 187–196
Distal Radius Fractures: External Fixation

and Supplemental K-Wires
Keith B. Raskin, MD*, Michael E. Rettig, MD
Department of Orthopaedic Surgery, New York University Medical Center,
New York University School of Medicine, 317 East 34th Street, Third Floor, New York, NY 10016, USA
Fractures of the distal radius are among the most commonly encountered injuries seen in the
emergency room setting. Understanding the normal distal radius anatomy is essential for the
treating physician. The outcome of management is related directly to successfully identifying,
reducing, and stabilizing those unstable fractures. Restoring articular congruity and the rela-
tion between the distal radius and the surrounding skeletal structures are key anatomic
considerations.
The radial length is defined as the relationship between the medial articular surface of the
radius and the corresponding articular head of the ulna. There is a great degree of normal
variation in length defined as positive ulnar variance (ulna length is greater than the radius) and
negative ulnar variance (ulna length is less than the radius). Radial inclination is the angle of the
surface as identified from the radial styloid to the medial articular surface. The normal is 22 ,
with a range of 13 to 30 . The volar tilt is the angle of the surface from the dorsal to the volar
surface as seen on the lateral radiograph. The average is 11 , with a range of 0 to 28 . The
scaphoid and lunate fossas are the articular surfaces that correspond with their adjacent carpal
bones, and the sigmoid notch is the articulating surface with the ulna head.
Principles of management
The fundamental goal of treatment for distal radius fractures is an accurate and stable
reduction. It generally is acknowledged that the reduction may be achieved easily but difficult to
maintain [1,2]. Successful treatment requires a method of reduction that restores anatomic re-
lationships between the fractured radius and adjacent ulna and carpus and maintains this align-
ment until the healing process is complete. Although a good functional result can be achieved
despite a poor radiographic result, excellent function is more likely to be attained when normal
anatomy has been restored [3].
Recognizing the stability of the fracture is paramount when selecting appropriate treatment.
Although stable fractures often can be reduced and maintained in a cast, closed techniques are
doomed to failure for the unstable fracture. Reduction of the unstable fracture may be possible,
but maintenance of the reduction until fracture healing is unlikely. As Gartland and Werley
observed, redisplacement of the unstable fracture, frequently to its prereduction position, is
inevitable [4].
Clearly identifiable radiographic features of initial displacement are markers of fracture
instability. Radial shortening in excess of 10 mm is predisposed to further collapse, resulting in
disabling distal radioulnar joint instability and ulnocarpal joint impaction. Lindstrom has
indicated that residual shortening of only 6 mm can compromise wrist function seriously [5].
E-mail address: drraskin@aol.com (K.B. Raskin).
1082-3131/06/$ - see front matter 2006 Elsevier Inc. All rights reserved.
188 RASKIN & RETTIG
Palmer and Short have demonstrated that even a lesser discrepancy in radioulnar length is likely
to cause deleterious alterations in load bearing, leading to articular deterioration [6]. Because
even relatively stable fractures tend to collapse several millimeters because of impaction of com-
minuted metaphyseal fragments, a successful closed reduction should secure the preinjury level
of radial length. Comparison radiographs of the contralateral wrist should be assessed to deter-
mine the normal radial length and to avoid misinterpretation because of anatomic variation.
Angulation or tilting of the radial articular surface greater than 15 to 20 in the sagittal plane
is a typical feature of the unstable distal radius fracture that is difficult to correct and maintain
by closed reduction and casting alone. Metaphyseal comminution involving both the volar and
dorsal radial cortices eliminates an intact bony buttress, upon which a stable reduction must
hinge (Fig. 1).
Preoperative planning
Standard radiographs of the wrist are obtained in the posteroanterior (PA), lateral, and
oblique views. Comparative views of the unaffected contralateral side also are recommended.
This enables the surgeon to determine the actual radial length, inclination, and volar tilt for each
individual patient, because a degree of acceptable variables exist within the population. If an
associated intercarpal ligament injury is suspected, then an MRI or intraoperative arthroscopy
may be warranted (Fig. 2). It is essential to encourage the patient to begin active range of mo-
tion exercises for the digits, elbow, and shoulder before surgical intervention. This diminishes
the likelihood of progression stiffness and functional limitations.
External fixation indications
Although volar interlocking plates recently have gained popularity for treating unstable
distal radius fractures, specific indications for external fixation remain. The most common
indication for external fixation is a displaced articular unstable fracture in which assessment and
reduction of the articular surface is paramount (Figs. 3, 4). Only with bridging external fixator
devices can the detrimental forces of the carpus be neutralized and the articular component of
the fracture reduced. External fixation also provides stabilization of these fractures without the
need for more significant soft tissue dissection and permanent hardware placement. Concomi-
tant soft tissue injuries to the scapholunate ligament, triangular fibrocartilage, or median nerve
also are suited for management in conjunction with external fixation.
Equipment
Equipment for treating distal radius fractures includes:

• External fixator
• Blunt-tipped external fixation half pins
Fig. 1. Lateral radiograph of an unstable dorsally angulated distal radius fracture with dorsal and volar comminution.
EXTERNAL FIXATION AND SUPPLEMENTAL K-WIRES 189
Fig. 2. (A) Preoperative radiograph of an unstable articular distal radius fracture with associated scapholunate ligament
tear. (B) Postoperative radiograph demonstrating accurate articular reduction of the radius fracture and restored carpal
alignment.
• Appropriate size drill bit and power drill

• 0.062 in smooth K-wires
• Bone graft substitute as needed
• Intraoperative fluoroscopy
• Surgical arm board
Intraoperative radiographic assessment of the radius fracture with respect to restoration of
radial length, inclination, volar tilt, and articular alignment mandates the use of fluoroscopic
equipment. The application of the external fixation device requires the appropriate drills, blunt
skeletal half pins, and external fixation frame of the surgeon’s choice. Supplemental K-wire
fixation has proven to add to fracture stability and is inserted with power wire driver. If bone
graft or bone graft substitute is needed, the proper surgical tools or products should be
available.
Fig. 3. Radiograph of typical intra-articular fracture displacement requiring external fixation and open reduction of sur-
face fragment.
190 RASKIN & RETTIG
Fig. 4. Radiograph of complex fracture configuration with involvement of the radiocarpal and radioulnar articular
surfaces.
Positioning and preparation
The surgery most commonly is performed under a regional anesthetic with supplemental
intravenous sedation. The patient is in a supine position with the arm abducted to the side of the
body at 90 to the body. The surgeon can sit comfortably within this inner side of the arm table
with the assistant opposite him or her. The surgeon must avoid hyperpronating the forearm in
an attempt to improve visualization during pin insertion, because this may lead to poor pin
placement or malreduction at the fracture site.
Surgical incision landmarks
Although the external fixation frames have been inserted previously through percutaneous
technique, the unacceptably high incidence of associated complications related to malposition-
ing of the pins and related soft tissue injury have led to the more commonly used limited incision
technique of half pin insertion. The pins are inserted into the index metacarpal proximal shaft
and the radial shaft approximately 3 to 4 cm proximal to the fracture.
The length of the external fixator should be identified clearly before making the skin
incisions, because this will determine the amount of distraction that the fixator can achieve. If
the proximal incision site along the radial shaft is too proximal in location, the fixator length
may prohibit obtaining sufficient ligamentotaxis.
Surgical approach and procedure
After an adequate anesthetic level has been achieved, the entire arm is prepared and draped in
a standard manner. The more severely deformed wrists are aligned relatively through primary
gentle closed manipulation (Fig. 5). The arm is exsanguinated with a compressive elastic ban-
dage, and then a well-padded tourniquet is inflated over the proximal arm to an appropriate
level. The planning of the pin placement for the fixator is aided through the proper positioning
of the fixation device along the radial side of the forearm before incisions (Fig. 6). The index
metacarpal is approached through a 2 cm longitudinal incision over the dorsal radial base.
Fig. 5. Initial closed manipulation of the distal radius fracture for gross reduction before application of external fixation
frame.
The terminal branches of the radial sensory nerve are protected, as the first dorsal interosseous
muscle and periosteum are reflected minimally.
The drill guide is aligned carefully with the surface of the metacarpal to assure bicortical pin
insertion. This decreases the likelihood of unicortical drilling with the related complications of
potential pin loosening, infection, or iatrogenic metacarpal fracture. After predrilling the pin
sites, the pins are inserted manually while maintaining the correct pin alignment [7].
The radial shaft pins then are place through a similar technique of insertion. Again, a 2 cm
longitudinal incision is created along the radial shaft proximal to the fracture site. The lateral
antibrachial cutaneous nerve branches are protected. The deeper dissection reveals the radial
sensory nerve as it pierces the fascial layer between the brachioradialis and the extensor carpi
radialis longus (Fig. 7).
The pins are inserted between the extensor carpi radialis longus and brevis, thereby avoiding
the radial sensory nerve. Accurate bicortical pin insertion is equally important at this location
(Fig. 8).
Once the pins have been inserted and placement confirmed with the intraoperative
fluoroscopy unit, the wounds are irrigated and closed before application of the external fixation
frame. This has allowed for better wound repair without the fixation frame interfering with
closure.
The external fixation frame now is secured to both sets of half pins, while the wrist is
maintained in a relatively aligned posture (Fig. 9). Most frames have a sliding clamp component
that allows for distraction (ligamentotaxis) across the wrist joint (Fig. 10). The authors have
found it useful to assist in the reduction with gentle longitudinal traction applied to the fingers
while countertraction is maintained at the 90 flexed elbow. Finger trap apparatus along with
a weight and pulley system has also been described with similar success.
After the compressive force of the carpus has been neutralized from the surface of the radius
through ligamentotaxis, closed manipulation of the fracture can be performed. Often the
residual dorsal angular deformity may prevail, despite restoration of radial length and
inclination. The fixator is adjusted temporarily in a flexed position, allowing for a greater
correction of volar tilt. By manual reduction of the distal fragments, with possible intrafocal
Fig. 6. Marked incision sites for external fixation pin placement using external fixator as guide for accurate placement.
192 RASKIN & RETTIG
Fig. 7. Radial nerve is identified and protected before placement of the proximal half pins. The nerve pierces the fascia
between the brachioradialis and extensor carpi radialis longus.
pinning or k wire stabilization from the radial styloid into the radial shaft, the correction of
volar tilt can be obtained (Fig. 11). Several of the newer external fixators have a mechanical abil-
ity to assist in restoring volar tilt and radial inclination and rotational alignment (Fig. 12).
Smooth K-wires are inserted percutaneously from the radial styloid fragment, into the intact
radial shaft, acting as a buttress support for the fracture. If intrafocal pins are to be added, care
is taken to avoid penetrating the extensor tendons. This may require a small stab incision and
spreading through the soft tissue before pin placement.
The authors prefer to insert two to three wires in a diverging pattern from the styloid or from
the dorsal radial border of the distal fragment into the radial shaft to add to the stability of the
configuration and thereby lessen the demands of the external fixator (Fig. 13). Although a trans-
verse wire can be placed safely from the radial styloid to the medial fracture fragment, often this
medial fragment is comminuted with little or no cortical bone purchase.
Once the wires are placed and intraoperative radiographs confirm placement, the fixator can
be restored to a neutral alignment, avoiding the flexed posture required for primary fracture
reduction (Fig. 14).
If the radiographs reveal malreduction of the fracture despite optimal frame and wire
application, a limited open reduction and additional bone graft or bone graft substitute are
suggested. This can be performed through a small incision over Lister’s tubercle with blunt
surgical spreading through the soft tissue until the fracture is encountered. The extensor pollicis
longus should be decompressed from within Lister’s tubercle to prevent potential attritional
rupture. Often a freer elevator can augment the elevation of the fracture fragments before
insertion of the bone graft. Fluoroscopic imaging or direct inspection of the articular surface
through a dorsal capsulectomy confirms final reduction.
One of the more common pitfalls of this procedure is to overdistract the carpus through
excessive ligamentotaxis. This commonly will lead to the complications of stiff digits with
residual loss of motion, loss of wrist flexion and extension arc, and possible reflex sympathetic
dystrophy (RSD)-type complaints.
Fig. 8. Completion of half pin placement for the external fixation frame using an open technique of pin placement.
Fig. 9. Pin incision sites are repaired before application of frame. Frame is secured in a neutral alignment avoiding hy-
perflexion and excessive ulnar deviation.
There are two basic intraoperative techniques that the authors have performed routinely to
assure avoidance of overdistraction and the subsequent complications. The most reliable
technique is a clinical passive finger flexion test. Once the fixator is in place and the fracture is
reduced, the surgeon passively flexes the patient’s metacarpophalangeal joints along with
simultaneous flexion of the interphalangeal joints. If the fingers can be flexed passively to the
level of the proximal palmar crease without excessive force, there is not excessive distraction
across the wrist joint. If there is a great degree of difficulty in passively flexing the digits,
however, then extrinsic extensor tendon tightness is present, which will be related directly to
overdistraction.
The intraoperative radiographic assessment is an additional secondary evaluation tool of
ligamentotaxis after fracture reduction. Based on the authors’ research in this field of study, the
distance of the radiocarpal joint space (RC) and the midcarpal joint space (MC) should be
measured on standard A/P fluoroscopic views [8]. If the ratio of the RC:MC joint was 2:1 or
less, then most patients fell within the safe zone of distractive force across the wrist. If there
was greater than a 1:1 RC:MC ratio (ie, 1:2 RC:MC) then the volar radioscaphocapitate and
radiolunotriquetral ligaments may be overdistracted and potentially can lead to the common
complications of stiffness.
Postoperative protocol
There are various methods of postoperative management of the external fixators, each of
which have their proponents. The authors have found that a dry sterile bandage surrounding the
fixator half pins along with dressing changes and pin care every 2 weeks have eliminated the
need for patient daily care and allowed for successful healing with a paucity of complications in
most patients. In the unlikely event that a superficial infection is encountered, local wound care
is performed on a daily basis along with oral antibiotics. It is rare to encounter a case of
Fig. 10. All mechanical adjustments of the external fixation frame should be aligned and stabilized before achieving pri-
mary distraction in an attempt to maintain direct ligamentotaxis across the radiocarpal joint while regaining radial
length. (From Raskin KB, Rettig ME. Distal radius fractures and malunions. Atlas of Hand Clinics 2000;5(1):70–2.)
194 RASKIN & RETTIG
Fig. 11. (A) Lateral radiograph of an unstable distal radius fracture revealing recurrence of dorsal collapse in plaster
cast. (B) Postoperative lateral radiograph demonstrating restored volar tilt and a fracture alignment after external fix-
ation and k-wire placement.
osteomyelitis and the need for premature removal of the fixator along with debridement and
intravenous antibiotics.
During the early postoperative period, it is imperative that finger, elbow, and shoulder range
of motion exercises be instituted. If there appears to be slow progress in regaining the acceptable
arc of motion, then a more comprehensive occupational therapy program is begun.
Fig. 12. (A) The rotational component of the external fixator allows for correction of pronation and supination defor-
mities. (B) The distal ball joint apparatus facilitates fracture realignment (C) Fine manipulation of the fracture can be
performed through the external fixation device to restore volar tilt and radial and ulnar translation. (D) The final appear-
ance of the external fixation device, with restored alignment of the distal radius and without obscuring the radiographic
assessment or clinical sign of excessive ligamentotaxis. (From Raskin KB, Rettig ME. Distal radius fractures and mal-
unions. Atlas of Hand Clinics 2000;5(1):70–2.)
Fig. 13. Insertion of 0.062 in k-wires from styloid into intact radial shaft.
Follow-up and results
Distal radius fractures often heal within 6 to 8 weeks. Once adequate healing is observed
clinically and radiographically, the fixator and pins can be removed under a local anesthetic. It
is not uncommon for the radiographic appearance of fracture bridging to lag behind the clinical
assessment of healing without point tenderness at the previous fracture site. Therapy is
advanced to include wrist range of motion and subsequent strengthening. Recent meta-analysis
of the results of external fixation demonstrated recovery of 55 of wrist flexion and extension,
75 of supination, and 84 of pronation. Radiographic evaluation revealed restoration of volar
tilt to 0.5 , radial inclination of 20.1 , and ulnar variance to 1 mm [9]. The authors recently re-
viewed 350 patients who had unstable distal radius fractures managed by external fixation and
supplemental K-wires with an average of 42 months follow-up. There was less than 1% compli-
cation of infection (three patients) and less than 1% iatrogenic injury to the metacarpal (two
patients) or radial shaft (one patient). No patient required further surgical intervention.
A comparison of spanning external fixation and nonspanning external fixation for the
treatment of distal radius fractures suggests improved results with the nonspanning fixator
[10,11] . Patients with nonspanning external fixation had statistically significant better radiologic
results, and their functional indices improved earlier after fixator removal.
Summary
The primary treatment goal for fractures of the distal radius is fracture reduction and
stabilization to permit restoration of pain-free wrist function.
Recognition of fracture instability based on the radiographic evaluation of fragment
comminution and displacement is the focus of current classifications. Although closed reduction
and cast immobilization remain a reliable treatment method for stable fractures, similar
management for unstable fractures is prone to failure.
Ligamentotaxis employing a spanning external fixator in conjunction with supplemental
Kirschner wires has proved to be a reliable means of maintaining an accurate reduction of
Fig. 14. Final alignment of the wrist after external fixation and k-wire stabilization.
196 RASKIN & RETTIG
unstable fractures. Successful uncomplicated treatment of distal radius fractures with external
fixation is related directly to precise, reproducible surgical technique. The frequently reported
pin-related complications can be reduced significantly by several key steps to surgical
application. Open bicortical half pin placement avoids soft tissue, tendon, and nerve iatrogenic
injuries, and minimizes the risk of unicortical pin insertion that can result in metacarpal or
radial shaft fractures or subsequent loosening or infection. Pin inflammation and superficial
infection often can be resolved by oral antibiotics, physician pin care, and gauze dressing.
Properly applied ligamentotaxis will allow healing of the distal radius fracture without
complications related to overdistraction [12,13].
External fixation frames have been modified to allow for early wrist range of motion during
the acute healing phase in an attempt to prevent potential residual wrist stiffness. Despite this
attractive concept, there appears to be no significant additional benefit to dynamic fixation of
these fractures compared with the traditional static wrist immobilization until completion of
union.
Although ligamentotaxis is effective in restoring length and inclination, it will not restore
articular congruity consistently in fractures characterized by marked articular displacement.
Restoration of articular congruity can be accomplished by open treatment [14].
Additional stability with improved restoration of volar tilt can be accomplished by closed
manipulation in conjunction with multiple percutaneous smooth K-wires inserted from the
volar aspect of the radial styloid into the intact dorsal ulnar cortex of the proximal shaft.
Excessive flexion or ulnar deviation should be avoided, as these positions potentate the risk of
median nerve compression at the wrist level. External fixation with supplemental K-wires is an
excellent method for stabilizing displaced unstable distal radius fractures. When properly used,
complications can be minimized, and an excellent radiographic and functional recovery can be
achieved. Meticulous attention to surgical detail and a comprehensive postoperative program
are the key components to a reliable and reproducibly successful recovery.
References
[1] Abbaszadegan H, Jonsson U, vonSilvers K. Prediction of instability of Colles’ fractures. Acta Orthop Scand 1989;
60:646–69.
[2] Jenkins NH. The unstable Colles’ fracture. J Hand Surg [Br] 1989;14:149–64.
[3] McQueen MM, Caspers JL. Colles fractures: does the anatomic result affect the final function? J Bone Joint Surg Br
1988;70:649–68.
[4] Gartland JJ Jr, Werley CW. Evaluation of healed Colles’ fractures. J Bone Joint Surg Am 1951;33:895–907.
[5] Lidstrom A. Fractures of the distal end of the radius. A clinical and statistical study of end results. Acta Orthop
Scand Suppl 1959;41:1–118.
[6] Palmer AK, Short WH, Werner FW, et al. A biomechanical study of distal radius fractures. J Hand Surg [Am] 1987;
12A:529–33.
[7] Raskin KB, Rettig ME. Distal radius fractures and malunions: skeletal realignment through external fixation. Atlas
of Hand Clin 2000;5:59–77.
[8] Raskin KB, Melone CP Jr, Rettig ME. External fixation by ligamentotaxis of distal radius fractures. Atlas of Hand
Clin 1997;2:51–72.
[9] Margaliot Z, Haase SC, Kotsis SV, et al. A meta-analysis of outcomes of external fixation versus plate osteosyn-
thesis for unstable distal radius fractures. J Hand Surg 2005;30A:1185–99.
[10] McQueen MM. Redisplaced fractures of the distal radius. A randomized prospective study of bridging versus non-
bridging external fixation. J Bone Joint Surg Br 1998;80B:665–9.
[11] McQueen MM. Nonspanning external fixation of the distal radius. Hand Clin 2005;21:375–80.
[12] Kaempffe FA, Wheeler DR, Peimer DA, et al. Severe fractures of the distal radius: Effect of amount and duration
of external fixator distraction on outcome. J Hand Surg [Am] 1993;18A:33–41.
[13] Loebig TG, Badia A, Anderson DD, et al. Correlation of wrist ligamentotaxis with carpal distraction: implications
for external fixation. J Hand Surg [Am] 1997;22A:1052–6.
[14] Melone CP Jr. Open treatment for displaced articular fractures of the distal radius. Clin Orthop 1986;202:103–11.
Atlas Hand Clin 11 (2006) 197–205
Nonbridging External Fixation

