I ARTICULAR FRACTURES OF THE DISTAL...

$: I ARTICULAR FRACTURES OF THE DISTAL RADIUSsites.surgery.northwestern.edu/reading/Documents...INTRA-ARTICULAR FRACTURES OF THE DISTAL RADIUS BY DAVID RING, MD Intra-articular fractures$
INTRA-ARTICULAR FRACTURES OF

THE DISTAL RADIUS

BY DAVID RING, MD

Intra-articular fractures of the distal radius are more challenging to treat thanextra-articular fractures. Optimal treatment is achieved when the pattern ofinjury is recognized and its component parts are adequately addressed. Theimportance of the final articular surface alignment has received substantialemphasis, but extra-articular alignment, the overall complexity of the injury,associated injuries, and complications are also very important determinants of thefinal functional result. No single implant or technique is appropriate for allfractures and surgeons should be familiar with a variety of options.

Copyright © 2002 by the American Society for Surgery of the Hand

D isplaced fractures of the articular surface ofthe distal radius have a worse prognosis thanextra-articular fractures because of the poten-

tial for incongruity and arthrosis of the radiocarpaland distal radioulnar joints, carpal subluxation, andassociated intercarpal ligament injuries. Surgicalstabilization of distal radial articular fragments ishindered by close association of the fragments withsurrounding ligaments and tendons, metaphysealcomminution and poor bone quality, the potential fordigit swelling and nerve dysfunction, and complica-tions associated with implants. Articular fractures ofthe distal radius occur in basic patterns, each of which

has specific pitfalls. Although treatment of these in-juries has improved over the past few decades, thecontinued expansion in the variety of implants andtechniques for treating fractures of the distal radiusreflects not only technical advances, but also the draw-backs of existing techniques and lack of consensus.

ANATOMY

The articular surface facing the carpus is split intodistinct facets that articulate with the scaphoid

and lunate. The basic compressive articular fractureline usually occurs between these facets. Additionalcompressive force will split the fragments in the coro-nal plane or cause central fragmentation and impac-tion.

The alignment of unstable displaced fragments isaffected by soft-tissue attachments.1 The triangularfibrocartilage complex (TFCC) attaches to the ulnarmargin of the lunate facet. The volar and dorsal mar-gins of the complex (radioulnar ligaments) can con-tribute to malrotation of lunate facet fragments. Stoutradiocarpal ligaments attach to the volar margin of thedistal radial articular surface and tend to pull it dis-

From the Harvard Medical School, Hand and Upper ExtremityService, Department of Orthopaedic Surgery, Massachusetts GeneralHospital, Boston, MA.Address reprint requests to David Ring, MD, Instructor of Ortho-paedic Surgery, Harvard Medical School, Hand and Upper ExtremityService, Department of Orthopaedic Surgery, Massachusetts GeneralHospital, ACC 527, 15 Parkman St, Boston, MA 02114. E-mail:[email protected]

Copyright © 2002 by the American Society for Surgery of the Hand1531-0914/02/0202-0005$35.00/0doi:10.1053/jssh.2002.33322

60 JOURNAL OF THE AMERICAN SOCIETY FOR SURGERY OF THE HAND � VOL. 2, NO. 2, MAY 2002

tally and rotate it into extension. The dorsal radiocar-pal ligaments are thinner and less important. Thebrachioradialis is the only tendon that inserts onto thedistal radius. It can contribute to malalignment of theradial styloid fragment.

The sigmoid notch on the ulnar surface of theradius articulates with the ulnar head. The sigmoidnotch has a greater radius of curvature than the ulnarhead and motion at the distal radioulnar joint is acombination of rotation and translation. The TFCCand the interosseous ligament stabilize the distal ra-dioulnar joint. The TFCC originates from the base ofthe ulnar styloid. A large fracture of the ulnar styloidor peripheral tear of the TFCC can destabilize thedistal radioulnar joint.

The carpal bones function as sophisticated ballbearings between the hand and wrist. They have beencharacterized as an intercalated segment because notendons directly affect their function. Instead, thebehavior of the carpal bones is determined by theirshape and ligament attachments. When an axial forceinjures the articular surface, the injury force maypropagate through the carpus leading to carpal frac-tures (most commonly the scaphoid) or intercarpalligament injuries (most commonly the scapholunateinterosseous ligament). There is a strong association ofassociated carpal ligament injury with radial styloidfractures.2

ARTICULAR INCONGRUITY: ITS MEASUREMENT

AND CONSEQUENCES

A lthough the worse prognosis of articular fractureshas long been recognized,3 the past 2 decades of

the 20th century witnessed a greater dissatisfactionwith these results and an interest in improving treat-ment.

Arthrosis of the radiocarpal or distal radioulnarjoints was second only to compressive neuropathy inthe description by Cooney et al4 published in 1980 ofthe problems arising from fracture of the distal radius.Arthrosis was nearly always associated with an artic-ular fracture

In 1986, Knirk and Jupiter5 reviewed 43 artic-ular fractures of the distal radius in 40 patientsyounger than 40 years of age at an average of 6.7years after injury. Twenty-one were treated in acast, 17 in pins and plaster, and 2 in an external

fixator. They found that the development of arthro-sis was strongly related to articular incongruity;that the magnitude of the incongruity correlatedwith the development and severity of arthrosis; andthat articular incongruity was the factor moststrongly related to an unsatisfactory functional re-sult. Because all of the patients with greater than 2mm of articular incongruity had arthrosis and apoor functional result, 2 mm has become the oft-referenced upper limit for acceptable articularalignment; however, the relationship between ar-ticular incongruity and arthrosis was essentiallylinear as has been confirmed by several subsequentinvestigators, some of whom have suggested thegoal of no more than 1 mm of articular incongru-ity.6-8

The value of such precise parameters depends onvalid and reliable measurement techniques. Standardmeasurement techniques have been described: articu-lar step has been distinguished from articular gap,9

and a computed tomography–specific arc method ofmeasurement has been advocated.10 Nonetheless, Kre-der et al9 found that measurements of articular stepand gap made by experienced surgeons on standardradiographs varied substantially. Other investigatorshave found that the use of tomography11 or computedtomography10,11 can improve the reliability of themeasurements, but that there is still only moderateagreement between observers and with repeated mea-surements. Others claim that the only reliable methodto assess articular congruity is direct evaluation byusing arthroscopy.12-14

Catalano et al15 reviewed 21 patients less than 45years old at an average of 7.1 years after an articularfractures of the distal radius treated surgically.They confirmed that the development of arthrosis isstrongly associated with residual articular incon-gruity. In contrast to Knirk and Jupiter,5 however,they found that arthrosis did not correlate with thefunctional result. The patients in the series of Cata-lano et al15 had surgical treatment using moreadvanced techniques compared with those in theKnirk and Jupiter5 series. Consequently, the extra-articular alignment of the radius and the radiocar-pal alignment were more predictably restored. Theresults of this investigation suggest that restorationof this extra-articular alignment was more impor-tant than residual articular incongruities and ar-

INTRA-ARTICULAR FRACTURES � RING 61

throsis in determining the functional result and theneed for reconstructive surgeries.

In other words, an emphasis on the articular align-ment may be somewhat misdirected. The quality ofthe articular reduction may actually be less importantthan factors such as the severity of the injury, associ-ated injuries, the quality of the extra-articular reduc-tion (the alignment of the carpus and hand with theforearm), and associated complications. Although it isclear that the best possible articular reduction is de-sirable, this must be balanced with the drawbacks andrisks of the various surgical techniques and the specificgoals of treatment for each patient. In addition, pre-cise restoration of articular congruity may not bepossible for some complex articular fractures,16,17 butthis does not necessarily preclude restoration of wristfunction.

GOALS OF TREATMENT

The treatment method selected should emphasizerestoration of full range of motion of the digits,

which usually requires limitation of edema and earlyexercises and functional use of the hand; full, stable,pain-free forearm rotation, which usually requireshealing of the fracture with good extra-articular aswell as intra-articular alignment; and a strong gripand limited pain, which usually return in the absenceof arthrosis, nerve compression, mal- or nonunion.Restoration of wrist flexion and extension is less pre-dictable and has a more variable influence on upper-extremity function. Perhaps one of the most impor-tant goals of treatment is to limit complications—thesurgeon should always ensure that the potential risksof surgical intervention are always balanced by thepotential benefits.

CLASSIFICATION

Patient-Related FactorsThe functional demands and expectations of in-

dividual patients may be a more important deter-minant of successful treatment of an intra-articularfracture of the distal radius than radiographic orclinical parameters. A distinction has long beenmade on the basis of age.18 The majority of distalradius fractures occur in older patients. The preva-lence of limited functional demands and acceptance

of deformity in this group of patients contributes toa high degree of satisfaction even in the presence ofpoor alignment. It is a common clinical observationthat older patients more readily regain motion,particularly forearm rotation, and that residual de-formity is less problematic than in younger pa-tients. This may be because, in part, these areusually relatively low-energy injuries.19

On the other hand, it may be unwise to allow theseage-related factors alone to guide treatment. The seg-ment of our society that is over age 60 is growingrapidly and becoming healthier and more active.20,21

The alignment and functional result that is good for arelatively infirm and home-bound patient may not bewell accepted by a patient that plays golf or tennisdaily. The goals of treatment are different for aninfirm or inactive patient than they are for a healthy,active patient who wants to remain active, regardlessof chronologic age.

Fracture CharacteristicsClassification Systems. Attempts to classify dis-

tal radius fractures have emphasized important man-agement issues. Frykman22 distinguished articular in-volvement of both the radiocarpal and distalradioulnar joints as well as fracture of the distal ulna,but not the complexity or pattern of articular involve-ment, the degree of displacement of the fragments, orthe size of the ulnar styloid fracture. The importanceof this classification lies in its emphasis on the distalradioulnar joint.

Melone1,23 described the most common major ar-ticular fragments: the radial styloid (or scaphoidfacet), the dorsal lunate facet, and the volar lunatefacet. He emphasized the importance of the lunatefacet. In particular, the entire carpus can displacevolarly with a displaced volar lunate facet. In addition,radiocarpal ligament attachments tend to pull thisfragment into malrotation that is difficult to correctand stabilize with closed reduction and percutaneousKirschner wires—a separate volar exposure of thefragment and internal fixation is often required. Mal-alignment of lunate facet fragments also affects thedistal radioulnar joint.

The term die-punch has been used variably to refer toeither an impacted dorsal medial lunate facet frag-ment,24 impaction of the entire lunate facet,25 orimpaction of central articular fragments with no lig-

62 INTRA-ARTICULAR FRACTURES � RING

ament attachments.16,26 Impacted central articularfragments will not reduce with ligamentotaxis or ma-nipulation of the major fragments—they require di-rect visualization and manipulation.

The Comprehensive Classification of Fractures27

distinguishes 3 types of fractures: extra-articular(Type A), partial articular (Type B), and completearticular fractures (Type C). Each type is subdividedinto 3 groups and 9 subgroups based on the extentof articular and metaphyseal fragmentation and theorientation of the articular fracture lines. Althoughthe use of this system for research purposes islimited by the unreliability of group and subgroupdistinctions,28,29 the concept of stratifying articularand metaphyseal fragmentation is useful. In partic-ular, the degree of metaphyseal comminution maybe as important as the complexity of the articularinjury because stable realignment of articular frag-ments is more challenging in the absence of a stablemetaphyseal base. In a study of extra-articular frac-tures treated with intrafocal pinning, Trumble etal30 conceived of the metaphysis of the distal radiusas a box with 4 sides.30 They specifically looked forcomminution of each of the dorsal, volar, ulnar, andradial cortices of the metaphysis. They found thatinvolvement of 2 or more cortices was associatedwith loss of alignment, less so when external fixa-tion was used.

The system of Fernandez and Jupiter31 is also com-prehensive, but is limited to simpler, higher-leveldistinctions: extra-articular fractures (Type 1); shear-ing, or partial-articular fractures (Type 2); compres-sion articular fractures (Type 3); radiocarpal fracture-dislocations (Type 4, featuring avulsion fractures); andcomplex, high-energy fractures (Type 5).

Current trends have emphasized and expanded onthe idea that articular fractures of the distal radiuscreate predictable fragments to suggest that each col-umn or fragment merits specific fixation. Rikli andRegazzoni32 conceived of the wrist as a 3-columnstructure with the radial and ulnar aspects of the distalradius representing 2 columns and the distal ulna thethird column. Similar to Trumble et al,30 Medoff33

divides the radius into 4 columns: ulnar, radial, dor-sal, and volar, and has developed a variety of implantsto reconstruct each column.

Fernandez and Jupiter31 have classified distal radio-ulnar joint injuries associated with distal radius frac-

tures as stable, unstable, or potentially unstable.When there is wide displacement of the distal radius(greater than 20° of dorsal angulation or greater than5 mm of shortening by ulnar variance), the triangularfibrocartilage complex is probably also injured.3,31

This can occur through a peripheral tear, a tear fromthe margin of the distal radius, or fracture of the ulnarstyloid at its base. Alternatively, there may be a moreproximal fracture of the distal ulna—these have beenclassified under the Comprehensive Classification ofFractures27 by using a Q modifier as follows: (1) ulnarstyloid fracture, (2) simple fracture of the ulnar neck,(3) comminuted fracture of the ulnar neck, (4) ulnarhead fracture, (5) ulnar head and neck fracture, and (6)fracture of the ulna proximal to the neck.

Management issues. None of the current classi-fication systems captures all of the important manage-ment issues, and in some cases important issues mayseemed underemphasized because of the complexity ofthe system.

One important issue is stability. Widely displacedfractures are very likely to settle and redisplace afterclosed reduction, particularly when bone quality ispoor.3,5 Fractures with very little displacement on theinitial radiographs (shortening by ulnar variance andarticular incongruity less than 2 mm; dorsal tilt lessthan 5°) are inherently stable, will rarely displace withcast immobilization, and may not need to be re-duced.31

Another issue is the energy involved in the injuryand the quality of the bone. A young, healthy personwith a displaced fracture of the distal radius hassustained a high-energy injury. Such patients are atrisk for acute carpal tunnel syndrome and forearmcompartment syndrome and are much more likely tostruggle regaining digit, wrist, and forearm range ofmotion because of the greater soft-tissue injury andswelling. In contrast, older patients with osteoporoticbone may have complex fractures involving the radiusand the ulna after simple falls and may do well despitepersistent radiographic deformity because they havelittle trouble regaining mobility.