of the Distal Radius
Margaret M. McQueen, MD, FRCSEd(Orth)*,
Ingri Ekrol, MB, Chir B
Edinburgh Orthopaedic Trauma Unit, Royal Infirmary of Edinburgh,
Little France Crescent, Edinburgh EH16 4SU UK
Distal radius fractures are the most common fracture treated by orthopedic surgeons and
occur mostly as low-energy extra-articular or minimal articular fractures in middle-aged to
elderly women, but with a small peak of incidence also in young men with higher energy injuries,
which tend to be intra-articular [1]. Most stable distal radial fractures can be treated in a cast.
Metaphyseal instability, defined as demonstrated or predicted inability to retain the reduced ra-
diologic position in a cast, and articular displacement are considered indications for surgical
treatment of distal radial fractures in independent patients regardless of age. Numerous surgical
techniques are possible in this situation, including nonbridging external fixation, which employs
pins in the distal fragment between the fracture and the radiocarpal joint and pins in the radius
proximal to the fracture. The fixator does not bridge the radiocarpal, intercarpal, or carpome-
tacarpal joints.
The first recorded use of external fixation in the wrist was reported by Ombrédanne, who
used a nonbridging technique for fractures and osteotomies of the forearm in children in 1929.
Ombrédanne concluded that ‘‘temporary osteosynthesis with external connection allows
a mathematical adjustment of the surgical correction . and guarantees further retention
with ample and sufficient precision’’ [2].
Bridging external fixation was popularized by Anderson and O’Neil in 1944 [3]. At that time,
external fixation generally was used for severely comminuted intra-articular fractures of the dis-
tal radius in young men, and metaphyseal instability in middle-aged or older patients was not
considered an indication for surgical treatment. Malunion was accepted in these patients. Inter-
est in the nonbridging technique did not revive until the 1990s, possibly because of increasing
numbers of fitter, older patients with low-energy fractures, who, in contrast to previous gener-
ations, were not prepared to accept malunion and possible functional deficit. Most of these pa-
tients sustain extra-articular or minimal articular fractures making nonbridging external fixation
a feasible option.
Indications
The major indications for the use of nonbridging external fixation of the distal radius are in
unstable, dorsally displaced extra-articular fractures; unstable intra-articular fractures with
undisplaced articular extensions; selected unstable, displaced intra-articular fractures; distal
radial osteotomy for dorsal malunion; and open fractures of the distal radius. The most
common indication is in an unstable distal radial fracture that is extra-articular or has an
undisplaced articular extension. Instability may be predicted or diagnosed because the fracture
E-mail address: mmcqueen@staffmail.ed.ac.uk (M.M. McQueen).
198 MCQUEEN & EKROL
has redisplaced in a cast (Fig. 1). Radiologic factors increasing the risk of instability are the
presence of metaphyseal comminution, increasing radial shortening, and increasing initial dorsal
angulation [4].
The principle of the technique of nonbridging external fixation of the distal radius is the
placement of fixator pins from a dorsal to a volar direction in the distal fragment of the fracture,
avoiding immobilization of the radiocarpal and intercarpal joints. For the technique to be
possible, 1 cm of intact volar cortex is required (see Fig. 1C). Intact dorsal cortex on the distal
fragment is not required because the pins obtain their purchase in the volar cortex. Articular
displacement is not a contraindication to the technique, provided that there is space for pins
in the distal fragment after reduction and internal fixation of the articular surface, which may
be achieved using a hybrid technique with multiplanar pins in the distal fragment [5].
Nonbridging external fixation also is indicated for corrective osteotomy of the distal radius.
The technique allows minimally invasive surgery through a 4- to 5-cm incision.
As in any other technique for the management of unstable distal radius fractures,
nonbridging external fixation is not recommended for frail elderly dependent patients. With
such patients, the fracture should be managed in a cast and malunion accepted [6]. Osteoporosis
in a fit patient is not a contraindication, however, because fixation failure is rare [7–12]. As with
any external fixation technique, insertion of pins through areas of possible skin infection also is
contraindicated. Nonbridging external fixation is not suitable for use in volar displaced frac-
tures. These are usually best treated by plating.
Surgical technique
Patient positioning
General or regional anesthesia may be used, although axillary or supraclavicular regional

block is recommended because there is some evidence that the use of this technique reduces the
incidence of complex regional pain syndrome type I [13]. The patient is positioned on the
Fig. 1. (A) Fracture of the distal radius with significant dorsal angulation, carpal malalignment, radial shortening, and
metaphyseal comminution. (B) The same fracture after closed reduction and application of a plaster cast. The fracture
has been satisfactorily reduced. (C) Ten days later, the fracture has redisplaced. To obtain a good functional result, re-
reduction is required. The lateral view shows more than enough intact volar cortex to allow placement of pins into the
distal fragment. More than 60% of unstable fractures have a distal fragment that is of sufficient size to allow placement
of fixator pins.
NONBRIDGING EXTERNAL FIXATION OF DISTAL RADIUS 199
operating table in the supine position with the arm extended on a hand table. A tourniquet is
used on the upper arm. The arm is draped with the forearm and hand free. The surgeon is po-
sitioned on the cephalic side of the hand table, and an image intensifier is positioned distal to the
hand. Anteroposterior and lateral views of the wrist are obtained by pronating and supinating
the forearm. The wrist is held in the lateral position by an assistant during pin insertion.
Unstable fracture
The distal pins are inserted first using an open technique to avoid damage to the extensor
tendons. The placement of the distal pins is dictated to some extent by the type of fixator used,
although in most cases two parallel pins are inserted on either side of Lister’s tubercle and the
extensor pollicis longus tendon (Fig. 2) 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, half-
way between the fracture site and the joint (Fig. 3). Two separate longitudinal incisions on either
side of Lister’s tubercle are made and deepened down to the extensor retinaculum. Extensor pol-
licis longus usually can 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 the extensor pollicis longus between the third and
fourth extensor compartments (see Fig. 2). A short longitudinal incision is made in the extensor
retinaculum, and the pin is placed onto the dorsal surface of the distal radius between the ex-
tensor pollicis longus and extensor digitorum communis. The starting position of the pin is
checked on the image intensifier with the wrist in the lateral position. It is not necessary to check
the anteroposterior view because the pin position is consistently on the ulnar side of the radius
(Fig. 4) 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 (Fig. 5). The pins always must be inserted by
hand and not with power because this may cause a ring sequestrum from heat necrosis.
The second distal pin is inserted in a similar manner, but between the second and third
extensor compartments (see Fig. 2) and parallel to the first pin in both planes. The periarticular
clamp or fixator may be used as a pin guide if desired to ensure correct spacing.
The proximal pins also are placed through an open approach. A short longitudinal incision is
made on the dorsal radial aspect of the radius approximately 5 cm proximal to the most
Fig. 2. Landmarks on the dorsum of wrist for pin placement. The pins are placed on either side of Lister’s tubercle and
the extensor pollicis longus tendon. One is placed between the second and third extensor compartments and one between
the third and fourth.
200 MCQUEEN & EKROL
Fig. 3. Marker placed on the skin to determine the level of skin incision.
proximal extent of the fracture. The incision is deepened to the tendons of the extensor carpi
radialis longus and extensor carpi radialis brevis, and the interval between the two is opened.
The radial sensory nerve is protected by the extensor carpi radialis longus at this point as it
emerges between it and the brachioradialis. Two parallel pins are inserted with or without
predrilling, engaging the opposite cortex.
The external fixator is assembled. Reduction 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 (Fig. 6). The correction obtained can be viewed on the image intensifier. If the radial
angle requires correction, this can be done by manipulation of the periarticular clamp. The fix-
ator components are tightened, and the adequacy of the reduction is assessed with the
fluoroscope.
The range of movement possible in the wrist is confirmed by flexing (Fig. 7A), extending
(Fig. 7B), 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 an unstable fracture, but because iliac crest bone
graft is used, this area also must be prepared and draped. A 4- to 5-cm transverse skin incision is
made first over the site of the deformity. 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 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
Fig. 4. If the correct extensor compartments have been identified, the ulnar pin is consistently in this position.
Fig. 5. Fluoroscopic view showing the placement of a pin. The starting point is between the fracture and the radiocarpal
joint. The pin is directed parallel to the radiocarpal joint and engages the volar cortex.
flap of the original transverse incision can be lifted to visualize insertion of the pins, avoiding
tendon damage. The distal pins followed by the proximal pins are inserted as described
previously for an unstable fracture.
A transverse osteotomy cut is 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 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
completed 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 using the distal pins. The
fixator is then assembled.
A small amount of cancellous bone graft is harvested from the iliac crest and placed in the
wedge-shaped defect in the distal radius (Fig. 8). The extensor retinaculum and the skin are
closed, but the pin tracks are left open. Light dressings are required on the pins and on the os-
teotomy 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 more radially to correct radial collapse. This technique also allows the use of
double bars, which can give extra rigidity to the frame.
Complications
Intraoperative
Intraoperative complications are unusual, provided that the preoperative selection of fracture
type has been adequate. If the size of the distal fragment is found to be too small to allow
Fig. 6. The fracture has been reduced. The normal volar angle has been restored along with the carpal alignment. The
large defect in the metaphysis that is the underlying cause of the instability can be seen easily.
202 MCQUEEN & EKROL
Fig. 7. The range of flexion (A) and extension (B) with a nonbridging external fixator after surgery. Rotation also is free.
insertion of the pins, 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
fractures. With the use of this technique in the authors’ institution in approximately 650 cases,
only 2 cases of pin loosening have occurred perioperatively, both because of surgeon error with
unnecessarily forcible fracture reduction. If pin loosening 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 also is unusual, but can occur if the fixator
is being applied late after fracture. Closed reduction is usually possible with this technique 3
weeks after the fracture. If reduction is impossible with the application of gentle and gradual
pressure on the distal pins, more forcible reduction should not be used because this would cause
pin loosening. In this situation, a small incision can be made over the fracture site to allow
insertion of a small lever that is used to achieve a reduction. Bone grafting is not used, unless
a formal osteotomy has been performed.
Postoperative
The most common postoperative complication is pin track infection, which occurs in around
10% of the total number of pins used [7,8]. Pin track infection can be minimized by careful in-
sertion techniques, ensuring that there is no skin tension around the pins, and by regular pin
track care. If infection intervenes, most cases are treated successfully by antibiotics and
Fig. 8. Malunion of the distal radius has been corrected with restoration of the volar tilt. The metaphyseal defect has
been filled with cancellous bone.
increased cleaning of the pin tracks. If pin loosening occurs as a result of a more severe infec-
tion, the fixator should be removed or the pin replaced in an infection-free area. If this is re-
quired with the distal pins, the fixator may be converted to a bridging construct. The
incidence of extensor pollicis longus rupture has not been increased by the use of nonbridging
external fixation [7–12], but pin placement should be open to prevent tendon damage.
Rehabilitation
Wrist and finger movement is encouraged immediately postoperatively. Most patients can be
discharged from hospital the same day with outpatient physiotherapy prescribed on clinical
indications such as reluctance to mobilize the hand. Pin tracks are cleaned and dressed on
a daily basis initially graduating to twice weekly if they remain healthy. The external fixator is
retained for 4 to 6 weeks for unstable fractures and 6 to 8 weeks for osteotomies. The fixator is
removed in an outpatient setting with local anesthetic if necessary.
Outcomes
Fractures
Radiologic outcomes of nonbridging external fixation for extra-articular or minimal articular