A major distinction to make among relatively sim-ple fractures is that between a shearing-type fracture(usually volar—also known as Barton’s fracture) and acompression-type fracture. Shearing-type fractures areinherently unstable, and by consensus are best treatedwith buttress plating.


Compression-type fractures vary substantially incomplexity. The extent of both articular and extra-articular comminution will affect the technical diffi-culty and predictability of surgical intervention.

The simplest type of articular injury is a splitbetween the scaphoid and lunate facets of the radio-carpal articular surface. The next degree of complexityusually occurs at the lunate facet where a coronalfracture line can create dorsal and volar lunate frag-ments. This is important because the volar lunate facetfragment may be difficult to realign and secure byusing closed techniques. Also, when not recognized orsecured adequately, the carpus can subluxate with thisfragment. A displaced volar lunate facet fragment alsoaffects the distal radioulnar joint.

Greater degrees of fragmentation can involve cen-tral impaction and very small articular fragments.These are particularly challenging fractures.

Given that stable fixation requires realignment ofarticular fragments with one another and with a me-taphyseal base, it is not surprising that comminution,either between articular fragments or in the metaph-ysis, will make it substantially more difficult to re-store and maintain alignment.

EVALUATION AND INITIAL TREATMENT

Large wounds are uncommon in association withfracture of the distal radius, but small wounds

created by fracture fragments or tearing of the skinwith marked deformity occur occasionally. These aremost commonly volar-ulnar in location because thefragments displace dorsal-radial. Even the most innoc-uous wound merits immediate treatment with exten-sion of the wound, debridement of devitalized tissue,and irrigation of the wound; however, definitive treat-ment may be delayed, particularly if the fracture is socomplex that referral to a colleague with more expe-rience treating these fractures is merited.

The median nerve should be carefully evaluated,particularly in high-energy injuries. Older patientsinjured in simple falls may have median nerve symp-toms or dysfunction related to deformity. This usuallyresolves with reduction of the fracture, but should becarefully evaluated and observed. In contrast, the me-dian neuropathy associated with high-energy injuriesmay develop over 48 to 72 hours.34 When patientswith high-energy injuries are discharged home aftersurgical treatment or for planned treatment in a few

days, they should be taught how to recognize progres-sive median neuropathy and given clear instructionsfor contacting their surgeon. Very high energy inju-ries can also be associated with forearm compartmentsyndrome.34 Acute carpal tunnel syndrome or forearmcompartment syndrome merit prompt surgical treat-ment.

Acute tendon injuries are uncommon, but the ten-dons should be evaluated, particularly the extensorpollicis longus and flexor pollicis longus.1

Some fractures for which surgical treatment isplanned will not benefit from attempts at reduction inthe emergency room if the overall alignment is rea-sonable (eg, most volar shearing or Barton’s fractures).A supportive volar splint should be used for comfort.It is important to leave the digits free, particularly themetacarpophalangeal joints, and encourage motionand elevation of the hand to prevent stiffness andedema.

Swelling in the fingers can contribute to digitstiffness and intrinsic contracture, adding a handproblem to the original wrist problem. When forcedto choose the surgeon should always choose to protectthe hand, even if it means that the distal radius willrequire surgical treatment. Because the alignment ofunstable articular fractures cannot be maintained in acast no matter how good the mold, there is no role fortight splints or casts. When patients present to theoffice with swollen digits, tight casts or splints shouldbe removed and replaced with noncircumferentialsupport. If surgical treatment is planned, the involve-ment of an occupational or hand therapist before thesurgery to help diminish edema and restore digitrange of motion is worthwhile.

IMAGING AND PREOPERATIVE PLANNING

Radiographs taken before reduction of the fractureshow the initial displacement of the fragments,

which is one of the best predictors of stability aftermanipulative reduction (Figs 1A and 1B). Fracturelines and specific fragments are often more easilyidentified on radiographs made after manipulativereduction (Figs 1C and 1D). Both are important.

For very complex fractures—or even simple artic-ular fractures when there is uncertainty about thestatus of the lunate facet— computed tomographyprovides additional information.35 With standard2-dimensional computed tomography scans it can be


difficult to follow specific fragments between images(Figs 1E and 1F). Three-dimensional reconstructionshave made interpretations very easy—particularlywhen the carpus is subtracted from the scan.14 Three-

dimensional reconstructions accurately depict the sizeof the volar fragment, the extent of comminution ofboth the dorsal and volar lips, and central impactionof articular fragments (Figs 1G and 1H). This can help

FIGURE 1. A 29-year-old man fell from a ladder sustaining a complex articular fracture of thedistal radius. (A and B) Lateral and posteroanterior radiographs taken before reduction toshow wide displacement of the fragments. It is difficult to determine the number and locationof the articular fragments. (C and D) On lateral and posteroanterior radiographs taken afterreduction, the fragments are better seen. The fracture is complex and unstable and willrequire surgical treatment to improve alignment. (E and F) Sagittal and coronal plane2-dimensional computed tomography provides additional information, but it can be difficult tofollow small articular fragments from one cut to another. (G and H) Three-dimensionalreconstructions with the carpus subtracted give a very clear view of the injury. In addition tosagittal and coronal plane splits, there is central articular impaction. (I and J) Fragment-specific fixation with 2.4- and 2.0-mm plates was performed through a dorsal and volarsurgical exposure. The radial plate lies between the first and second extensor compartments.The volar plate was applied through a limited volar-ulnar exposure between the ulnar nerveand artery and the contents of the carpal canal. Copyright © held by David Ring, MD.


determine the surgical exposures, the use of arthros-copy, the need for capsulotomy, and whether there area few specific fragments that can be supported againstone another or there is extensive fragmentation so thatthe goal should be containment and support of thefragments.

When there is concern about the integrity of thescapholunate interosseous ligament and arthroscopy orcapsulotomy are not otherwise necessary, the imageintensifier can be used to view the wrist under tractiononce the patient is anesthetized. A break in the prox-imal carpal arc with traction suggests a complete tear(Fig 2).

SPECIFIC TREATMENT

Shearing FracturesThere is general agreement that shearing fractures

of the dorsal or volar articular margin are best treatedwith plate and screw fixation. The oblique fracturelines and radiocarpal subluxation are not well con-trolled by external fixation or Kirschner wires. For thisreason, shearing and compression articular fractures

are usually considered separately. Volar marginal frac-tures (volar Barton’s fractures) are common, whereasdorsal marginal fractures (dorsal or reverse Barton’sfractures) are unusual.

Volar shearing fractures. One of the pitfalls oftreatment of a volar shearing fracture is an unrecog-nized dorsal cortical fracture line.36 Standard surgicaltechnique for volar shearing fractures involves leavingthe plate relatively straight so that as screws areinserted from distal to proximal, the plate compressesthe volar marginal articular fragments against theintact dorsal metaphysis. If the dorsal metaphysealcortex is fractured, this technique will displace thearticular fragments dorsally, leading to dorsal trans-lation and, in some cases, dorsal angulation of thearticular surface.