fractures are uniformly good (Table 1). The first report of nonbridging external fixation with
anatomic results was a comparison of plaster and nonbridging external fixation in patients
younger than age 60 with displaced distal radial fractures. The quality of the reduction was
good in both groups, but the reduced position was maintained better (P !.01) by the external
fixation group [14].
The first randomized study of nonbridging external fixation was a comparison with bridging
external fixation [7]. Sixty patients with redisplaced distal radial fractures and an average age of
61 years were included. Nonbridging external fixation showed statistically significant improve-
ment in dorsal angle and radial shortening at all stages of review, successfully maintaining volar
tilt until final review at 1 year. There were no malunions in the nonbridging group in this study.
The main radiologic advantage of nonbridging external fixation is restoration and
maintenance of the normal volar tilt of the distal radius. In bridging external fixation, reduction
of the fracture depends on ligamentotaxis. Volar tilt may not be restored because the volar
ligaments are shorter and stronger than the dorsal ligaments and prevent full reduction [15].
With nonbridging external fixation, the reduction is performed using the distal pins as a joystick
allowing the surgeon direct control of the distal fragment and obviating the need for
ligamentotaxis.
Table 1
Published outcomes for nonbridging external fixation of distal radius fractures
Fracture type Malunion Function Major PTI EPL rupture
Jenkins, et al, 1987 [14] Extra/minimal articular 2 NA 0 0
n ¼ 32
McQueen, 1998 [7] Extra/minimal articular 0 Grip strength 87% 0 2
n ¼ 30
Krishnan et al, 1998 [22] Intraarticular 0 29/30 excellent/good 2 0
n ¼ 22
McQueen et al, 1999 [8] Extra/minimal articular 1 Grip strength 88% 1 0
n ¼ 20
Krishnan et al, 2003 [16] Intra-articular NR Grip strength 45% 0 3
n ¼ 30
Flinkkila et al, 2003 [9] Extra/minimal articular 2 Grip strength 90% 1 0
n ¼ 52
Gradl et al, 2005 [5] Extra/severe articular 1 96% excellent 2 0
n ¼ 25
Abbreviations: EPL, extensor pollicis longus; NA, not applicable; NR, not reported; PTI, pin track infection.
204 MCQUEEN & EKROL
Superior functional outcomes also are reported in nonbridging external fixation for unstable
fractures of the distal radius compared with bridging techniques [7]. In this study, the nonbridg-
ing group grip strength was restored to 87% of the opposite normal side, allowing for domi-
nance. Other indices of function also showed superior results in the nonbridging group.
Table 1 shows a summary of the reports available in the literature on nonbridging external
fixation. In extra-articular and minimal articular fractures, functional results are excellent.
The only exception to that rule is when the technique is used for severe articular fractures
when it is likely that the severity of the injury dictates the outcome [16].
There have been no randomized studies as yet comparing nonbridging external fixation with
the more invasive technique of plating for the management of unstable distal radius fractures.
The popularity of dorsal plating has declined in recent years because of the high rate of extensor
tendon irritation or rupture [17] necessitating secondary surgery and because of the invasive na-
ture of the technique. Volar locked plating has been introduced more recently for unstable distal
radius fractures. This technique also is more invasive than nonbridging external fixation and
may allow fracture collapse in osteoporotic patients [18,19]. There also remains a significant
rate of secondary surgery for implant removal owing to flexor tendon problems from the plate
or extensor tendon irritation or rupture owing to screw penetration dorsally [18,19]. Percutane-
ous pin fixation has not shown benefit compared with cast alone and so is unlikely to confer
improved outcomes compared with nonbridging external fixation [20,21]. Randomized studies
are required to compare these techniques including nonbridging external fixation.
Osteotomy
Little is reported on the use of nonbridging external fixation for radial osteotomy. In a series
of 23 patients treated in this way for symptomatic malunion of the distal radius in the authors’
institution, there were statistically significant improvements in dorsal angulation and radial
shortening with dorsal angulation improving from a mean of 18.6 to a mean volar tilt of 6.5 at
final review. All functional measures were statistically significantly improved at final review
compared with preoperative levels except wrist extension and key grip strength. The only major
complications were two patients with extensor pollicis longus ruptures. Radial osteotomy with
nonbridging external fixation provides a minimally invasive technique for distal radial
osteotomy with reliable radiologic and functional results.
Summary
Nonbridging external fixation of the distal radius for metaphyseal unstable fractures is
a simple, minimally invasive technique that allows the surgeon to obtain and maintain an
excellent reduction. Functional results are generally satisfactory with a rapid return to function
and good long-term function. Nonbridging external fixation has been shown to be superior to
bridging external fixation in the treatment of unstable distal radius fractures. The technique has
not been compared directly with dorsal or volar plating, but is likely to have less fracture
collapse, fewer tendon problems, and less secondary surgery.
References
[1] McQueen MM. Fractures of the distal radius and ulna. In: Court-Brown CM, McQueen MM, Tornetta P, editors.
Orthopaedic surgery essentials: trauma. Philadelphia: Lippincott Williams & Wilkins; 2006. p. 153–69.
[2] Fernandez DL, Flury MC. History, evolution and biomechanics of external fixation of the wrist joint. Injury 1994;
25(Suppl 4): S-D2–13.
[3] Anderson R, O’Neil G. Comminuted fractures of the distal end of the radius. Surg Gynaecol Obstet 1944;78:434.
[4] Mackenney P, McQueen MM. Prediction of instability of fractures of the distal radius. J Bone Joint Surg Am 2006;
88A:1944–51.
[5] Gradl G, Jupiter JB, Gierer P, et al. Fractures of the distal radius treated with a nonbridging external fixation tech-
nique using multiplanar K wires. J Hand Surg Am 2005;30:960–8.
[6] Beumer A, McQueen MM. Fractures of the distal radius in low-demand elderly patients: closed reduction of no
value in 53 of 60 wrists. Acta Orthop Scand 2003;74:98–100.
[7] McQueen MM. Redisplaced unstable fractures of the distal radius: a randomised prospective study of bridging ver-
sus non-bridging external fixation. J Bone Joint Surg Br 1998;80:665–9.
[8] McQueen MM, Simpson D, Court-Brown CM. Metaphyseal external fixation of redisplaced unstable distal radial
fractures: use of the Hoffman 2 compact external fixator. J Orthop Trauma 1999;13:501–5.
[9] Flinkkila T, Ristiniemi J, Hyvonen P, et al. Nonbridging external fixation in the treatment of unstable fractures of
the distal forearm. Arch Orthop Trauma Surg 2003;123:349–52.
[10] Fischer T, Koch P, Saager C, et al. The radio-radial external fixator in the treatment of fractures of the distal radius.
J Hand Surg Br 1999;24:604–9.
[11] Uchikura C, Hirano J, Kudo F, et al. Comparative study of nonbridging and bridging external fixators for unstable
distal radius fractures. J Orthop Sci 2004;9:560–5.
[12] Bednar DA, Al-Harran H. Non-bridging external fixation for fractures of the distal radius. J Can Chir 2004;6:
426–30.
[13] Reuben SS, Pristas R, Dixon D, et al. The incidence of CRPS after fasciectomy for Dupuytren’s contracture: a pro-
spective observational study of anaesthetic techniques. Anaesth Analg 2006;102:499–503.
[14] Jenkins NH, Jones DG, Johnson SR, et al. External fixation of Colles’ fractures: an anatomical study. J Bone Joint
Surg Br 1987;69:207–11.
[15] Bartosh RA, Saldana MJ. Intraarticular fractures of the distal radius: a cadaveric study to determine if ligamento-
taxis restores radiopalmar tilt. J Hand Surg [Am] 1990;15:18–21.
[16] Krishnan J, Wigg AER, Walker RW, et al. Intra-articular fractures of the distal radius: a prospective randomised
controlled trial comparing static bridging and dynamic non-bridging external fixation. J Hand Surg Br 2003;28:
417–21.
[17] Rozental TD, Beredjiklian PK, Bozentka DJ. Functional outcome and complications following two types of dorsal
plating for unstable fractures of the distal part of the radius. J Bone Joint Surg Am 2003;85:1956–60.
[18] Drobetz D, Kutcha-Lissberg E. Osteosynthesis of distal radial fractures with a volar locking screw plate system. Int
Orthop 2003;27:1–6.
[19] Rozental 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.
[20] Stoffelen DV, Broos PL. Closed reduction versus Kapandji-pinning for extra-articular distal radialfractures. J Hand
Surg Br 1999;24:89–91.
[21] Azzopardi T, Ehrendorfer S, Coulton T, et al. Unstable extra-articular fractures of the distal radius: a prospective,
randomised study of immobilisation versus supplementary percutaneous pinning. J Bone Joint Surg Br 2005;87:
837–40.
[22] Krishnan J, Chipchase LS, Slavotinek J. Intraarticular fractures of the distal radius treated with metaphyseal exter-
nal fixation. J Hand Surg Br 1998;23:396–9.
Atlas Hand Clin 11 (2006) 207–219
Intramedullary Fixation of Fractures of the Distal

Radius
Department of Orthopaedics, Thomas Jefferson University Hospital, Jefferson Medical College,
The Philadelphia Hand Center, 834 Chestnut Street, Suite G114, Philadelphia, PA 19106, USA
Fractures of the distal radius are among the most common injuries affecting the
musculoskeletal system. Additionally, they are among the most common fractures treated by
orthopedic surgeons, and their incidence is continuing to increase as improving health care has
led to increased longevity. There has been an evolution of treatment for these fractures, as cast
immobilization and percutaneous pin fixation initially were the mainstays of treatment. The
advent of improved biomaterials and implant development, however, has led to an increasing
trend toward internal fixation and early mobilization.
Management of distal radius fractures has continued to evolve, with increasing recognition
that the restoration of articular congruity, fracture alignment, and the relationship of the radius
to the surrounding carpus, ulna, and soft tissues play critical roles in having a successful
outcome. All distal radius fractures, however, are not created equal, and prompt recognition of
critical radiographic criteria is essential to developing a systematic approach to treatment of
these difficult fractures. Once a careful assessment of the fracture pattern has been done, one
must determine which treatment option best suits that individual fracture. In addition, the age
of patient, demands of the patient, and bone quality are critical factors in determining treatment
selection.
Several forms of treatment have been used alone or in combination to treat fractures of the
distal radius, including cast immobilization, percutaneous pinning, external fixation, and
internal plate fixation. In addition, arthroscopy has provided additional insight on associated
soft tissue injuries, and in some cases, it has aided in the improvement of articular reduction.
Little attention, however, has been directed at the concept of intramedullary fixation of distal
radius fractures.
Intramedullary fixation has long been the mainstay of treatment for other fractures of the
extremities, including the tibia and femur, and it has been shown to have excellent results.
Benefits of intramedullary fixation include minimally invasive surgery with less soft tissue
trauma, preservation of the vascularity of fracture fragments, and an implant that acts as a load-
sharing device rather than a load-bearing one. Although open reduction and internal plate
fixation has been shown to have excellent results, several common complications remain,
including tendon irritation and rupture, implant prominence, extensive soft tissue trauma, and
failure of fixation. This may lead to the necessity of hardware removal.
In addition, there are several anatomic considerations unique to the distal radius that must be
considered. There is a very thin soft tissue envelope surrounding the distal radius, and the close
proximity of tendon and neurovascular structures further support the concept that an
intramedullary device would offer an enormous advantage by avoiding impingement on critical
neighboring soft tissues and preventing complications. Some prior investigators examined the
concept of intramedullary fixation for fractures of the distal radius, but no specific completely
intramedullary implant for the distal radius was developed.
E-mail address: pkdantuluri@handcenters.com
208 DANTULURI
To this end, several investigators in conjunction with Wright Medical Technologies,

Incorporated (Memphis, Tennessee) have developed a novel intramedullary device (Micronail)
for fixation of distal radius fractures (Fig. 1). The implant uses fixed-angle locking screw tech-
nology to provide a load-sharing construct that can be inserted through minimally invasive in-
cisions and provide stable fixation of certain types of fractures of the distal radius. This limited
surgical dissection and stable intramedullary fixation preserve fracture fragment vascularity, al-
lowing for early postoperative mobilization.
Implant design rationale
The implant itself has been designed to allow restoration of the normal anatomy of the distal
radius by the use of a fixed-angle intramedullary device (Fig. 2). The implants are of titanium
construction and universal configuration, so that the same implant can be used in either the
right or left extremity. There are three distal locking screws (2.5 mm fixed-angle screws), which
form a subchondral buttress underneath the articular surface of the distal radius, supporting the
carpus, helping to restore the appropriate radial inclination, length, and volar tilt. The distal
screws also are splayed outward volarly and dorsally when viewed from the lateral view to pro-
vide a broad surface to buttress the articular surface and lock in the distal fragment. Two prox-
imal self-tapping bicortical screws (2.7mm screws) lock the distal fragment and the nail to the
proximal shaft, preventing the loss of reduction. The proximal screws are designed to fix the
nail to the shaft and prevent shortening and rotational or angular displacement of the distal
fragment. An external jig is used to insert the intramedullary nail and help align guides for
the insertion of the proximal and distal screws. There is also a separate 1.6 mm hole machined
in the body of the nail that allows preliminary K-wire fixation of the implant to the proximal
shaft to prevent loss of reduction while inserting the proximal screws.
Indications
The intramedullary nail is indicated for extra-articular distal radius fractures that are
unstable (Fig. 3) and cannot be maintained with closed reduction (Fig. 4). The device also can be
used for intra-articular fractures; however, these fractures should have minimal stable articular
fragments and should not involve numerous small, comminuted articular fragments. Fractures
also should not have extensive metaphyseal–diaphyseal extension, as this can compromise the
fixation of the implant and lead to loss of reduction. Another good indication is in malunion
Fig. 1. Intramedullary fixation device known as the Micronail, distributed by Wright Medical, shown demonstrating
fixed-angle distal locking screws and proximal bicortical screw fixation. (Courtesy of Wright Medical Technology,
Arlington, TN. Used with permission.)
INTRAMEDULLARY FIXATION 209
Fig. 2. View of completed intramedullary fixation of extra-articular distal radius fracture, demonstrating restoration of
the normal anatomic parameters of the distal radius. (Courtesy of Wright Medical Technology, Arlington, TN. Used
with permission.)
surgery, as the nail is an excellent option to be used in correction of extra-articular malunions of

the distal radius. The nail is not indicated for use in the pediatric population with open growth
plates. Indications are being refined in a prospective multi-center study. Careful assessment of
the initial injury films and postreduction films can help guide the selection of appropriate pa-
tients for intramedullary nail fixation.
Preoperative planning
Standard radiographs are acquired of the injured extremity, including posterioanterior (PA),
lateral, and oblique views of the wrist. Contralateral views of the other wrist are recommended
to carefully assess the actual radial inclination, length, and volar tilt of each individual patient’s
distal radius to better clarify the goals of reduction and account for anatomic variability in the
population. Postreduction films should be viewed carefully if available to help assess fracture
stability. Appropriate diagnostic studies should be ordered if additional injuries are suspected.
A careful assessment of the entire upper extremity is critical, with particular attention focused
upon the elbow and shoulder of the injured extremity, as other injuries can be missed easily.
Fig. 3. Initial radiographs of unstable extra-articular distal radius fracture demonstrating significant dorsal angulation,
radial shortening, and loss of inclination.
210 DANTULURI
Fig. 4. Preoperative radiographs following closed reduction and splinting reveal loss of reduction demonstrating insta-
bility of the fracture and significant residual deformity.
A thorough neurovascular examination is of paramount importance, and the condition of the