In a more complex fracture the dorsal fracture linemay be displaced and the injury may not be recog-nized as a shearing-type fracture. The argument can bemade that, when the dorsal cortex is fractured, thefracture should not be classified as a partial articularfracture (AO Type B) because the entire articularsurface is separated from the metaphysis (AO Type C).On the other hand, because the major fragment—thevolar articular margin—has an unstable obliqueshearing pattern, attempts to treat this fracture withexternal fixation and Kirschner wires may not be ableto prevent displacement and radiocarpal subluxation.Because fragments with oblique, shearing-type frac-ture lines are best treated with plate and screw fixa-tion, these fractures are best distinguished from com-pression articular fractures—the treatment of which ismore variable.

Another pitfall in the treatment of volar shearingfractures is failure to account for fragmentation of thevolar articular margin.37 Through the standard volar-radial (Henry38) approach, it may be more difficult tovisualize and manipulate more ulnar (lunate facet) frag-ments. If the plate does not adequately capture thisfragment, particularly if the fragment is very small, itmay slip around the plate and the entire carpus maysubluxate with it. Small fragments may benefit from awire or suture loop engaging the radiocarpal ligamentattachments to the fragment.39 In addition, a direct volaror volar ulnar exposure may afford better access to theulnar aspect of the distal radius.

Jupiter et al37 reviewed 49 patients with volarshearing fractures of the distal radius treated with

FIGURE 2. Fernandez described the Shenton’s sign of thewrist. When there is a possibility of a complete tear of thescapholunate interosseous ligament, a traction view will oftenshow a break in the arc formed by the proximal carpal row.Copyright © held by David Ring, MD.


plate and screw fixation. Forty-four fractures (90%)were comminuted. The results were good or excellentin 84% of patients.

Keating et al36 noted reversal of the normal palmartilt of the articular surface of the distal radius reflect-ing an unrecognized or unaccounted for dorsal corticalfracture in 22 of 79 patients (28%).

Dorsal shearing fractures. Dorsal shearing frac-tures are much less common and are usually associatedwith some central impaction of the articular surface(Fig 3). These can be treated with an open reductionand dorsal capsulotomy with realignment of the ar-ticular surface and buttress plating of the dorsal ar-ticular margin with or without bone grafting. Theprognosis is not as good as with volar shearing frac-tures.

Compression FracturesNonsurgical treatment. The inherent instability

of displaced articular fractures is well documented.Knirk and Jupiter5 noted in their series that all of the

displaced articular fractures that were immobilized inplaster alone lost some reduction. In some cases thiswas extra-articular and the settling of the fractureactually improved the articular reduction. They alsoobserved loss of reduction despite traction treatment(pins in plaster or external fixation). Perhaps mostinteresting was their observation of late settling of thefracture fragments in a few patients when immobili-zation was discontinued 6 to 11 weeks after injury.The risk for late settling may be greater when there isa substantial metaphyseal defect across which healingcan be delayed.

Leung et al19 reviewed the treatment of 80 dis-placed articular fractures. Displacement was defined asgreater than 10° of dorsal angulation or 2 mm orgreater of articular incongruity or radial shorteningcompared with the opposite side. Thirty-one fracturesredisplaced in a cast. Twenty of those displaced aftera second reduction and were treated surgically. For theremaining 11 fractures treated in a cast, the average

FIGURE 3. A 35-year-old man fell from a roof sustaining afracture-dislocation of his wrist. (A) A lateral radiographshows slight residual dorsal subluxation of the carpus, somedorsal articular impaction, and fracture of the dorsal articularrim (dorsal Barton’s or dorsal shearing fracture). (B) A dorsalexposure is made, mobilizing the extensor pollicis longus andelevating the fourth dorsal compartment subperiosteally. Thedorsal articular rim fragments remain attached to the capsule.The dorsal articular surface has lost its subchondral supportand is essentially a thin wafer of cartilage. (C) After bonegrafting behind this cartilage and dorsal plating, the carpus isreduced and the fracture healed. Full forearm and digit mo-tion was achieved, but the arc of wrist motion was limited to40°. Copyright © held by David Ring, MD.


final dorsal angulation was 16°, reflecting the inherentstability of these fractures. Residual articular incon-gruity was not addressed.

Rodriguez-Merchan40 treated 20 patients with dis-placed articular fractures of the distal radius (�10°dorsal angulation, �3 mm articular step-off) in a castas part of a prospective trial. Fifteen of 20 redisplacedin the cast and were remanipulated.

Minimally displaced fractures. Fractures withless than 5° of dorsal angulation of the distal radiusarticular surface and less than 2 mm of articularincongruity or shortening (by ulnar variance) on theinitial injury radiographs are very unlikely to displacein a cast.31 Treatment of these minimally displacedfractures should provide comfort and protection.There is no need for reduction or tightly molded casts.In a reliable patient, a removable splint will facilitatebathing. The splint or cast should not restrict motionof the digits or forearm. Functional use of the hand forlight tasks should be encouraged.

Leung et al19 treated 11 minimally displaced fracturesin a short arm cast without reduction and noted no lossof reduction and good or excellent results in all patients.

Displaced fractures in inactive or infirm pa-tients. When the goal of treatment is healing of thefracture and early return to function, and the patientand surgeon have decided to accept deformity becauseof limited functional demands or infirmity, there is noneed for a tight circumferential cast. A simple volarsplint usually provides adequate support for comfortand healing and, because it is nonconstricting, mayhelp limit swelling and improve hand function (Fig4). A removable plastic splint facilitates hygiene and

is usually lighter and less cumbersome. Functional useof the limb should be encouraged.

Surgical TechniquesIntraoperative assessment and restoration of ar-

ticular alignment. The alignment of articular frac-tures can be monitored with image intensification,arthroscopy, dorsal capsulotomy, or indirectly by ex-posing and realigning metaphyseal fracture lines. Theadvocates of arthroscopic-assisted treatment of articu-lar fractures of the distal radius claim that imageintensification does not depict articular alignmentaccurately; however, the clinical significance of smallresidual incongruities that are not well depicted byimage intensification is uncertain. Arthroscopy anddorsal capsulotomy allow inspection of the intercarpalligaments and the triangular fibrocartilage complex,but it is unclear how identification and treatment ofthese injuries affects the functional results. For in-stance, it is not clear that partial tears of the scapholu-nate interosseous ligament benefit from specific treat-ment.

External fixation. External fixation was intro-duced as an alternative to pins and plaster as a methodof sustained portable traction. Unfortunately, tractionalone cannot always restore articular alignment. Trac-tion may worsen the alignment of some fragments (eg,the volar aspect of the lunate facet) and will not affectothers (eg, impacted central articular fragments).26,41,42

Attempts to improve the radiographic appearance of afracture may result in a distracted wrist positioned inflexion. Substantial distraction across the wrist maycontribute to wrist stiffness and digit stiffness, the

FIGURE 4. An infirm 78-year-old man who lives in a nursing home had a tight sugar tong splint applied after manipulativereduction of a fracture of the distal radius. (A) The immobilization of the elbow and forearm add substantial disability and thesplint is very heavy and cumbersome. (B) The tightness of the cast contributed to substantial swelling and stiffness in the hand.For this patient the goal of treatment was immobilization for comfort and function and healing of the fracture. These were easilyachieved in a light removable plastic volar splint that facilitated hygiene and edema control. Copyright © held by David Ring, MD.


latter by tightening the extrinsic flexor and extensortendons.41-43 Wrist flexion will contribute to digitstiffness by diminishing the effectiveness of the ex-trinsic tendons (tight extensors, lax flexors) as one caneasily show by attempting to make a tight fist withthe wrist flexed. A flexed position can also increasepressure in the carpal tunnel and contribute to amedian neuropathy.

The complications associated with the external fix-ation device and its placement include injury to thesuperficial radial nerve, tethering and scarring of mus-cles or tendons, pin track infections including pintrack osteomyelitis, fracture through a pin site, pinloosening, and tender or unsightly scars.41,44 Pin trackinfections are common, but are usually easily managedwith oral antibiotics. Severe or recalcitrant infectionswill require pin removal.

Given the complications of external fixation, therehas been some interest in using a plate applied acrossthe wrist for sustained traction. The plate can beplaced by using 2 small incisions and is removedunder local anesthesia 8 weeks after the injury.45

External fixation that does not cross the wrist (so-called nonbridging fixation) has been suggested for ex-tra-articular and simple articular fractures.46-49 A frac-ture that creates a simple split between the scaphoidand lunate facets can be controlled with a Schantzscrew (Synthes, Ltd, Paoli, PA) placed in each majorarticular fragments stabilized to Schantz screws an-chored in the diaphysis. The screws placed into thearticular fragments can be used to directly manipulatethe fragments. The technique is only suitable whenthere is limited metaphyseal comminution and thebone quality is adequate for the Schantz screws to holdin the small metaphyseal fragments. Superficial infec-tions around the distal Schantz screws are commonbecause early wrist motion creates substantial motionbetween the skin and the screws.49 Oral antibioticswill usually control the infection and allow retentionof the frame for the duration of treatment.

Percutaneous Kirschner wire fixation. Direct orintrafocal Kirschner wire fixation of articular fractureswith cast or splint immobilization instead of externalfixation is only suitable for very simple articular frac-tures. Although the intrafocal technique was origi-nally described without ancillary cast immobilization,a cast or external fixator is usually used.30 A cast ismost appropriate when soft-tissue swelling and me-

taphyseal comminution are limited. Kirschner wiresprovide very limited fixation and are best neutralizedor protected with more rigid external fixation.30 Inaddition, it is desirable to avoid potentially constric-tive circumferential immobilization when there issubstantial digital swelling. The prospective trial ofRodriquez-Merchan clearly showed the advantages ofpercutaneous pinning and cast immobilization overcast immobilization alone.40

Combined external fixation and Kirschner wires.The combination of external fixation and Kirschnerwires can help overcome the drawbacks of each indi-vidual technique.25 With Kirschner wires helping tosecure the fragments, the external fixator can be placedin a relatively neutral position and with limited dis-traction. External fixation provides more rigid neu-tralization of Kirschner wire fixation than can beachieved with a cast. However, even with externalfixation, Kirschner wires may not provide adequatefixation of small articular fragments, particularly dis-impacted central fragments and volar lunate facetfragments.

Bone grafts and bone substitutes. Autogenouscancellous bone grafts can accelerate healing acrossmetaphyseal defects created by realignment of fracturefragments.50 They are also used to support disim-pacted articular fragments.6,7,26 Other materials (so-called bone graft substitutes) have been used for thispurpose in an attempt to avoid the morbidity andinconvenience associated with obtaining an autoge-nous graft. These include coral, solid and injectablehydroxyapatites, allograft bone, and bone deriva-tives.51 Recent basic science advances hold promise fortissue engineering and the use of growth factors.Currently, at least when healing across a metaphysealdefect is the concern; autogenous bone grafts remainthe most reliable choice.

Internal fixation. Internal fixation of fractures ofthe distal radius has increased in popularity recently,partly as a result of the introduction of several newimplants.

Inherent Drawbacks of Internal FixationImplants placed on the distal radius are directly

under or adjacent to tendons. Even very smooth im-plants can cause extensor tendon irritation and rup-ture.6,7,52,53 Trimming a plate will create sharp sur-faces that can be particularly problematic54—if a plateused on the distal radius is trimmed, the edges should


be filed smooth. In many cases, the plates must beplaced in a very distal position adjacent to the joint.This represents a relatively prominent site over whichtendons pass and can also contribute to problems. Itappears that, no matter how carefully designed, im-plants placed directly adjacent to the tendons posesome risk for painful irritation or rupture. Patientsneed to understand that these tendon ruptures canoccur and that a second surgery to remove the implantmay be necessary. In practice, dorsal plates are usuallyremoved and volar plates are removed only when theyirritate the flexor pollicis longus.

Considering these drawbacks, it may be best toreserve plate and screw fixation for shearing fracturesand complex articular fractures. Although some sur-geons have suggested that even simple articular frac-tures of the distal radius merit internal fixation,52

there is insufficient evidence of benefit over simplertechniques such as the combined use of external fix-ation and Kirschner wires to merit the additionaldissection, cost, and surgical time, not to mention therisks to tendons and the possibility of a second surgeryto remove the implant.

ImplantsSeveral new implants have recently been intro-

duced.33,52,53,55,56 The features of these new platesinclude recessed screw heads or pins; smaller, betterpositioned screws; and fixed-angled tines or buttresspins. Recessed screws and other design features havenot eliminated the risk for tendon problems.52,53

The standard 3.5-mm oblique T-plate (Synthes,Paoli, PA) and the Forte plate (Zimmer, Warsaw, IN)use 3.5-mm screws that are often too large and riskfragmenting small articular fragments. In addition,standard screws may not gain adequate fixation ofbone that is fragmented or osteopenic. Volar displace-ment of the fragments was a common problem in 1series of patients treated with the Forte plate.57

Another approach has been to use a combination ofwire forms and narrow plates that provide internalsupport for standard Kirschner wires (Trimed, Valen-cia, CA).33 Wire forms are wires bent into shapesintended to provide a fixed buttress for articular frag-ments. The wire forms are secured to the radius witha screw. It is becoming clear that these implants areless predictable in poor quality bone.

The notorious disadvantages of small screws andwires in poor quality bone have increased the appeal of

fixed-angled devices that do not depend on implant-bone engagement, and several implants now incorpo-rate this concept.53,55,56 This technique has been ap-plied with success for metaphyseal fixation at othersites; however, there are no comparative studies doc-umenting improved outcomes for fractures of the dis-tal radius.

Fragment-Specific FixationThe Trimed implants were developed for fragment-

specific fixation of the distal radius. In other words,each of the specific components of the injury is ad-dressed individually with a specific fixation device.The appeal of this approach relates to the relativelypredictable pattern of articular injuries. The recom-mended management of articular fractures has essen-tially been fragment-specific for some time: Fernandezand Geissler58 recommended that the radial styloidand dorsal lunate fragments be reduced and securedwith Kirschner wires, whereas a volar lunate facetfragment often requires direct open manipulation andinternal fixation. The difference with the current ver-sion of fragment-specific fixation is that each fragmentis secured internally through a separate incision.33

One relatively unusual aspect of the Trimed systemis the use of an implant applied to the direct radialsurface of the radial styloid.33 Even with the newerplates that have longer radial extensions for capturingthe radial styloid,53 fixation of the radial styloid hasproved unpredictable, particularly when the fragmentor its metaphyseal fracture line are comminuted. Adirect radial plate provides a direct buttress for thisfragment.