surrounding soft tissue envelope must be assessed.
Surgical technique
Patient positioning
Intramedullary nail fixation of the distal radius is performed most easily with the patient in
the supine position, but it can be done with the patient in either a lateral decubitus or prone
position. This allows greater versatility in the multiply injured patient, but if there is no
contraindication, the supine position is preferred. A single-arm board is attached to the side of
the operating room table and is used to support the operative extremity (Fig. 5). Alternatively,
a hand table can be used, but the single-arm board is the more versatile, as it can be moved out
of the way during the procedure when the fluoroscopic unit is in use. A mini C arm is the fluo-
roscopic unit of choice in these cases as it is more maneuverable in crowded operating rooms
and presents less radiation risk. A standard-size fluoroscopic unit, however, also can be used.
Fig. 5. Typical patient positioning with patient supine on the operating table with a single-arm board used to support
the injured extremity.
Fig. 6. The borders of the radial styloid are delineated here, and the proposed incision for the insertion of the nail is
demonstrated.
Surgical landmarks
Once the appropriate anesthetic choice has been made for the patient, the wrist is examined
carefully, and several critical landmarks are identified. The radiocarpal joint and radioulnar
joints generally can be palpated easily. If there is excessive soft tissue swelling, however, these
can be identified fluoroscopically. The contours of the radial styloid are identified carefully, as
are the boundaries of the first and second dorsal extensor compartments.
Surgical approach
The injured extremity is prepared and draped in the usual sterile manner, and the arm is
placed on the sterilely draped arm board. The arm board should be covered adequately with
a sterile drape, allowing the surgeon to grasp the arm board and move it without the risk of
contamination. The mini C arm then is brought in, and the fracture is assessed under
fluoroscopy to confirm that it can be reduced easily or is able to be reduced with minimal
percutaneous incisions. Once this has been confirmed, the arm is placed back on the arm board,
and the tip of the radial styloid is identified with the wrist in the lateral position. At that point,
typically a 2 to 3 cm longitudinal incision is made over the radial styloid (Fig. 6). Surgical dis-
section is performed carefully, and any branches of the radial sensory nerve within the operative
field are identified and protected. Care is taken just to identify and protect these branches, and
no skeletonization of these nerve branches should be performed.
Once the tip of the styloid is identified, the edges of the first and second dorsal compartments
are identified. The periosteum then is incised in line with the skin incision, and the radial styloid
Fig. 7. The periosteum has been incised, and the cortical window for insertion of the intramedullary nail has been
created.
212 DANTULURI
Fig. 8. Initial closed reduction with preliminary Kirschner wire fixation of unstable extra-articular distal radius fracture.
is exposed just enough to allow the proposed entrance site for the nail to become visible (Fig. 7).
An attempt is made to preserve the edges of the periosteum so that the periosteum can be closed
over the entrance site for the implant once the procedure has been completed.
Preliminary reduction
At this point, the fracture should be reduced with preliminary K-wire fixation (Fig. 8). The
mini C arm once is again brought in and used to verify the reduction. Generally, the fracture can
be reduced easily, and the distal fragment then is pinned with a 0.62 K-wire inserted through the
radial styloid, with fixation in the proximal shaft. This K-wire should be inserted if possible in
the volar portion of the styloid so that it will not interfere with insertion of the nail, but provides
very stable fixation of the distal fragment and also protects the tendons of the first dorsal exten-
sor compartment and sensory branches of the radial sensory nerve. A second percutaneous 0.45
K-wire then is inserted dorsally, typically between the fourth and fifth extensor compartments.
This K-wire should capture the dorsal ulnar corner of the distal fragment and together with the
wire through the radial styloid provide rigid 90/90 fixation of the distal fragment (Fig. 9). It is of
great benefit to acquire a stable well-fixed distal fragment before nail insertion, as it can be dif-
ficult to assess the reduction once the implant and external jig are in place. In addition, the in-
creased stability of the preliminary reduction provided by 90/90 K-wire fixation can prevent the
loss of reduction during nail insertion.
Fig. 9. Fluoroscopy is used to verify successful closed reduction with preliminary Kirschner wire fixation of unstable
extra-articular distal radius fracture.
Fig. 10. Insertion of starter drill guide wire for creation of entry insertion point for intramedullary nail. (Inset courtesy
of Wright Medical Technology, Arlington, TN. Used with permission.)
If the reduction of the fracture cannot be achieved by closed means, the nail can be placed on
the dorsal surface of the skin with the wrist in a posteroanterior position on the fluoroscopic
unit. The nail then can be positioned in its expected intramedullary position. At that point,
a small dorsal incision can be made where the anticipated dorsal incision will be made for the
proximal locking screws. A Freer elevator can be inserted here to help reduce difficult fractures,
particularly in the region of the sigmoid notch, and also aid in achieving an anatomic reduction
before nail insertion.
Nail insertion
Once anatomic reduction has been achieved with preliminary K-wire fixation, the tip of the
radial styloid is identified, and a cortical window is made in the styloid approximately 5 mm
proximal to the tip of the styloid. Care must be taken to ensure that this cortical window is made
proximal enough so that the scaphoid facet of the distal radius is not violated with successive
broaching of the distal radius. The window can be made in the radius with either an awl or with
the 6.1 cannulated drill over a guide wire (Fig. 10). Fluoroscopy should be used to ensure that
the cortical window is made in the appropriate position for implant insertion.
After the cortical window has been made, a small rongeur can be used to expand the window,
typically in the proximal direction longitudinally in line with the radius for about 5 mm to allow
Fig. 11. Insertion of canal finder along radial cortex to prevent perforation of the ulnar cortex of the distal radius.
214 DANTULURI
Fig. 12. Sequential broaching of the endosteal canal of the distal radius before intramedullary nail insertion.
easy broach insertion. A small canal finder then is introduced through the cortical window and
inserted into the medullary canal (Fig. 11). This canal finder should stay radially in the canal to
prevent penetration of the ulnar cortex of the radial shaft. With the aid of the fluoroscopy unit,
a small broach then is inserted across the fracture site and advanced proximally across the meta-
physeal–diaphyseal junction (Fig. 12). Progressively larger broaches then are inserted sequen-
tially until the broach is large enough within the canal to resist spinning when rotational
torque is applied. Also, preoperative templating using the contralateral wrist radiographs can
provide the surgeon with information as to which size implant is best for each individual patient.
After the last broach has been removed, the implant is mounted on the external jig and gently
inserted following the path of the prior broach (Fig. 13). The nail should be carefully inserted
medially far enough into the radius so that no part of the nail is protruding above the radial
cortex (Fig. 14). This will prevent any contact between the nail and the undersurface of the ten-
dons of either the first or second compartment. In addition, the nail is inserted gently proximally
enough so that the distal most locking screw will be just underneath the subchondral bone sup-
porting the radiocarpal articular surface. A K-wire or a drill bit can be inserted through the dis-
tal most drill guide and then checked under fluoroscopy to ensure that the distal most locking
screw will be in the desired subchondral position (Fig. 15). At this point, the distal locking
screws holes are drilled and measured, and three distal locking screws are inserted into the
nail with the distal most screw inserted first (Fig. 16). Fluoroscopy also should be used when
measuring the length of the screws to ensure that they do not penetrate the sigmoid notch
and enter the distal radioulnar joint (Fig. 17). Once all of the distal locking screws have been
locked into the nail, the fracture reduction should be assessed carefully. If there has been a slight
Fig. 13. External alignment jig with intramedullary nail inserted into the endosteal canal of the distal radius. (Courtesy
of Wright Medical Technology, Arlington, TN. Used with permission.)
Fig. 14. Intraoperative view demonstrating intramedullary nail insertion with external alignment jig attached.
loss of reduction of the fracture because of nail insertion, the fracture can be gently reduced an-
atomically before proximal screw insertion (Fig. 18).
A K-wire then is inserted through the dorsal cortex and the nail to rigidly hold the implant in
place and prevent subtle displacement of the implant within the canal allowing easy proximal
screw insertion. The proximal screws can be inserted through two small 1 cm incisions or one
single 2 cm dorsal incision. The appropriate drill guide and sleeves are used to drill and insert the
proximal screws (Fig. 19). These screws acquire bicortical purchase and lock the implant in
place. Care must be taken to ensure that no soft tissue or extensor tendons are trapped under-
neath the proximal screw heads during insertion. Also, care must be taken not to compromise
purchase of the proximal locking screws by overtightening, as there are only two proximal lock-
ing screws, and they are critical in maintaining implant position.
Final fluoroscopic images are used to verify that the reduction of the fracture has been
accomplished and that the implant and all screws are in appropriate positions (Fig. 20). The
periosteum then is closed over the cortical window in the radial styloid if possible to prevent
any contact of the nail with the surrounding soft tissues. Routine closure then is performed
and a sterile dressing applied with a short-arm splint.
Fig. 15. Drilling for insertion of distal most locking buttress screw, demonstrating avoidance of drill bit penetration into
the radiocarpal and distal radioulnar joints. (Inset courtesy of Wright Medical Technology, Arlington, TN. Used with
permission.)
216 DANTULURI
Fig. 16. Insertion of distal most locking buttress screw demonstrating careful avoidance of radiocarpal and distal radio-
ulnar joints. (Inset courtesy of Wright Medical Technology, Arlington, TN. Used with permission.)
Postoperative regimen
Patients are instructed to begin immediate active finger, elbow, and shoulder range-of-motion
exercises. Patients typically are seen 7 to 10 days after the surgical procedure for their first
postoperative visit. A removable orthoplast splint is provided for comfort at the first
postoperative visit, and patients may perform active wrist range-of-motion exercises as
tolerated. The splint typically is discontinued at 4 weeks, and therapy is progressed. Union
typically is achieved at 6 weeks postoperatively and can be assessed with serial radiographs
(Fig. 21).
Follow-up and results
Distal radius fractures can be treated successfully with intramedullary fixation. Tan and
colleagues presented a prospective study of 23 consecutive fractures treated with intramedullary
Fig. 17. Insertion of oblique distal locking buttress screws. Both screws are measured carefully to avoid distal radioulnar
joint penetration. (Inset courtesy of Wright Medical Technology, Arlington, TN. Used with permission.)
Fig. 18. After distal screw insertion, fluoroscopy is used to verify that the fracture reduction has been maintained and
that the implant and screws are in the appropriate positions.
fixation using the Micronail. All patients had a follow-up of at least 6 months. Outcomes were
excellent at 6-month follow-up in terms of radiographic parameters of the distal radius, range of
motion, and improvement of grip strength. Patients also were evaluated with standardized out-
come measurement tools Disabilities of the Arm, Shoulder, and Hand (DASH) and achieved
very good results. Complications were few and consisted of three transient radial sensory nerve
injuries and three patients who had loss of fracture alignment, but these patients had more com-
plex intra-articular fracture types. Complications can occur with intramedullary nail fixation if
screws are measured improperly; the radiocarpal or radioulnar joints are penetrated, or if the
distal buttress screws are not placed just under the articular surface of the distal radius. In ad-
dition, careful preoperative evaluation is critical in selecting fracture patterns most amenable to
intramedullary fixation. A prospective randomized multi-center prospective trial is in progress
comparing several forms of operative fixation of distal radius fractures including intramedullary
fixation. It is clear in early follow-up, that intramedullary fixation of distal radius fractures is
not only possible, but can lead to excellent results in properly selected patients.
Fig. 19. Insertion of proximal bicortical screws. Drill and screw guides are used to insert both proximal bicortical screws.
(Inset courtesy of Wright Medical Technology, Arlington, TN. Used with permission.)
218 DANTULURI
Fig. 20. Radiographs of completed intramedullary fixation. Note anatomic reduction of the unstable extra-articular dis-
tal radius fracture with restoration of volar tilt, radial length, and radial inclination.
Fig. 21. Follow-up postoperative radiographs demonstrating rigid maintenance of reduction despite early motion post-
operative protocols.
Summary
Distal radius fractures have historically been treated many different ways including with cast
immobilization, percutaneous pinning, external fixation, and internal plate fixation. Complica-
tions are seen with every technique used to treat these fractures, including loss of reduction, pin
tract infection, tendon and nerve injuries, and loss of fixation. The close proximity of tendons,
nerves, and vascular structures to the distal radius may contribute to the development of some
of these complications. In an attempt to minimize these complications, intramedullary fixation
of the distal radius has been developed as a treatment option for fractures of the distal radius.
Careful surgical technique and proper patient selection can lead to successful outcomes in
patients with distal radius fractures treated with intramedullary fixation.
Further readings
Bennett GL, Leeson MC, Smith BS. Intramedullary fixation of unstable distal radius fractures: a method of fixation
allowing early motion. Orthop Rev 1989;18(2):210–6.
Brooks KR, Capo JT, Warburton M, et al. Internal fixation of distal radius fractures with novel intramedullary im-
plants. Clin Orthop Relat Res 2006; Apr;445:42–50.
Cooney WP. Distal radius fractures: external fixation proves best. J Hand Surg (Am) 1998;23(6):1119–21.
Culp RW, Osterman AL. Arthroscopic reduction and internal fixation of distal radius fractures. Orthop Clin North Am
1995;26:739–48.
Gao H, Luo CF, Zhang CO, et al. Internal fixation of diaphyseal fractures of the forearm by interlocking intramedullary
nail: short-term result in eighteen patients. J Orthop Trauma 2005;19(6):384–91.
Jakob M, Rikli DA, Regazzoni P. Fracture of the distal radius treated by internal fixation and early function. A pro-
spective study of 73 consecutive patients. J Bone Joint Surg 2000;82:340–4.
Knirk JL, Jupiter JB. Intra-articular fractures of the distal end of the radius in young adults. J Bone Joint Surg 1986;68:
647–59.
Lafontaine M, Hardy D, Delince P. Stability assessment in distal radius fractures. Injury 1989;20:208–10.
McQueen MM. Redisplaced unstable fractures of the distal radius. A randomized prospective study of bridging versus
nonbridging external fixation. J Bone Joint Surg 1998;80:665–9.
Orbay JL, Fernandez DL. Volar fixed-angle plate fixation for unstable distal radius fractures in the elderly patient.
J Hand Surg 2004;29:96–102.
Pritchett JW. External fixation or closed medullary pinning for unstable Colles’ fractures? J Bone Joint Surg 1995;77:
267–9.
Ring D, Prommersberger K, Jupiter JB. Combined dorsal and volar plate fixation of complex fractures of the distal part
of the radius. J Bone Joint Surg Am 2004;86:1646–52.
Rozental TD, Beredjiklian PK, Bozentka DJ. Functional outcome and complications following two types of dorsal plat-
ing for unstable fractures of the distal part of the radius. J Bone Joint Surg Am 2003;85:1956–60.
Rozental TD, Blazar PE. Functional outcome and complications after volar plating for dorsally displaced, unstable frac-
tures of the distal radius. J Hand Surg (Am) 2006;31(3):359–65.
Ruch DS, Papadonikolakis A. Volar versus dorsal plating in the management of intra-articular distal radius fractures.
J Hand Surg (Am) 2006;31(1):9–16.
Saeki Y, Hashizume H, Nagoshi M, et al. Mechanical strength of intramedullary pinning and transfragmental Kirschner
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Atlas Hand Clin 11 (2006) 221–230
Considerations in Dorsal Plating of Distal