Smaller 2.0- and 2.4-mm plates have been used forfragment specific fixation (Figs 1I and 1J). Implantsincorporating fixed-angle blades or buttress pins haveproved useful (Fig 1J) and new plates for fragment-specific fixation will incorporate these features.

Surgical ExposuresSafe surgical exposure of the distal radius can be

achieved in a variety of ways. The skin incision mustaccount for and protect the branches of the superficialradial nerve, the dorsal cutaneous branch of the ulnarnerve, and the palmar cutaneous branch of the mediannerve. Volar incisions should cross the transverse wristcrease obliquely to limit scar contracture. Oblique,curved, or Y-shaped incisions are not necessary on thedorsum of the wrist where the skin is more mobile and


elastic and is not prone to form scar contracture. Deepexposure must protect the median nerve and the ulnarnerve and artery.

Volar exposure is usually achieved through Henry’sinterval38 (between the radial artery and the flexorcarpi ulnaris) or a volar ulnar exposure (between theflexor tendons and the ulnar nerve and artery).1 Amore radial incision and interval has been used tofacilitate additional access to the direct radial aspect ofthe radial styloid.33 In addition, many favor a directvolar exposure identifying and protecting the mediannerve and creating an interval between the flexortendons.7,59 The pronator quadratus must be incisedand mobilized and cannot always be strongly repaired.Nonetheless, functional problems are rarely encoun-tered.

Exposure of the dorsal surface of the distal radiusrequires mobilization of the tendons of the second,third, and four extensor compartments. Traditionally,this was performed directly through the fourth exten-sor compartment. In an attempt to protect the exten-sor tendons from implants placed on the dorsal surfaceof the distal radius, dorsal exposure has been modifiedto attempt to elevate the fourth extensor compartmentsubperiosteally. The extensor retinaculum is incisedover the extensor pollicis longus tendon (third com-partment) and the fourth compartment is elevatedsubperiosteally. The extensor pollicis longus is mobi-lized radialward and left in the subcutaneous tissues atthe time of closure.

The second compartment cannot be elevated sub-periosteally. The creation of an ulnar-based flap ofextensor retinaculum to place between the radial wristextensor tendons and dorsal implants has been sug-gested,53 but may not be able to prevent tendonproblems any better than recessed screws.

The dorsal skin is elastic and easily mobilized andretracted. As a result, a straight longitudinal skinincision will provide access to nearly the entire dor-sum of the radius. Branches of the superficial radialnerve and the dorsal cutaneous branch of the ulnarnerve are elevated with the skin flap. The skin incisionis usually centered over Lister’s tubercle.

Exposure and fixation of the direct radial aspect ofthe radius is becoming more popular.33 The radialstyloid points volarly as it extends radialward. Place-ment of an implant on the direct radial aspect of theradius can be achieved through a volar radial or direct

radial skin incision. The first dorsal compartmentmust be opened and the implant is often placeddirectly below these tendons.

Alternatively, implants can be placed on the dorsalaspect of the radial styloid between the first andsecond dorsal compartments. Incision of these com-partments and mobilization of the tendons is oftenrequired, but the implant is less likely to be directlyunder the tendons, at least distally. The dorsal aspectof the radial styloid can be accessed through a dorsalskin incision. Usually a single limited incision cen-tered over Lister’s tubercle allows access to the dorsalradial and dorsal ulnar aspects of the distal radius.

Dorsal capsulotomy can be performed either longi-tudinally or transversely and should not be repaired atclosure. In some cases with extensive comminution itmay be preferable to mobilize small fracture frag-ments with the capsule rather than cutting the capsuleand creating small free fragments (Fig 3B). Incision ofthe volar capsule should be avoided if possible.

Arthroscopy can be performed with traction or withexternal fixation used to distract the wrist. An infu-sion pump is not necessary and may increase the riskfor forearm compartment syndrome or other problemsrelated to fluid extravasation. In addition to standarddorsal portals, a volar portal has been suggested.14

Treatment Options for Specific Types of DisplacedCompression Fractures

Simple split between scaphoid and lunate facet.One of the most common types of compression artic-ular fractures is a simple split between the scaphoidand lunate facets. Often this split is minimally dis-placed and treatment can focus on the displaced me-taphyseal component of the injury.8

A displaced fracture between the scaphoid and lu-nate articular facets of the distal radius can usually bemanipulated and monitored by using closed meansand image intensification. The static injury radio-graphs combined with a traction image of the wristunder fluoroscopy will usually identify a complete tearof the scapholunate interosseous ligament. Arthros-copy would provide direct visualization of the carpalligaments and the triangular fibrocartilage complex,but is probably not necessary for monitoring thearticular reduction.

Fixation with Kirschner wires and either a cast orexternal fixator is usually adequate. A nonbridging


fixator with pins stabilizing each of the major articularfragments could be considered.

Some of these simple articular fractures have sub-stantial metaphyseal comminution (Subgroup C2 ofthe Comprehensive Classification of Fractures). Whenrealignment of the articular fragments creates a me-taphyseal defect, there may be a tendency for settlingof the fragments or delayed healing. If stable fixationcan be achieved with Kirschner wires and/or externalfixation, then considerations include either leaving thefixator in place for longer than usual (8-10 wks ratherthan 6 wks), or packing the defects with autogenouscancellous bone grafts to help support the fragmentsand speed healing. If the metaphyseal comminutionprevents stable realignment of the articular fragmentsby using closed or percutaneous techniques, then openreduction and internal fixation with or without bonegrafting may need to be considered.

Coronal split of the lunate facet. The next levelof complexity involves a coronal split in the lunatefacet. This fragment is often depicted in schematicdrawings as being small and confined to the lunatefacet. In many cases, however, the volar lunate facetfragment extends quite radial with the radial styloidfragment being smaller and more dorsally based. Al-though some investigators emphasize the added chal-lenges of the coronal split, indicating that open expo-sure and internal fixation of the volar lunate fragmentis usually required,1,58 others describe reduction byusing an arthroscope or dorsal capsulotomy to assistreduction and fixation without the use of a separatevolar incision.14

The potential problems associated with the volarlunate fragment should not be underestimated. Thevolar radiocarpal ligaments tend to rotate this frag-ment into a relatively extended position. This ro-tational malalignment can block wrist flexion andforearm rotation and may not be apparent on imageintensification or arthroscopy. The volar lunatefragment is also an important support of the carpus.Treatment with a dorsal plate alone can push thisfragment and the carpus into a volarly subluxatedposition (Fig 5). Inadequate control of this frag-ment with Kirschner wires may have the sameresult.

A volar exposure allows direct visualization of themetaphyseal fracture line, reduction of which usuallyrealigns the fragment. Large fragments can be fixed

with a plate and screws.58 Small fragments can besecured with a suture or wire loop.39

Central impaction. Central impaction usuallyoccurs in the scaphoid or lunate facet of the artic-ular surface, occasionally both. For relatively simplefractures (such as radial styloid fractures with im-paction of the scaphoid facet articular surface), ar-throscopic-assisted reduction can be performed. As-sociated scapholunate interosseous ligament injuryis common and can be addressed simultaneously(Fig 6). On the other hand, an open exposure forapplication of supportive bone grafts and for directrepair of the scapholunate ligament may be desir-able.

Complex articular fractures. It is common forpublished studies of articular fractures of the distalradius to identify most fractures as complex Sub-group C2 and C3 fractures, but show relativelysimple and straightforward fractures in the illustra-tions.6,7,33,53,58 High-energy injuries in young pa-tients and moderate-energy injuries in osteoporoticindividuals can create very complex articular andmetaphyseal fractures that are uniquely difficult totreat and need to be considered separately. It is notuncommon to find articular fragments in the softtissues of the forearm and cortical bone fragmentsin the joint after reduction of the fracture. Externalfixation will not support the fragments adequatelyand there is no place to anchor Kirschner wiresexcept, perhaps, the ulna. If there is extensive ar-ticular fragmentation it will prove difficult to an-chor the small fragments reliably with wires. If aplate is applied to the volar or dorsal surface thefragments will collapse opposite the plate.16

The complexity of these fractures and the diffi-culties in treatment are apparent in the fact thatsome surgeons have considered primary wrist arth-rodesis.60 This seems extreme given that, despitethe difficulties managing complex articular frac-tures of the distal radius, subsequent wrist arthro-desis is unusual, at least within the first decade afterinjury.6,7,15-17

Other surgeons have used combined internal and ex-ternal fixation61 or combined dorsal and volar plate fix-ation.16,17 Combined dorsal and volar plate fixation cra-dles the complex articular comminution and supportsboth volar and dorsal metaphyseal comminution (Fig 7).This type of double plating raises concerns regarding


avascular necrosis, infection, and nonunion, but thesehave not been observed at the distal radius.16,17

RESULTS

Surgical fixation of fractures of the distal radiusleads to good or excellent results according to the

rating system of Gartland and Werley3 in 52% to86% of patients in various series.6,14,16,53 When thesystem of Cooney et al62 is used, the results are usuallymuch worse because the system is far more stringent.Residual articular incongruity correlates with arthro-sis, but not always with function.15

Inconsistencies in classification are common-place. For instance, Melone Type 4 fractures repre-sent complex articular comminution and should beclassified as Group C3 in the Comprehensive Clas-sification of Fractures, but are often classified asGroup C2.8 Another study lists volar shearing frac-tures as an exclusion criteria and then includes

several Group B3 fractures.14 Although most seriesinclude mostly Group C2 and C3 fractures, theseverity of comminution and displacement varysubstantially and are not well accounted for. Theseinconsistencies hinder reliable interpretation andcomparison of studies.

Even with the direct visualization and manipula-tion possible with open reduction and internal fixa-tion, residual articular malalignment is not uncom-mon.16,17 When Schneeberger et al17 reviewed theirresults in 18 patients, 7 had a residual step or gap of2 mm or more on the immediate postoperative radio-graph. Three patients had subsequent loss of reductionso that only 8 patients (44%) had less than 2 mm stepor gap at final follow-up. These findings reflect theinherent limitations in our ability to achieve stableanatomic alignment of complex articular fractures.These relate to fragmentation of the articular surfaceand the metaphysis, diminished bone quality, andimperfect fixation devices.

FIGURE 5. A 30-year-old woman was in a motor vehiclecollision and sustained a fracture of the femur and the con-tralateral distal radius. (A) Careful review of a lateral radio-graph after closed reduction and casting suggests a dis-placed, rotated volar lunate facet fragment. (B) Treatmentwith a dorsal plate contributed to volar displacement of thecarpus with this fragment. (C) A second plate applied volarlyhelped restore radiocarpal alignment. Copyright © held byDavid Ring, MD.


CONCLUSIONS

The variety of treatment methods and the number ofmanagement issues that are controversial are a re-

flection of continued dissatisfaction with the treatment

of intra-articular fractures of the distal radius. Areas ofdispute include indications for surgical treatment, par-ticularly in older-aged patients; the relative merits ofinternal and external fixation; whether osteopenic bonelimits the use of internal fixation; the need for direct

FIGURE 6. A 28-year-old man injured his wrist in a motorcycle accident. (A) The injury radiograph shows central impaction ofthe scaphoid into the scaphoid facet of the distal radius. (B) Arthroscopic-assisted reduction and fixation showed a complete tearof the scapholunate interosseous ligament. Reduction and fixation with 3.0-mm cannulated screws were accomplishedpercutaneously. (C) A posteroanterior radiograph after hardware removal shows slight settling of the articular fragments. Anopen exposure for the application of a bone graft or bone graft substituted to the defect created by the reduction might haveprevented this. (D) The final lateral radiograph shows good scapholunate alignment. Copyright © held by David Ring, MD.


FIGURE 7. A 33-year-old man fell from a tree onto his out-stretched hand. (A) The lateral radiograph taken before ma-nipulative reduction shows a complex articular fracture withcomplex comminution and impaction of the articular surfaceand both dorsal and volar metaphyseal comminution. (B)Treatment with combined dorsal and volar exposure andplate fixation helped cradle the fragments and support theelevated articular fragments. (C) The complexity of the injuryis emphasized by the fact that, on exposure, a metaphysealcortical bone fragment was found in the joint and an articularfragment was found proximally in the dorsal soft tissues. (Dand E) Lateral and posteroanterior radiographs taken afterhardware removal show a reasonable radiographic result.Full forearm and digit range of motion were regained and thearc of wrist motion was 90°. Copyright © held by David Ring,MD.


exposure and fixation of a volar lunate facet fragment; therole of bone graft and bone graft substitutes; and the roleof wrist arthroscopy. Even when the alignment of thedistal radius is restored, digit stiffness, peripheral neu-

ropathy and nerve injury, unsightly scars, and implant-related complications often affect the result. Study ofthese issues is hindered by variability in classification andradiographic measurement of fractures.

REFERENCES

1. Melone CP. Open treatment for displaced articular fracturesof the distal radius. Clin Orthop 1988;202:103-111.

2. Mudgal C, Hastings H. Scapho-lunate diastasis in fractures ofthe distal radius. Pathomechanics and treatment options.J Hand Surg [Br] 1993;18B:725-729.

3. Gartland JJ, Werley CW. Evaluation of healed Colles’ frac-tures. J Bone Joint Surg Am 951;33A:895-907.

4. Cooney WP, Dobyns JH, Linscheid RL. Complications ofColles’ Fractures. J Bone Joint Surg Am 1980;62A:613-619.

5. Knirk JL, Jupiter JB. Intraarticular fractures of the distal endof the radius in young adults. J Bone Joint Surg Am 1986;68A:647-659.

6. Bradway JK, Amadio PC, Cooney WP. Open reduction andinternal fixation of displaced, comminuted, intra-articularfractures of the distal end of the radius. J Bone Joint Surg Am1989;71A:839-847.

7. Axelrod TS, McMurty RY. Open reduction and internalfixation of comminuted, intraarticular fractures of the distalradius. J Hand Surg [Am] 1990;15A:1-17.

8. Trumble TE, Schmitt SR, Vedder NB. Factors affectingfunctional outcome of displaced intraarticular distal radiusfractures. J Hand Surg [Am] 1994;19A:325-340.