Radius Fractures
Thomas E. Dudley, MD, PhD,
Matthew D. Putnam, MD*
University of Minnesota, Department of Orthopaedic Surgery, Riverside Campus,
2512 South 7th Street, Minneapolis, MN 55454, USA
The radiocarpal and distal radioulnar joints have a low degree of tolerance for residual
articular incongruency and malunion following fracture of the distal radius. Articular
displacement of only 1 to 2 mm is associated with the development of post-traumatic arthrosis,
pain, and wrist stiffness [1–3]. Radial shortening, dorsal angulation, and residual subluxation of
the distal radioulnar joint results in an ulnar positive variance [4], restricted forearm rotation
[4–6], altered tendon excursion [7], and carpal bone kinematics [8], an increase in load across
the radioulnar joint [4], and decreased grip strength [4]. Management of distal radius fractures
may be complicated further by concomitant fracture and/or ligamentous injury about the car-
pus [4,9]. Patient factors (eg, age, activity level, and physical demand) and inherent fracture
characteristics (eg, degree of stability, comminution, and displacement) affect the proposed
treatment algorithm. Operative treatment of distal radius fractures should be considered
when acceptable anatomic reduction cannot be obtained and maintained by closed methods.
The surgical treatment of fractures of the distal radius has evolved with the heightened
appreciation of the importance of restoration of the anatomy and the development of newer
technologies available for treatment. Distal radius fractures may be managed surgically with
closed reduction and pinning with immobilization, external fixation with or without limited
internal fixation, or open reduction and fixation using either dorsal, volar, or a combination of
dorsal and volar plates. Intramedullary fixation of fractures is the newest method described, but
long-term data are lacking.
Open reduction and fixation with a dorsal plate is recognized as an effective treatment option
for comminuted, intra-articular fractures of the distal radius. Several series have reported
satisfactory functional and anatomic outcomes after treatment with a dorsal plate [2,10,11]. As
with most fractures treated surgically, however, complications exist. Axelrod and McMurtry
[10] reported an overall complication rate of 50% (15% early, 35% late) in their series of 17
patients who had comminuted, intra-articular fractures of the distal radius. Tendon irritation,
attrition, and frank rupture have been reported as complications for volar [12–15] and dorsal
[10,11,16] methods of internal stabilization of distal radius fractures. Tendon-related problems
more frequently have been associated with dorsal plating and the close proximity of the implant
to the extensor tendons. Additional factors, including technical errors in plate placement, plate
loosening or breakage, screw prominence, and plate design and composition, have been linked
to tendon-related complications after dorsal plating.
One of the authors has received or will receive benefits for personal or professional use from a commercial party re-
lated directly or indirectly to the subject of this article.
E-mail address: mdpmd@umn.edu (M.D. Putnam).
222 DUDLEY & PUTNAM
Recent experience with dorsal plating of the distal radius
The SCS-D plate
Gesensway and Putnam reported on the design of a three-dimensional plate to provide

support to the distal radius subchondral surface [17]. This plate (SCS-D, Avanta Orthopaedics/
Small Bone Innovations, New York, New York) subsequently was approved for use by the US
Food and Drug Administration (FDA), and initial reports regarding successful use were re-
ported [18–20]. This was the first distal radius plate to integrate subchondral support into its
design (Fig. 1). At the time of its initial use, the plate differed from all predecessors because
of its three-dimensional shape, which demanded accurate reduction of the radial styloid and
dorsal ulnar corner fragment. Additionally, because the subchondral support was integral to
the plate itself, the surgical repair was believed to be sufficient to support early hand and wrist
active-assisted range of motion. This belief was supported by rehabilitation force modeling in
the same laboratory [21]. This plate is still in use. Fig. 2 demonstrates the use of this plate in
conjunction with ORIF of a scaphoid and lunate fracture all thru a dorsal approach. Fig. 3
demonstrates the use of this plate in a younger patient with significant intra-articular incongru-
ity. In this case, the rigid fixation enabled early return to the patient’s musical vocation, which
appeared to aide in his rehabilitation.
The Pi plate
Ring and colleagues [22] reported on the use of the titanium Pi plate (Synthes, Limited, Paoli,
Pennsylvania) for managing fractures of the distal radius. The plate’s design incorporates two
proximal limbs connected by a precontoured juxta-articular band designed to support commi-
nuted elements of the distal articular surface [22]. The overall profile of the plate is lowered by
allowing for screw and pin recession within the plate, a feature specifically incorporated in an
effort to lessen the risk of extensor tendon irritation. The early results reported described no in-
cidence of plate failure or loss of initial fracture reduction. Similar findings of the Pi plate’s du-
rability and ability to provide stable fixation for unstable distal radius fractures have been
reported [23]. Several studies have reported satisfactory functional outcomes and maintenance
of fracture reduction following dorsal application of the Pi plate [16,23–25] for intra-articular
distal radius fractures.
The problem of extensor tendon irritation has not been eliminated with the use of the Pi
plate. Ring and colleagues [22] reported that 5 of 22 patients (23%) developed tendonitis of the
second dorsal extensor compartment, with four of five patients requiring subsequent plate re-
moval. Campbell [16] reported 3 of 25 patients (12%) requiring Pi plate removal for either dor-
sal wrist pain or extensor tendon irritation with 1 of 25 patients (4%) experiencing extensor
tendon rupture. Although Rozental and colleagues [23] described a 25% incidence of extensor
tendonitis and 7% incidence of tendon rupture in their retrospective series, all patients were re-
ported to have had either excellent or good functional outcomes on the Garland and Werley
Fig. 1. Axial and Sagital CAT scans of dorsal plate showing anatomic fit of subchondral support.
DORSAL PLATING CONSIDERATIONS 223
Fig. 2. (A) An AP x-ray showing a comminuted extra-articular distal radius with radial column instability and associ-
ated displaced and unstable fractures of the scaphoid and lunate. (B) The dorsal surgical approach enabling exposure of
all fractures. (C) The post reduction PA x-ray at 6 weeks with repair of the radius, scaphoid, and lunate. (D) The post-
reduction Lateral x-ray at 6 weeks with repair of the maintained extra and inter-carpal alignment.
scoring system. Fawzy and colleagues [25] reported 3 of 23 patients (13%) with extensor tendon
irritation and no cases of tendon rupture in their experience with the Pi plate. By comparison,
Kambouroglou and Axelrod [26] reported a 63% incidence of extensor tenosynovitis in their
small series of patients treated with the titanium Pi plate, with two of eight patients (25%) hav-
ing associated extensor tendon rupture. Also noted was a case of plate breakage and screw back-
out [26]. Chiang and colleagues [27] reported the need for plate removal in 45% of patients
secondary to dorsal wrist pain following dorsal fixation with the Pi plate. A recent retrospective
study with a large patient population reported a 7.9% overall rate of complications and a 6.7%
incidence of complications occurring within the first 2 months of operative treatment; 50% of these
problems were attributed to wrist pain [24]. The incidence of late extensor tendon rupture was
1.3%, with all ruptures occurring before 6 months. The authors concluded that the Pi plate was
a good surgical option for treating comminuted, intra-articular fractures of the distal radius [24].
The disparity between the reported incidence of extensor tendon irritation and rupture across
series evaluating the Pi plate may be related to variables, including technical factors related to
plate placement, plate design, and/or the composition of the plate. Lucas and Fejfar [28] felt the
leading edge of the Pi plate was a concerning source that may contribute to extensor tendon at-
trition and rupture. Coverage of the distal transverse limb of the Pi plate with a retinacular flap
has not been found to effectively decrease the incidence of dorsal wrist pain [27].
Plate composition also has been suggested as a factor contributing to the incidence of tendon
irritation after dorsal plating. Although currently available in stainless steel or titanium, the
original Pi plate was composed solely of titanium. Titanium has been associated with the
production of inflammatory mediators in vivo [29]. A recent study in a canine model has shown
that peri-tendinous inflammation and adhesion correlates with plate composition, with in-
creased inflammation and fibrosis associated with an increasing amount of titanium composite
[30]. Rozental and colleagues [23], however, did not find a difference in complication rates be-
tween patients treated with dorsal plates consisting of stainless steel or titanium.
The Forte plate
The low-profile Forte (Zimmer; Warsaw, Indiana) has been reported as providing a high
degree of good-to-excellent functional outcomes [31,32] following treatment of distal radius
fractures. The plate is composed of 316L stainless steel and is anatomically preshaped with
224 DUDLEY & PUTNAM
Fig. 3. (A) An unstable intra- and extra-articular fracture in a professional guitar player after a non-contact sports in-
jury. (B) 1 and 2- PA and lateral after reduction and fixation. (C) Playing guitar at 6 weeks.
recessed screw holes. The Forte plate initially was reported as being stronger and having an in-
creased ability to resist static bending loads when compared with the Pi plate [31]. Carter and
colleagues [31] reported maintained fracture reduction in 88% of patients with use of the Forte
plate. It must be noted, however, that this plate does not provide secure subchondral support.
Accordingly, it is not surprising that Finsen and Aasheim [32] noted a troubling increased ten-
dency for volar angulation after treatment in 20 of 25 patients. Nine of these patients exhibited
greater than 10 of volar angulation, which was thought to be attributed to a greater degree of
initial volar fracture comminution and the inability of the plate and screw construct to prevent
subsequent volar displacement. The incidence of extensor tendon irritation and tenosynovitis
has been reported as 8% to 11% with use of the Forte plate [31,32]. Nineteen percent of patients
required plate removal for technical errors in plate placement or tendon irritation in the series
reported by Carter and colleagues [31].
Double plating
Double plating methods of internal fixation also have been used for treating comminuted
fractures of the distal radius. The biomechanical basis for double plating is based on the three-
column theory of the distal forearm as proposed by Rikli and Regazzoni [33]. Double plating
with 2 mm plates has been shown to have increased stiffness compared with the AO 3.5 mm
T plate and the Pi plate, although bending and bone gap to failure has not been shown to be
statistically different in biomechanical studies [34]. Hahnloser and colleagues [35] reported their
experience in dorsal stabilization of the distal radius with the use of two 0.25 in tubular plates
compared with the Pi plate. Eighty-two percent of patients stabilized with two 0.25 in tubular
plates achieved excellent-to-good results with improved wrist motion and no reported compli-
cation [35]. A good-to-excellent result was achieved comparatively in 56% of patients treated
with the Pi plate, with a corresponding 14.3% incidence of complication. Jakob and colleagues
[36] reported excellent and good anatomic results in 90% and 8%, respectively, for patients
treated with two 2 mm titanium plates. This correlated with a 97% reported excellent-to-
good functional outcome. The mean loss of radial length was 1 mm, with a mean increase in
palmar tilt of 1.7 at 6-week follow-up. The incidence of extensor tendon irritation was 5.5%
in this series, with an overall tendon rupture rate of 7% [36]. The authors believed that all ten-
don ruptures were attributed to technical considerations, including cutting the plate prior to its
placement. The sharp edge of the cut surface was associated with attritional rupture with no
subsequent ruptures occurring after abandoning the practice of cutting the plate [36].
Volar versus dorsal plating
More recently, there has been a trend towards fixation of comminuted fractures of the distal
radius with a volar plate. Recent studies suggest a fixed volar angle plate retains a higher degree
of stiffness in response to cyclic loading when compared with an unlocked dorsal construct [37].
Gesensway and colleagues [17], however, reported improved strength and rigidity with a fixed
angle plate specifically designed for dorsal application, thus suggesting that improved biome-
chanical strength may be a result of the fixed-angle nature of the construct rather than the sur-
face to which the plate is applied. One study has compared directly the relative biomechanical
strength of dorsal and volar plates when both are of a fixed-angle design [38]. This study showed
the SCS-volar plate to be stronger than the dorsal Pi plate, but it did not compare the SCS-volar
to the SCS-dorsal plate [38].
Equivalent functional outcomes and maintenance of reduction have been reported with volar
plating when compared with dorsal plating [15]. The reported incidence of extensor or flexor
tendon irritation is lower with volar plating [15]; however, this problem has not been eliminated
with the use of a volar plate [15,38]. Additional problems have been reported with volar plating,
including a case report of a radial artery pseudoaneurysm secondary to technical error in volar
plate placement [39].
Surgical exposure for application of a dorsal plate to the distal radius allows for the direct
assessment and reduction of the radiocarpal articular surface and distal radioulnar joint. A
dorsal approach further allows the surgeon to address most associated carpal injuries at the time
of distal radius reduction and fixation. Further, the dorsal exposure allows for the use of bone
graft to the comminuted dorsal aspect of the distal radius. By contrast, preservation of the
volar–capsular ligaments of the wrist necessitates that reduction of distal radius intra-articular
fragments be accomplished indirectly when using a volar plate for fixation. The volar approach
provides a limited exposure of the volar–ulnar aspect of the radius and distal radiocarpal joint
and cannot be used to address concomitant scapholunate interosseous ligament tears or carpal
bone fracture through a single incision.
Dorsal exposure of the distal radius
The dorsal surface of the distal radius is approached by means of a longitudinal incision
made in line with the third metacarpal and based just ulnar to Lister’s tubercle. The length of the
incision can be extended distally to provide exposure of the proximal carpal row of the wrist.
226 DUDLEY & PUTNAM
Fig. 4. PA idealized drawing showing osteotomy of Lister’s tubercle to raise a sleeve of periosteum as a means of gaining
an extensile exposure to the dorsal distal radius.
The subcutaneous fat is incised sharply in line with the skin incision, and small self-retaining
retractors are placed proximally and distally. Full-thickness flaps are bluntly developed medially
and laterally after reaching the level of the extensor retinaculum and dorsal antebrachial fascia.
The risk of injury to the dorsal branches of the superficial radial and ulnar nerves is minimized
by careful elevation of full-thickness flaps. The extensor retinaculum is exposed and evaluated.
The extensor retinaculum is divided in an oblique fashion over the fourth dorsal compartment,
and the underlying extensor digitorum communis (EDC) tendons are retracted ulnarly. Alter-
natively, the extensor retinaculum may be divided longitudinally over the third dorsal compart-
ment and the extensor pollicis longus (EPL) elevated and retracted radially. The posterior
interosseous nerve is identified and protected, or a neurectomy may be performed.
The periosteum is incised just ulnar to the sheath of the EPL. Distal extension of this incision
allows exposure of the radiocarpal joint and proximal carpal row. Subperiosteal dissection
progresses ulnarly to expose the ulnar aspect of the distal radius. Care is taken to avoid exposure
of the distal radioulnar joint in order to prevent destabilization of the dorsal origin of the
triangular fibrocartilage complex (TFCC). If the EPL was preserved within its sheath, a curved
osteotome is used to reflect Lister’s tubercle (with the EPL sheath in continuity) for direct
subperiosteal exposure of the radial aspect of the distal radius (Fig. 4). If the EPL was released
initially, a rongeur is used to remove Lister’s tubercle, and subperiosteal dissection progresses to
Fig. 5. (A) 1 and 2- PA and lateral showing a large dorsal ulnar corner fragment in an unstable fracture. (B) 1 and 2- PA
and lateral showing the same fragments reduced and captured.
Fig. 6. The rehabilitation program emphasizes edema control using a combination of removable splint supports, Jobst
gloves, and Active-assisted range of motion.
Fig. 7. (A) Lateral x-ray showing a comminuted fracture involving the joint in an independent-living woman 75 years of
age. (B) PA x-ray showing the same comminuted fracture. (C) The fractures healing in two projections at 6 weeks with
intact subchondral support plates. These plates are sometimes removed. In this case, the plate has remained in place. (D)
Wrist flexion at approximately 10 weeks. (E) Supination at the same time.
228 DUDLEY & PUTNAM
expose the entire dorsal aspect of the radial side of the distal radius. Careful attention to sub-
periosteal dissection of the wrist capsule provides a distinct anatomic layer for later closure, al-
lowing for the recreation of a smooth surface for the extensor tendons following fracture
fixation. Distal exposure of the proximal carpal row is achieved by sharp, longitudinal dissection
and reflection of the dorsal wrist capsule.
The fracture is irrigated and inspected, and intra-articular elements are evaluated. Before
application of the dorsal plate can be achieved, the fracture and its elements are distracted and
reduced. Distraction at the level of the fracture is achieved through longitudinal traction, either
with finger traps or the use of a temporary external fixator. Anatomic reduction of the distal
radius in all planes is mandatory prior to dorsal plating in order to minimize the risk of plate
malposition and subsequent tendon irritation. Direct anatomic reduction of the dorsal ulnar
corner fragment is one of the key advantages of the dorsal approach. Fig. 5 shows fixation cap-
turing this fragment directly.
Expected outcomes
As stated earlier, many of the currently marketed plate constructs appear to offer the
advantage of anatomic shape, subchondral support, and fixation strength sufficient to enable an
accurate reduction with fixation capable of acting in a load-sharing fashion during early healing
such that active and active-assisted range-of-motion exercises can be initiated within days of
surgery. To date, a controlled study regarding the utility of postinjury/surgery hand therapy has
not been completed. The need for such care, however, seems obvious. The authors’ protocol
includes use of a splint and edema control glove as early as day 2 after surgery (Fig. 6). This
program includes shoulder, elbow, forearm, and finger motion with assistance. In almost all
cases, assisted motion of the wrist is begun also. In cases where insufficient fixation strength
has been gained to allow early motion of the wrist and forearm, the surgeon should reconsider
the fixation construct chosen and possibly augment with an external fixateur applied to neutral-
ize residual axial loading.
Older patients present the surgeon with fracture pattern and bone strength challenges. The
authors’ experience with dorsal plating has shown it to be useful in properly selected patients.
Fig. 7 shows a patient with a comminuted intra-articular fracture treated with dorsal plating
alone, early remobilization, and her outcome at 12 weeks.
Summary
Dorsal plating is an effective method of stabilization of complex, comminuted intra-articular

fractures of the distal radius. Complications do exist regarding dorsal plate fixation and may be
related to technical considerations in plate placement, design, or composition. The most
significant complications associated with dorsal plating of the distal radius continue to be those
associated with dorsal wrist pain or extensor tendon irritation or rupture. Dorsal plate
application offers the advantages of improved surgical exposure of the distal radio–ulnar joint
and proximal carpal row when fractures are associated with these concomitant injuries. In
summary, dorsal plating is a useful and occasionally preferred method of treating distal radius
fractures.
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Atlas Hand Clin 11 (2006) 231–241
Arthroscopy in the Treatment of Distal Radial

Fractures with Assessment and Treatment
of Associated Injuries
A. Lee Osterman, MD*, Scott T. VanDuzer, MD
The Philadelphia Hand Center, Thomas Jefferson University, 834 Chestnut Street, Philadelphia, PA 19107, USA
Wrist arthroscopy has become a valuable adjunct in the treatment of a unique subset of distal
radial fractures. Comminuted fractures involving the distal radial articular surface frequently
result from high-energy impact injuries. These fractures have an inherent tendency to shorten
and collapse and are less amenable to closed manipulation and casting. Arthroscopic assistance
in the management of these fractures provides an ideal view of the distal radial joint surface
allowing precise internal reduction of fracture segments. This has been referred to as arthro-
scopic-assisted reduction/internal fixation (ARIF). In addition, arthroscopic assistance allows
identification and removal of foreign bodies in the radiocarpal joint and assessment and treat-
ment of the frequently associated soft tissue injuries.
Precise reduction of the distal radial articular surface is important to prevent the late result of
traumatic arthritis. It has been shown that a poor result is likely if greater than 2 mm of articular
incongruity is present at the radiocarpal joint (Fig. 1) [1,2]. Subsequent reports indicate that
even 1 mm of step-off may contribute to a poor outcome [3,4]. Diastasis of the articular surface
in the radioulnar plane (Fig. 2) or in the volar-dorsal plane (Fig. 3) may play an even more im-
portant role than step-off in the progression to traumatic arthritis. Defective intra-articular re-
duction greater than 1 mm may lead to radiographic traumatic arthritis of the wrist in most
patients [5]. It also has been shown that subchondral hematomas in the radiocarpal joint in
the setting of distal radial fractures, even without a fracture line as shown by arthroscopy,
can lead to early onset of mild osteoarthritis and worse outcomes after 1 year [6].
ARIF allows an ideal, well-lit, magnified view of the distal radial joint surface with minimal
morbidity. ARIF is superior to C-arm and plain radiographs for assessing the gap between
articular fragments [7]. In a study in which intra-articular distal radial fractures underwent
closed manipulation and percutaneous pinning, then sequential assessment of reduction by
C-arm, x-ray, and wrist arthroscopy, 33% of cases judged to have had optimal reduction by
C-arm and x-ray were found to have an articular displacement of greater than 1 mm by adjunc-
tive arthroscopy [7]. It has been shown that arthroscopically assisted reduction and external fix-
ation of distal radius fractures permits a more thorough inspection of the ulnar-sided
components of the injury compared with fluoroscopically assisted reduction and external fixa-
tion of distal radius fractures alone [8]. In addition, a prospective cohort study showed that
at follow-up examination, patients who underwent arthroscopically assisted procedures had
a greater degree of supination, flexion, and extension than patients undergoing fluoroscopically
assisted surgery [8]. It is now recognized that intraoperative fluoroscopic imaging does not pro-
vide sufficient precision to visualize a 1-mm step-off in the radial articular surface despite often
satisfactory postoperative x-rays [5,9].
E-mail address: Loster51@bellatlantic.net (A.L. Osterman).
232 OSTERMAN & VANDUZER
Fig. 1. (A) Distal radius fracture with greater than 2 mm articular incongruity. (B) Results in traumatic arthritis.
ARIF is particularly useful as an adjunctive measure in the management of unstable or

displaced intra-articular fractures and in comminuted articular fractures. ARIF is useful in
management of radial styloid fractures, lunate die-punch fractures, three-part T fractures, and
Melone four-part fractures (Fig. 4) [10]. ARIF may be used in conjunction with various fixation
techniques including percutaneous pinning, open reduction internal fixation (ORIF), and exter-
nal fixation [11]. ARIF may be contraindicated in the setting of forearm compartment syn-
drome, untreated median nerve compression, and severe soft tissue or open joint injury.
ARIF is optimally performed 3 to 7 days after fracture. This time frame avoids visualization
difficulty secondary to active bleeding and avoids the later difficulty of manipulating fracture
segments. A horizontal or vertical arthroscopic setup may be used (Fig. 5) [12]. The operating
room setup and arthroscopic portals are similar to those used in elective wrist arthroscopy.
Fluoroscopy can aid in needle placement and portal establishment. Traction provides ligamen-
totaxis, which aids in fragment reduction (see Fig. 8B). The arthroscopic sheath usually is intro-
duced in the 3–4 portal, and an outflow cannula established in the 6-R portal. Fluid
extravasation into the forearm may be limited by Esmarch wrapping of the forearm. The first
views obtained are often those of fibrin clot and debris, and lavage is particularly useful and
nearly always necessary to clear the joint of clot and debris. Careful attention to this step allows
adequate visualization and precise fragment manipulation and reduction. Washing out fracture
hematoma and debris also may contribute to the increased range of motion and functional out-
come that have been shown with ARIF [13,14].
Fig. 2. Distal radius fracture with greater than 2 mm radial ulnar diastasis.
ARTHROSCOPY IN DISTAL RADIAL FRACTURES 233
Fig. 3. Distal radius fracture with greater than 2 mm dorsal volar diastasis.
Midcarpal arthroscopy has been shown to add statistically significant information to the
radiocarpal examination compared with wrist arthroscopy performed without a midcarpal
examination, especially in the setting of arthroscopy performed for assessment of soft tissue
injuries associated with distal radial fractures [15]. Hofmeister and colleagues [15] showed that
additional pathology leading to additional surgical intervention was found on midcarpal exam-
ination in more than 60% of patients undergoing arthroscopy for evaluation of soft tissue in-
juries in the setting of distal radial fractures.
Two-part radial styloid fractures
Most radial styloid fractures may be reduced by closed manipulation. Adequate reduction
may be evaluated fluoroscopically, arthroscopically, or a combination of both techniques.
Kirschner wire joysticks can be used to manipulate fracture segments. These may be inserted
through 14G needles to protect the surrounding neurovascular structures. Arthroscopic
assessment of adequate reduction of the articular surface is best evaluated by placing the scope
in the 4–5 portal. When adequate reduction is obtained, the Kirschner wires may be driven
across the fracture, or another means of fixation, such as a cannulated screw, may be applied
(Fig. 6). Arthroscopic assistance also is useful in assessing for associated intra-articular fractures
and soft tissue injuries in the setting of radial styloid fractures. The arc of injury passes through
the radial styloid and into the scaphoid or across the scapholunate (SL) ligament. In the former,
this pattern creates a scaphoid fracture (Fig. 7). In the latter, an SL tear is created (see Fig. 11).
SL ligament injury has been identified in 50% of radial styloid fractures [16].
Fig. 4. Schema of intra-articular fracture pattern after Melone. Four part intra-articular distal radial fracture, with ulnar
styloid fracture. (Adapted from Melone CP. Articular fractures of the distal radius. Orthop Clin North Am 1984;15:217–36.)
Fig. 5. (A) Vertical setup in arthroscopic tower with external fixator already applied but not locked out. (B) Horizontal
traction over a hand table also can be used.
Three-part fractures
The arthroscopic assisted approach to management of three-part fractures includes pre-

liminary reduction of the radial styloid as described previously. This reduced styloid segment
may be used as a landmark to reduce the medial fragment (Fig. 8). Articular gaps may be re-
duced with the aid of a bone tenaculum, and depressed articular fragments may be elevated
with the aid of a bone awl or a percutaneously placed Steinmann pin. After elevating a depressed
fragment, bone grafting may be required [17]. Arthroscopic assistance allows superior assess-
ment of articular surface reduction and assessment of associated soft tissue injuries [18].
Fig. 6. (A) Classic radial styloid fracture. (B) Arthroscopic view from 6R portal with Kirschner wire placement to allow
fragment manipulation and provisional fixation. (C) Postreduction view of anatomic reduction. (D and E) Fixation can
be held by Kirschner wires (D) or cannulated screws (E).
Fig. 7. (A) Two-part fracture associated with scaphoid waist fracture. (B) Post ARIF of the distal radius fracture and
percutaneous fixation of the scaphoid.
Four-part fractures
Four-part fractures are characterized by further splitting of the medial segment into volar
and dorsal fragments [10]. Initial traction allows ligamentous reduction of fracture segments
(Fig. 9). Attention is directed first toward reduction of the radial styloid, which serves as a guide
for further fragment reduction. A limited open volar incision often is required to allow adequate
mobilization and reduction of the volar fragment. Buttress plate fixation, through a small volar
Fig. 8. (A) Schema of three-part fracture. (B) Typical x-ray. (C) Use of a tenaculum to reduce the separated articular
fragments. (D) Final fixation.
Fig. 9. (A) Four-part fracture. (B) Initial traction to get the multiple fragments in the reduction ballpark. (C) Arthro-
scopic view from 6R portal showing fragment displacement. (D) Postreduction view. (E) Exterior view showing Kirsch-
ner wires and external fixation. Bone graft has been placed through an enlarged 3–4 portal to augment and support the
previously depressed chondral fragments. (F) Postreduction x-ray. (G) Final range of motion.
ulnar incision between the ulnar neurovascular bundle and the carpal canal contents, allows sta-
bilization of the volar fragment, which may be used as a fulcrum to reduce the dorsal fragment.
Arthroscopic visualization aids in evaluating adequate reduction of the dorsal fragment.
Arthroscopic assessment and treatment of associated injuries
In 1996, Geissler and colleagues [19] reported a high percentage of tears of the carpal inter-
osseous ligaments and the triangular fibrocartilage complex (TFC) occurring in patients who
had a displaced fracture of the distal end of the radius. Of patients with intra-articular fractures
of the distal end of the radius, 68% had associated soft tissue injuries of the wrist. The most
commonly associated injury was a tear of the TFC (49%), followed by injury to the SL inter-
osseous ligament (32%) and injury to the lunotriquetral (LT) interosseous ligament (15%).
Twenty percent of patients had multiple soft tissue injuries, and chondral lesions of the carpal
bone occurred in 23% to 44% of patients with displaced distal radial fractures. These data par-
alleled the authors’ findings (Fig. 10), and subsequent studies have shown similar results
[16,17,20].
Chondral lesions
Cartilage lesions of the distal radius and carpal bones, associated with and without
underlying fractures, have been identified in 18% to 44% (average 27%) of patients with distal
radial fractures evaluated arthroscopically [5,6,19,21–23]. These lesions include subchondral he-
matomas and cartilage impaction lesions and chondral fractures. Lindau and colleagues [6]
showed that subchondral hematomas found on arthroscopy in one third of patients with dislo-
cated distal radius fractures ultimately lead to early onset of mild osteoarthritis in the same area
as the identified lesion and worse outcome at 1-year follow-up.
Scapholunate injuries associated with distal radial fractures
SL interosseous ligament injuries have been reported to occur in 18% to 54% (average 31%)
of patients undergoing arthroscopy in the setting of distal radial fractures [5,16,17,19,21–25].
Geissler and colleagues [19] described an arthroscopic classification of tears of the intracarpal
ligaments that has gained wide acceptance. Briefly, grade I tears represent attenuation of the lig-
ament with no incongruence of carpal alignment. Grade II tears represent partial tears of the
ligament. Grade III tears are characterized by incongruence or step-off of carpal alignment
when viewed from the radiocarpal and midcarpal joints; this represents a complete tear of
Fig. 10. Soft tissue lesions are common with distal radius fractures. In the authors’ series, the incidence of SL ligament
injury was 32%; LT ligament injury, 15%; and TFC injury, 56%; 22% had combinations of the aforementioned lesions.
the intracarpal ligament. A probe may be passed through the gap between the carpal bones.
Grade IV lesions represent gross instability of carpal bones with incongruence and the ability
to pass the 2.7-mm arthroscope through the gap between the carpal bones (the so-called
drive-through lesion). In studies that grade SL injuries associated with distal radial fractures,
grade II tears are the most commonly reported SL lesion (roughly 50%). Overall, SL tears
are associated with radial styloid and lunate impaction fractures, dorsal displacement of the ra-
dius greater than 20 , and static dorsal intercalated segment instability on prereduction films.
When carpal incongruence is apparent through radiocarpal and midcarpal portals, and a probe
can be passed from the radiocarpal to the midcarpal joint through the SL ligament (grade III
tears and greater), ARIF is indicated. ARIF is performed by SL ligament débridement and
transfixion with Kirschner wires (Fig. 11). Grade III tears requiring pinning are reported to oc-
cur in 25% to 37% of patients [12,13]. The usual time of pin fixation is 6 weeks. The prognosis
for an acute SL tear associated with a fracture is much better than for isolated SL disruption.
Lunotriquetral injuries associated with distal radial fractures
LT ligament injuries are reported in 12% to 15% of patients undergoing arthroscopy in the
management of distal radial fractures. These injuries may be associated with a basiulnar styloid
fracture or volar intercalated segment instability pattern on the prereduction radiograph.
Geissler and colleagues [19] reported LT tears in 9 of 60 patients (15%). Seven of these nine pa-
tients (77%) had grade III complete tears. The other two patients had partial tears of the LT
ligament. In the authors’ series, only 5% of patients with identified LT tears were considered
unstable enough to require pinning with Kirschner wires; however, others report LT transfixa-
tion in 75% of patients with identified LT tears in the setting of distal radial fractures [22,26].
Fig. 11. (A) Distal radius fracture with obvious SL diastasis. (B) Arthroscopic view of Geissler type IV drive through SL
injury. (C) Postreduction view confirming alignment of the intra-articular distal radius and the SL interval.
Triangular fibrocartilage complex injuries associated with distal radial fractures
Traumatic injury of the TFC is the most commonly reported soft tissue injury associated with
displaced distal radial fractures. Descriptive studies report TFC injuries in 27% to 60% (average
47%) of patients evaluated arthroscopically after sustaining displaced distal radial fractures. In
Geissler and colleagues’ 1996 article [19], 50% of the patients with TFC injuries had Palmer type
IB (acute peripheral ulnar-sided tear) tears, with or without an associated fracture of the ulnar
styloid process (Fig. 12). The remaining TFC injuries were nearly equally divided between
Palmer type ID, acute peripheral radial-sided tears (Fig. 13) and Palmer type IA, acute central
TFC tears [19,27]. Subsequent descriptive studies also have shown that peripheral ulnar-sided
tears are the most common (roughly 50%) TFC tears identified arthroscopically in the setting
of distal radial fractures [23].
Overall, TFC injuries are commonly found with radial shortening greater than 4 mm, dorsal
displacement greater than 20 , and an impacted lunate die-punch fracture. Treatment depends on
the Palmer classification of the tear. Central lesions are generally débrided. Distal radioulnar joint
(DRUJ) instability, when compared with the patient’s opposite uninjured wrist, necessitates
further repair. Palmer IB tears are repaired by previously described and well-accepted standard
techniques [17]. Outside-in techniques or newer all-inside techniques may be used (Fig. 12) [24].
Radial-sided ID tears may be pinned to the radius with Kirschner wires introduced from the ulnar
aspect of the wrist. These pins generally are removed at 4 weeks (Fig. 13). Several studies have
shown excellent clinical outcomes and a high degree of patient satisfaction after arthroscopically
assisted TFC repair in conjunction with distal radius fixation [23,24,28].
Concurrent bony injuries
Roughly 20% of patients may have combined soft tissue injuries in association with
arthroscopically evaluated distal radial fractures [19,26]. Combined injuries most commonly in-
volve TFC and SL injuries, followed by TFC and LT injuries and SL and LT injuries. Slade and
colleagues [29] reported combined fractures of the scaphoid and distal radius treated by percu-
taneous and athroscopic techniques. They recommended percutaneous reduction of the scaph-
oid fracture and provisional stabilization with a guidewire placed along its central axis,
percutaneous/arthroscopic reduction and rigid fixation of the distal radius fracture to permit
early motion, and fixation of the scaphoid fracture with implantation of a cannulated headless
compression screw (see Fig. 7). Fractures of the ulnar styloid frequently are associated with dis-
tal radial fractures as well. Arthroscopy helps to provide a treatment rationale in approaching
management of the ulnar styloid fracture. Loss of the trampoline effect of a probe on the TFC
indicates laxity of the articular disk and may be indicative of DRUJ instability, which should be
Fig. 12. (A) Peripheral Palmer IB tears occur through the peripheral TFC, the ulnar styloid, or both. (B) If there is TFC
laxity or DRUJ instability, arthroscopic repair, as shown here, is straightforward.
Fig. 13. (A) Palmer ID radial TFC tears also are common. (B) ID tear seen from the 3–4 portal. (C) Kirschner wire
fixation of the ulnar styloid and the radial TFC tear in a patient with DRUJ instability.
sought. If there is no demonstrable laxity of the TFC and a stable DRUJ, the ulnar styloid frac-
ture likely does not need to be stabilized. If there is laxity of the articular disk or DRUJ insta-
bility or both, the ulnar styloid fracture should be fixed with pins or screws (see Fig. 13).
Complications
Complications of ARIF have been minimal in reported case series. Of patients, 15% to 20%
may have some settling of the fracture fragments postoperatively resulting in some loss of volar
tilt. Five percent to 10% of patients may develop complications related to percutaneous pin
placement, including loosening, infection, and sensory nerve irritation, but these finding are not
directly related to ARIF itself [26]. Several cases of complex regional pain syndrome have been
reported after ARIF of distal radial fractures [5].
Outcomes
To date, there are no prospective, randomized, double-blinded studies comparing ARIF with
ORIF without arthroscopic assistance in the management of distal radial fractures. Several
studies have compared results of ARIF versus ORIF in the treatment of distal radial fractures,
however [13,26]. These studies uniformly describe increased range of motion, better outcomes,
and better articular reduction with arthroscopic assistance compared with open reduction with-
out arthroscopic assistance.
In the authors’ large consecutive series of distal radius fractures, arthroscopy was used in 11%.
The arthroscopic group consisted of 56 patients with a mean age of 44. Relative to fracture pattern,
16 were radial styloid, 13 were three-part, and 27 were four-part. Concomitant injuries were treated
in 81%. At a follow-up greater than 5 years, all patients had functional wrist motion with an
average loss of 35 in the flexion-extension arc. Ninety-five percent of the rotational arc was
restored. Grip strength measured a 23% decrease. No patient required secondary wrist surgery.
When assessing outcomes with respect to use of arthroscopy in the management of selected
distal radial fractures several questions should be posed. The orthopedic literature proves there
is a direct relationship between the quality of anatomic reconstruction (which implies the
recognition of all injuries), the minimal morbidity and subsequent stability of that reconstruc-
tion allowing preservation of motion, and the long-term functional outcome. It is reasonable to
ask: Does the use of arthroscopy assist in identifying and evaluating distal radial fractures and
their associated injuries? Multiple studies described in this article would indicate that it does
[19,26]. Does the use of arthroscopy in selected distal radial fractures facilitate anatomic reduc-
tion and reconstruction? Multiple studies would answer that it does [7,8]. Does this improved
anatomic reconstruction translate into improved functional outcome? Several studies suggest
it does [13,26].
Summary
Fractures of the distal radius are common fractures of the upper extremity. The literature
proves there is a direct relationship between the quality of anatomic reconstruction and the
long-term functional outcome. A contemporary approach to management of intra-articular
distal radial fractures is likely to involve arthroscopic assistance of some form. The authors
recommend intraoperative arthroscopy to control the treatment of selected intra-articular radial
fractures to ensure satisfactory reduction with less than 1 mm defect in the articular surface and
to search for and treat any associated intra-articular injuries [5,9,17]. Only long-term studies can
substantiate the role of arthroscopy in intra-articular fractures of the distal radius, but early
follow-up studies suggest improved results.
References
[1] Knirk KL, Jupiter JB. Intra-articular fractures of the distal end of the radius in young adults. J Bone Joint Surg Am
1986;68:647–59.
[2] Bradway JK, Amadio P, Cooney WP. Open reduction and internal fixation of displaced, comminuted intra-articular
fracture of the distal end of the radius. J Bone Joint Surg Am 1989;71:83–98.
[3] Fernandez DL, Geissler WB. Treatment of displaced articular fractures of the radius. J Hand Surg Am 1991;16:375–84.
[4] Trumble TE, Schmidt SR, Vedder NB. Factors affecting functional outcome of displaced intra-articular distal ra-
dius fractures. J Hand Surg Am 1994;19:325–40.
[5] Cognet JM, Bonnomet F, Ehlinger M, et al. Arthroscopy-guided treatment of fractures of the distal radius: 16
wrists. Rev Chir Orthop Reparatrice Appar Mot 2003;89:515–23.
[6] Lindau T, Adlecreutz C, Aspenberg P. Cartilage injuries in distal radial fractures. Acta Orthop Scand 2003;74:327–31.
[7] Edwards CC, Haraszti CJ, McGillivary GR, et al. Intra-articular distal radius fractures: arthroscopic assessment of
radiographically assisted reduction. J Hand Surg Am 2001;26:1036–41.
[8] Ruch DS, Vallee J, Poehling GG, et al. Arthroscopic reduction versus fluoroscopic reduction in the management of
intra-articular distal radius fractures. Arthroscopy 2004;20:225–30.
[9] Nijs S. Broos PL. Fractures of the distal radius: a contemporary approach. Acta Chir Belg 2004;104:401–12.
[10] Melone CP. Articular fractures of the distal radius. Orthop Clin North Am 1984;15:217–36.
[11] Geissler W, Freeland A. Arthroscopic management of intra-articular distal radius fractures. Hand Clin 1999;15:455–66.
[12] Lindau T. Wrist arthroscopy in distal radial fractures using a modified horizontal technique. Arthroscopy 2001;17:E5.
[13] Doi K, Hattoi Y, Otsuka K, et al. Intra-articular fractures of the distal aspect of the radius: arthroscopically assisted
reduction compared with open reduction and internal fixation. J Bone Joint Surg Am 1999;81:1093–110.
[14] Geissler WB. Intra-articular distal radius fractures: the role of arthroscopy? Hand Clin 2005;21:407–16.
[15] Hofmeister EP, Dao KD, Glowacki KA, et al. The role of midcarpal arthroscopy in the diagnosis of disorders of the
wrist. J Hand Surg Am 2001;26:407–14.
[16] Lindau T, Arner M, Hagberg L. Intra-articular lesions in distal fractures of the radius in young adults: a descriptive
arthroscopic study in 50 patients. J Hand Surg Br 1997;22:638–43.
[17] Culp RW, Osterman AL, Kaufmann RA. Wrist arthroscopy: operative procedures. In: Green DP, editor. Operative
hand surgery. New York: Elsevier; 2005. p. 781–803.
[18] Levy HJ, Glickel SZ. Arthroscopic assisted internal fixation of volar intra-articular wrist fractures. Arthroscopy
1993;9:122–31.
[19] Geissler WB, Freeland AE, Savoie FH, et al. Intracarpal soft-tissue lesions associated with an intra-articular frac-
ture of the distal end of the radius. J Bone Joint Surg 1996;78A:357–65.
[20] Hanker GJ. Radius fractures in the athlete. Clin Sports Med 2001;20:189–201.
[21] Mathoulin C, Sbihi A, Panciera P. Interest in wrist arthroscopy for treatment of articular fractures of the distal
radius: report of 27 cases. Chir Main 2001;20:342–50.
[22] Shih JT, Lee HM, Hou YT, et al. Arthroscopically-assisted reduction of intra-articular fractures and soft tissue
management of distal radius. Hand Surg 2001;6:127–35.
[23] Rose S, Frank J, Marzi I. Diagnostic and therapeutic significance of arthroscopy in distal radius fracture. Zentralbl
Chir 1999;124:984–92.
[24] Bohringer G, Schadel-Hopfner M, Junge A, et al. Primary arthroscopic treatment of TFCC tears in fractures of the
distal radius. Handchir Mikrochir Plast Chir 2001;33:245–51.
[25] Schadel-Hopfner M, Bohringer G, Junge A, et al. Arthroscopic diagnosis of concomitant scapholunate liament
injuries in fractures of the distal radius. Handchir Mikrochir Plast Chir 2001;33(4):229–33.
[26] Culp RW, Osterman AL. Arthroscopic reduction and internal fixation of distal radius fractures. Orthop Clin North
Am 1995;26:739–48.
[27] Palmer AK. Triangular fibrocartilage complex lesions: a classification. J Hand Surg Am 1989;14:594–606.
[28] Ruch DS, Yang CC, Smith BP. Results of acute arthroscopically repaired triangular fibrocartilage complex injuries
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Atlas Hand Clin 11 (2006) 243–250
Bone Grafts and Bone Graft Substitutes

in Distal Radius Fractures
Jeffrey Yao, MD*, Amy L. Ladd, MD
Department of Orthopaedic Surgery, Stanford University Medical Center,
Robert A. Chase Hand & Upper Limb Center, 770 Welch Road, Suite 400, Palo Alto, CA 94304, USA
Fractures of the distal radius are common injuries seen by the orthopaedic surgeon. The
average life expectancy of the population of the United States has increased steadily over the
past few decades. There has been a corresponding increase in the incidence of distal radius
fragility fractures [1–2]. Restoration of the normal anatomy, fracture stability, fracture union, and
restoration of function are the primary goals of the treating orthopaedic surgeon. Trends in distal
radius fracture treatment focus on achieving those specific objectives using less invasive techni-
ques in a shorter amount of time. Rigid fixation of distal radius fractures has been discussed
elsewhere in this issue and has revolutionized the treatment of these fractures. Rigid fixation has
allowed for earlier stability of the fracture and earlier mobilization and return to activity.
Simple metaphyseal distal radius fractures treated with casting or external or internal fixation
rarely proceed to nonunion [3–10]. Osteoporotic, ‘‘fragility’’ fractures often lack the bony archi-
tecture and stability, however, to heal in correct alignment without augmentation of the meta-
physeal bone and cortical reconstitution. Bone graft and bone graft substitutes are increasingly
used for the treatment of these osteoporotic fractures and potentially decrease healing time in
addition to augmenting fracture repair.
The current ‘‘gold standard’’ used in the treatment of metaphyseal defects is autograft. The
most common site of harvest is the iliac crest. The harvest of autograft is associated with
increased operative time, increased chance of complication, and increased pain and time to
recovery [11,12]. Fundamental properties of bone healing are osteoconductivity, osteoinductivity,
and osteogenicity. Various bone graft substitutes mimic these properties, with osteoconductivity
being the most common with the mineral substitutes. Osteoinductivity is more common with
substitutes associated with proteins and growth factors, and its presence is difficult to assess.
Osteogenesis, which requires cellular activity, remains elusive. Autograft, depending on its qual-
ity and source, may possess all of these attributes, and the search for an ideal substitute that
obviates the potential complications associated with autograft is an active area of research
and commercial interest [13,14]. The current literature lacks good scientific evidence to support
the routine use of one substitute over another. This article discusses autograft, allograft, and
the different classes of the currently commercially available bone graft substitutes.
Biology of bone
The fundamental structure of bone consists of calcium hydroxyapatite, Ca10(PO4)6(OH)2, de-

posited on a matrix of type I collagen (Fig. 1). Organic components comprise approximately
40% of the dry weight of bone. Collagen type I represents greater than 90% of the organic
E-mail address: jyao@stanford.edu (J. Yao).
244 YAO & LADD
Ca10 (PO4)6(OH)2
(K,+ Mg,++ Sr,++ Na+) (CO3-2) (SO4-2) (F-)
Fig. 1. Hydroxyapatite, the mineral backbone, with ion substitutions as shown.
matrix and contributes to the tensile strength of bone. Matrix proteins comprise the other 10%
of the organic matrix and consist of osteocalcin, osteonectin, and osteopontin.
Inorganic components comprise 60% of the dry weight of bone. Hydroxyapatite, a calcium
phosphate salt, composess most of the inorganic matrix of bone and provides strength in
compression. Mineralization of hydroxyapatite occurs in hole zones and pores within the
collagen matrix.
Various growth factors and cytokines also exist in the matrix of bone and aid in bone cell
differentiation and regulation. These factors include transforming growth factor-b, platelet-
derived growth factor, vascular endothelial growth factor, fibroblast growth factor, interleukins
(IL-1, IL-6, IL-10), insulin-like growth factor, and the bone morphogenetic proteins (BMPs).
The cellular components of bone include osteoblasts, osteoclasts, and osteocytes. Osteoblasts
form bone and are responsive to parathyroid hormone, vitamin D3, and steroids. Osteoclasts
resorb bone and are responsive to calcitonin. Local metabolism of bone is regulated by osteo-
cytes, the resident cells of bone. An osteocyte is a former osteoblast surrounded by the matrix it
formed and continues to maintain. Osteoblasts and osteoclasts work in a coordinated fashion to
form and remodel bone [15]. Remodeling occurs in response to mechanical stress (Wolff’s law)
[16] and in response to hormonal changes, as described previously.
Fracture healing occurs as a continuum of inflammation, through repair and remodeling.
Inflammation occurs immediately after the fracture and is characterized by the formation of
a hematoma in the area of the fracture. This hematoma provides a rich source of hematopoietic
cells that secrete tissue and growth factors to stimulate osteoprogenitor cells to differentiate into
osteoblasts in an effort to begin forming new bone. Within 2 weeks, soft (bridging) callus forms
and subsequently is replaced via enchondral ossification by hard callus (woven bone). The
amount of callus formed is inversely related to the stability of the fracture. By 4 to 6 weeks, the
fracture typically heals. Lastly, remodeling occurs after the fracture has healed and may
continue over several years.
Bone graft historically has been used to augment this healing process by adding structure,
growth factors, and cells to the fracture site. Autograft remains the ‘‘gold standard’’ for
augmenting fracture healing. It contains the mineral, protein, and cellular elements of the
patient’s own bone, arranged in a physiologic matrix. The most common donor site is the iliac
crest, although the quality of this bone depends on the patient’s age and comorbidities, such as
smoking, diabetes, and long-term steroid use [17]. Autograft incorporates and remodels by os-
teoclastic resorption followed by new bone formation modulated by osteoblasts. This process is
called creeping substitution.
Autograft is not without associated morbidity, especially with the use of iliac crest bone [5,6].
Increased operative time, potential infection rate, postoperative pain associated with the donor
site, and increased recovery time including ambulation all are potential problems associated
with autograft harvest. The commercial interest exists for developing graft substitutes with sim-
ilar properties to autograft, without donor morbidity.
Essential characteristics of bone graft
Osteoconductivity
Osteoconduction describes the scaffold on which new bone is formed. Autograft is naturally
osteoconductive as the native matrix is preserved. Human allograft also is osteoconductive.
Bone graft substitutes have used collagen, mineral, and other matrices in an effort to provide
osteoconduction, with mineral substitutes being the most common.
BONE GRAFTS IN DISTAL RADIUS FRACTURES 245
Osteoinductivity
Osteoinduction is the process by which the formation of new bone is stimulated. This process
is driven by tissue and growth factors, such as transforming growth factor-b, platelet-derived
growth factor, vascular endothelial growth factor, fibroblast growth factor, and the BMPs.
Autograft possesses osteoinductive factors, whereas allograft does not because these factors are
removed in the sterilization process of allograft. Some current bone graft substitutes have shown
osteoinductive potential in animals, although the true level of osteoinduction in humans is
unclear.
Osteogenicity
A substance is termed osteogenic if it is capable of intrinsically forming new bone, which re-
quires cellular activity along with the presence of structural and regulatory matrix proteins. To
date, autograft is the only type of graft with true osteogenic potential.
Structural strength
The last useful characteristic of bone graft or graft substitute is structural strength. This
strength is useful to help neutralize the deforming forces across a fracture as it is healing, most
notably in compression, tension, and shear. Cortical autograft has the best strength, but
sacrifices osteoinductive and osteogenic properties. Conversely, cancellous autograft has lower
structural strength than cortical bone, but is rich in osteoinductive and osteogenic potential. A
combination of bothdcorticocancellous constructsdtends to be the most useful for most
fracture applications when metaphyseal voids accompany cortical disruption.
Currently approved bone graft substitutes
Although autograft remains the most ubiquitous graft in the treatment of distal radius
fractures, the increased morbidity, operative time, and recovery time have led to a significant
amount of interest in identifying commercially available alternativesd‘‘graft extenders’’ to
reduce the requirement of autograft when filling a large defect [18,19]. The remainder of this ar-
ticle examines human allograft, demineralized bone matrix, coralline hydroxyapatite, calcium
phosphate, collagen mineral composite graft, calcium sulfate, bioactive glass, and osteoinduc-
tive materials, with special attention to their osteoconductive, osteoinductive, osteogenic, and
structural strength properties.
Human allograft
Freeze-dried and fresh-frozen human allograft has been available as an alternative to

autograft and a graft extender for many years. Corticocancellous allograft has excellent
osteoconductive and structural strength properties, but poor to nonexistent osteoinductive and
osteogenic properties owing to the extensive processing required in its preparation to limit
immunogenicity. Despite this extensive processing, there is still a theoretical potential for disease
transmission with the use of allograft. Frozen bone grafts retain greater structural strength than
freeze-dried bone, but also maintain a greater antigenicity and disease transmission potential.
Allograft demineralized bone matrix
Demineralized bone matrix (DBM) is human allograft bone that is processed in hydrochloric
acid to remove its nonorganic materials, theoretically leaving its organic collagen matrix. Urist
and others [20,21] previously showed in an animal model that DBM does have osteoinductive
properties, although this remains controversial. The lack of nonorganic mineral in the prepara-
tion provides the theoretical advantage that the graft may mineralize directly without undergo-
ing remodeling, as mineralized allograft might in the process of creeping substitution. Bone that
246 YAO & LADD
lacks remodeling or remodels by creeping substitution lacks structural strength, however, which
is an important desired characteristic of a distal radius graft. Because a high percentage of these
vascular metaphyseal fractures heal without the use of graft and rarely proceed to nonuniondin
contrast to long bone fractures that have a propensity for nonuniondthe primary use of graft is
to strengthen the construct and resist collapse. Early stability in the presence of fractures that
heal readily reduces the need for prolonged immobilization. Graft alternatives that lack struc-
tural strength but have theoretical inductive properties, such as DBM, are probably less useful
in the treatment of distal radius fractures than long bone fractures prone to nonunion. DBM
composite preparations have been developed that address the potential disadvantage of absent
structural support with the original DBM products [3,20]. These newer composites use various
carriers with DBM, such as porcine gelatin, which when warmed to body temperature hardens
to a firm, rubber-like consistency, and traditional calcium-based minerals. No studies to date
have reviewed the potential benefits and limitations of these composites. Lastly, DBM is pro-
cessed from allograft bone, so the theoretical disadvantage of disease transmission remains
an issue.
Coralline hydroxyapatite
Initially approved in 1992, coralline hydroxyapatite is formed via a thermochemical reaction

with Pacific coral and ammonium phosphate. Similar to the other mineral substitutes, it is based
on the hydroxyapatite backbone (see Fig. 1). This reaction transforms the coral’s native trical-
cium phosphate into a more slowly resorbed calcium hydroxyapatite [22]. The advantage of this
implant is its porous microstructure that appears structurally similar to cancellous bone (Fig. 2).
Osteoblasts may deposit bone on the porous surfaces, but osteoclastic resorption is much less
predictable, so true remodeling may be impossible [23]. Wolfe and colleagues [24] showed results
using coralline hydroxyapatite that were comparable to autograft in the treatment of distal ra-
dius fractures with external fixation. Although coralline hydroxyapatite lacks any osteoinduc-
tive or osteogenic properties, the benefit of this substitute in the treatment of distal radius
fractures is based on its excellent osteoconductive potential and structural strength. The lack
of remodeling and persistence of the material is a potential, if not theoretical, disadvantage.
Calcium phosphate
Calcium phosphate, the fundamental nonorganic precursor to hydroxyapatite, is commer-

cially available as a bone graft substitute in the treatment of fractures. It is available in many
formulations with variation in its ionic substitution, lending different setting and material
characteristics. Different calcium phosphate materials exist, including chips, morsels, and
blocks, in a collagen-type matrix and various cement preparations. In cement form, it is easily
Fig. 2. The ultrastructure of ProOsteon 500 (left) and human cancellous bone (right). (Image B courtesy of Interpore
Cross International, Irvine, CA; with permission.)
injected or molded as a putty into bone voids and allowed to harden at body temperature, with
a minimally exothermic reaction compared with acrylic cements. Calcium phosphate cement has
excellent strength in compression, but poor strength in torsion and shear. Radiographic and
histologic studies in animal and human studies indicate that calcium phosphate cement is
capable of undergoing remodeling via osteoclastic activity (Fig. 3) [25–27]. An example of com-
mon usage of calcium phosphate cement in a highly comminuted distal radius fracture is shown
in Fig. 4.
The noncement form, typically tricalcium phosphate preparations, has mechanical and
resorptive characteristics that mimic the characteristics of cancellous bone. It is more porous
than the cement and allows the infiltration of blood-borne growth factors and cellular elements.
Depending on the form, tricalcium phosphate void filler has good structural strength and
osteoconductive properties, but lacks osteogenic and osteoinductive potential [23,28].
Autologous bone marrow may be harvested via needle aspiration from the iliac crest, which is
far less invasive than autograft, and mixed with void filler to add osteoinductive and osteogenic
properties to the graft. This process requires an additional small incision and procedure, and the
true osteogenicity of the bone marrow aspirate is considered poor, especially in older patients
[3,17].
Collagen mineral composite graft
Chapman and colleagues [29] reported on using a composite graft consisting of hydroxyap-
atite, tricalcium phosphate, and bovine collagen in the treatment of comminuted long bone frac-
tures. The authors concluded that the composite led to comparable union rates compared with
autograft. Scaglione and Buchman [30] reported similarly positive results when using this com-
posite. As with many of the bone graft substitutes available, however, this composite lacks
structural strength, and its routine use in the treatment of predominantly metaphyseal distal ra-
dius fractures may be limited.
Calcium sulfate
Calcium sulfate is well known to orthopedists in the form of plaster of Paris [3]. It has been
used for decades as a bone void filler. Current formulations include calcium sulfate combined
with antibiotics, with the theoretical advantage of allowing the antibiotic to elute out of the graft
in the case of an infected nonunion. Calcium sulfate is resorbed quickly (6–8 weeks), however,
and is not reliably present for the duration of the healing process of a fracture or nonunion [31].
It also lacks structural support, so its use must be in conjunction with supplemental surgical fix-
ation. Newer preparations include a combination of calcium sulfate and DBM, although no
long-term studies exist to support the preferential use of these preparations.
Fig. 3. Radiographic evidence of calcium phosphate bone remodeling in distal radius fracture. (Courtesy of Synthes
Inc., West Chester, PA; with permission.)
248 YAO & LADD
Fig. 4. Clinical and radiographic use of calcium phosphate cement in a complex distal radius fracture with significant
metaphyseal void. (Courtesy of Amy L. Ladd, MD, Stanford, CA.)
Bioactive glass
Glass beads as a bone graft substitute have been approved for periodontal indications [23].
These beads, composed of silica (SiO2, 45%), calcium oxide (CaO, 24.5%) disodium oxide
(Na2O, 24.5%), and pyrophosphate (P2O5, 6%), range from 90 to 710 mm in size [3]. The beads
reportedly bind to collagen and fibrin to form an osteoconductive matrix, which is infiltrated by
osteogenic cells. This matrix provides scaffolding for the formation of new bone. The matrix
offers some strength in compression that may be a potential benefit when treating fractures
of the distal radius. The silica in the glass is gradually resorbed and excreted, although the rates
of resorption and excretion are currently unknown. The beads offer an osteoconductive matrix,
but are lacking in osteoinductivity, osteogenicity, and structural strength. Better understanding
of the resorption properties and Food and Drug Administration approval are required before
bioactive glass composites are considered in the treatment of distal radius fractures, nonunions,
and malunions.
Osteoinductive materials
Significant interest exists in developing substitutes that possess not only osteoconductive
properties, but also osteoinductive properties, which to date are not well developed. Research
has identified the family of BMPs, a family of proteins that have been linked to the increased
expression of osteogenic factors and differentiation of osteogenic cells. Currently, recombinant
BMP-2 and BMP-7 are available for use in spinal fusions and long bone nonunions [32]. These
factors are osteoinductive only and inherently lack osteoconductivity. They currently are avail-
able to be used with collagen carriers to provide an element of osteoconductivity. The high cost
of these factors makes the routine use of them in the treatment of distal radius fractures imprac-
tical, however.
Distal radius nonunions rarely occur. Given the richly vascular metaphyseal bone with ample
cellular and growth factors, these fractures nearly uniformly heal with the appropriate
treatment. Nonunions typically occur in the face of an ongoing infection or in patients with
poor bone healing potential (eg, smoking history, diabetes, poor nutritional status) [5]. In the
rare case of a distal radius nonuniondtypically after open injuries, complex fractures extending
into the diaphysis, and failed open fixationdosteoinductive growth factors, when used with an
osteoconductive carrier, may be useful in treatment.
Other growth factors have been similarly studied. Transforming growth factor-b, fibroblast
growth factor, and platelet-derived growth factor are factors that stimulate cell differentiation,
but are not intrinsically osteogenic. Their role in treating distal radius fractures remains to be
seen and is an area of research with significant interest academically and commercially.
Summary
Fractures of the distal radius are common fractures seen by orthopaedic surgeons today, and
the numbers continue to increase as the population grows older. Current treatment trends
emphasize earlier stability by operative means, which provides earlier rehabilitation and
a quicker recovery time. Such a trend also includes operative repair of more complex fracture
patterns, and rigid fixation is often combined with autograft, allograft, or graft substitutes that
enhance the stability and ultimate treatment of the fractured distal radius. To date, no good
comparison studies of currently commercially available substitutes exist to assess critically the
quality, utility, and superiority to justify their routine use and expense.
A truly osteogenic bone graft substitute that also is osteoconductive and osteoinductive and
comparable to autologous bone graft remains an elusive creation, although future trends in
graft development will focus on composites with varying degrees of bone healing properties.
These types of substitutes would enhance not only routine and complex fractures of the distal
radius, but also likely would advance the treatment of orthopaedic fractures and other
conditions associated with bone loss requiring structural reconstitution.
References
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[4] Lafontaine M, Hardy D, Delince P. Stability assessment in distal radius fractures. Injury 1989;20:208–10.
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914–9.
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[7] Carter PR, Frederic HA, Laseter GF. Open reduction and internal fixation of unstable distal radius fractures with
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[14] Gazdag AR, Lane JM, Glaser D, et al. Alternatives to autogenous bone graft: efficacy and indications. J Am Acad
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[Maquet P, Trans.; original work published 1982.].
[17] Muschler GF, Nitto H, Boehm CA, et al. Age- and gender-related changes in the cellularity of human bone marrow
and the prevalence of osteoblastic progenitors. J Orthop Res 2001;19:117–25.
[18] Bucholz RW. Nonallograft osteoconductive bone graft substitutes. Clin Orthop 2002;395:44–52.
[19] Hartigan BJ, Cohen MS. Use of bone graft substitutes and bioactive materials in treatment of distal radius frac-
tures. Hand Clin 2005;21:449–54.
[20] Martin GJ, Boden SD, Titus L, et al. New formulations of demineralized bone matrix as a more effective graft
alternative in experimental posterolateral lumbar spine arthrodesis. Spine 1999;24:637–45.
[21] Urist MR, Silverman BF, Buring K, et al. The bone induction principle. Clin Orthop 1967;53:243–83.
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[22] Bucholz RW, Carlton A, Holmes R. Interporous hydroxyapatite as a bone graft substitute in tibial plateau frac-
tures. Clin Orthop 1989;240:53–62.
[23] Jensen SS, Aaboe M, Pinholt EM, et al. Tissue reaction and material characteristics of four bone substitutes. Int J
Oral Maxillofac Implants 1996;11:55–66.
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analysis. J Hand Surg Am 1998;23:127–34.
[25] Constanz BR, Ison IC, Fulmer MT, et al. Skeletal repair by in situ formation of the mineral phase of bone. Science
1995;267:1796–9.
[26] Frankenburg EP, Goldstein SA, Bauer TW, et al. Biomechanical and histological evaluation of a calcium phosphate
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[28] Yetkinler DN, Ladd AL, Poser RD, et al. Biomechanical evaluation of fixation of intra-articular fractures of the
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Distal Radius Fractures

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Atlas of the Hand Clinics

Copyright © 2006 Saunders, An Imprint of Elsevier

Volume 11, Issue 2 (September 2006)

Volar Plating of Distal Radius Fractures

Fragment-Speciﬁc Fixation of Distal Radius

Fig. 4. The basic 2.4 mm Synthes fragment-speciﬁc locking plate system.

Dorsal fragment ﬁxation

• Displaced dorso-ulnar fragment

Palmar plate ﬁxation

Box 2. Rationale for palmer plating in simple Colles Fx

Combined palmar and dorsal ﬁxation

Fragment-Speciﬁc Fixation of Distal Radius Fractures

E-mail address: rmedoff@lava.net

Three-part articular fracture

Volar shear fractures

Dorsal shear fractures

Comminuted articular fractures

Comminuted articular fractures with volar rim instability

Biomechanics of fragment speciﬁc ﬁxation

Closed Reduction and Percutaneous Pinning

Indications and contraindications

Fig. 1. Preoperative radiographs of an unstable distal radius fracture in a 55-year-old woman.

Fig. 3. Initial closed reduction lateral.

Fig. 5. Placement of the radial styloid K-wires is conﬁrmed with imaging.

Fig. 8. After ﬁxation of the distal radius, DRUJ stability is tested.

Postoperative care and rehabilitation

Results and complications

Distal Radius Fractures: External Fixation

External ﬁxation indications

Equipment for treating distal radius fractures includes:

• Appropriate size drill bit and power drill

Positioning and preparation

Surgical incision landmarks

Surgical approach and procedure

Follow-up and results

Nonbridging External Fixation

General or regional anesthesia may be used, although axillary or supraclavicular regional

Distal radial osteotomy

Radiologic outcomes of nonbridging external ﬁxation for extra-articular or minimal articular

Intramedullary Fixation of Fractures of the Distal

E-mail address: pkdantuluri@handcenters.com

To this end, several investigators in conjunction with Wright Medical Technologies,

Implant design rationale

surgery, as the nail is an excellent option to be used in correction of extra-articular malunions of

A thorough neurovascular examination is of paramount importance, and the condition of the

Follow-up and results

Considerations in Dorsal Plating of Distal

Recent experience with dorsal plating of the distal radius

The SCS-D plate

Gesensway and Putnam reported on the design of a three-dimensional plate to provide

The Forte plate

Volar versus dorsal plating

Dorsal exposure of the distal radius

Dorsal plating is an eﬀective method of stabilization of complex, comminuted intra-articular

Arthroscopy in the Treatment of Distal Radial

ARIF is particularly useful as an adjunctive measure in the management of unstable or

Two-part radial styloid fractures

The arthroscopic assisted approach to management of three-part fractures includes pre-

Arthroscopic assessment and treatment of associated injuries

Scapholunate injuries associated with distal radial fractures

Lunotriquetral injuries associated with distal radial fractures

Triangular ﬁbrocartilage complex injuries associated with distal radial fractures

Concurrent bony injuries