9. Kreder HJ, Hanel DP, McKee MD, Jupiter JB, McGillivaryG, Swiontkowski MF. X-ray film measurements for healeddistal radius fractures. J Hand Surg [Am] 1996;21:31-39.

10. Cole RJ, Bindra RR, Evanoff BA, Gilula LA, Yamaguchi K,Gelberman RH. Radiographic evaluation of osseous displace-ment following intra-articular fractures of the distal radius:reliability of plain radiography versus computed tomography.J Hand Surg [Am] 1997;22A:792-800.

11. Freedman DM, Dowdle J, Glickel SZ, Singson R, Okezie T.Tomography versus computed tomography for assessing stepoff in intraarticular distal radial fractures. Clin Orthop 1999;361:199-204.

12. Auge WK, Velazquez PA. The application of indirect reduc-tion techniques in the distal radius: the role of adjuvantarthroscopy. Arthroscopy 2000;16:830-835.

13. Edwards CC, Harazli CJ, McGillivary GR, Gutow AP. Intra-articular distal radius fractures: arthroscopic assessment ofradiographically assisted reduction. J Hand Surg [Am] 2001;26A:1036-1041.

14. Doi K, Hattori T, Otsuka K, Abe T, Yamamoto H. Intra-articular fractures of the distal aspect of the radius: arthro-scopically assisted reduction compared with open reductionand internal fixation. J Bone Joint Surg Am 1999;81A:1093-1110.

15. Catalano LW, Cole RJ, Gelberman RH, Evanoff BA, GilulaLA, Borrelli J. Displaced intra-articular fractures of the distalaspect of the radius. Long-term results in young adults afteropen reduction and internal fixation. J Bone Joint Surg Am1997;79A:1290-1302.

16. Fitoussi F, Chow SP. Treatment of displaced intraarticular

fractures of the distal end of the radius with plates. J BoneJoint Surg Am 1997;79A:1303-1312.

17. Schneeberger AG, Ip WY, Poon TL, Chow SP. Open reduc-tion and plate fixation of displaced AO Type C3 fractures ofthe distal radius: restoration of articular congruity in eighteencases. J Orthop Trauma 2001;15:350-357.

18. Young BT, Rayan GM. Outcome following nonoperativetreatment of displaced distal radius fractures in low-demandpatients older than 60 years. J Hand Surg 2000;25A:19-28.

19. Leung F, Ozkan M, Chow SP. Conservative treatment ofintra-articular fractures of the distal radius—factors affectingfunctional outcome. Hand Surgery 2000;5:145-153.

20. Schoenborn CA. Health habits of U.S. adults 1985: the“Almeda 7” revisited. Public Health Rep 1985;101:571-580.

21. Rowe JW, Kahn RL. Successful aging. New York: PantheonBooks, 1998.

22. Frykman G. Fracture of the distal radius including sequelae:shoulder-hand-finger syndrome, disturbance in the distal ra-dio-ulnar joint and impairment of nerve function: a clinicaland experimental study. Acta Orthop Scand Suppl 1967;108:5-153.

23. Melone CP. Articular fractures of the distal radius. OrthopClin North Am 1984;15:217-236.

24. Scheck M. Long-term follow-up of treatment of comminutedfractures of the distal end of the radius by transfixation withKirschner wires and cast. J Bone Joint Surg Am 1962;44A:337-351.

25. Seitz WH, Froimson AI, Leb R, Shapiro JD. Augmentedexternal fixation of unstable distal radius fractures. J HandSurg [Am] 1991;16A:1010-1016.

26. Trumble TE, Culp R, Hanel DP, Geissler WB, Berger RA.Intra-articular fractures of the distal aspect of the radius.J Bone Joint Surg Am 1998;80A:582-600.

27. Muller ME, Nazarian S, Koch P, Schatzker J. The compre-hensive classification of fractures of long bones. Berlin:Springer-Verlag, 1990.

28. Kreder HJ, Hanel DP, McKee MD, Jupiter JB, McGillivaryG, Swiontkowski MF. Consistency of AO fracture classifica-tion for the distal radius. J Bone Joint Surg Br 1996;78B:726-731.

29. Flinkkila T, Nikkola-Sihto A, Kaarela O, Paakko E, Raati-kainen T. Poor interobserver reliability of AO classification offractures of the distal radius: additional computed tomogra-phy is of minor value. J Bone Joint Surg Br 1998;80B:670-672.

30. Trumble TE, Wagner W, Hanel DP, Vedder NB, Gilbert M.Intrafocal (Kapandji) pinning of distal radius fractures withand without external fixation. J Hand Surg [Am] 1998;23:381-394.

31. Fernandez DL, Jupiter JB. Fractures of the distal radius. Apractical approach to management. New York: Springer-Verlag, 1995.

32. Rikli D, Regazzoni P. Fractures of the distal radius treated by


internal fixation and early function. J Bone Joint Surg Br1996;78B:588-592.

33. Wigart CR, Wolfe SW. Limited incision open techniques fordistal radius fracture management. Orthop Clin North Am2001;32:317-327.

34. Simpson NS, Jupiter JB. Delayed onset of forearm compart-ment syndrome: a complication of distal radius fracture inyoung adults. J Orthop Trauma 1995;9:411-418.

35. Rozental TD, Bozentka DJ, Katz MA, Steinberg DR, Bered-jiklian PK. Evaluation of the sigmoid notch with computedtomography following intra-articular distal radius fracture.J Hand Surg [Am] 2001;26A:244-251.

36. Keating JF, Court-Brown CM, McQueen MM. Internal fix-ation of volar displaced distal radius fractures. J Bone JointSurg Br 1994;76B:401-405.

37. Jupiter JB, Fernandez DL, Toh CL, Fellman T, Ring D. Theoperative management of volar articular fractures of the distalend of the radius. J Bone Joint Surg Am 1996;78A:1817-1828.

38. Henry AK. Extensile exposure. 2nd ed. Edinburgh: ChurchillLivingstone, 1973.

39. Chin KR, Jupiter JB. Wire-loop fixation of volar displacedosteochondral fractures of the distal radius. J Hand Surg[Am] 1999;24A:525-533.

40. Rodriguez-Merchan EC. Plaster cast versus percutaneous pinfixation for comminuted fractures of the distal radius inpatients between 46 and 65 years of age. J Orthop Trauma1997;11:212-217.

41. Weber SC, Szabo RM. Severely comminuted distal radialfractures as an unsolved problem: complications associatedwith external fixation and pins and plaster techniques. J HandSurg [Am] 1986;11A:157-165.

42. Agee JM. External fixation: technical advances based uponmultiplanar ligamentotaxis. Orthop Clin North Am 1993;24:265-274.

43. Kaempffe FA, Wheeler DR, Peimer CA, Hvisdak KS, Cera-volo J, Senall J. Severe fractures of the distal radius: effect ofamount and duration of external fixator distraction on out-come. J Hand Surg [Am] 1993;18A:33-41.

44. Zanotti RM, Louis DS. Intra-articular fractures of the distalend of the radius treated with an adjustable fixator system.J Hand Surg [Am] 1997;22A:428-440.

45. Becton JL, Colborn GL, Goodrich JA. Use of an internalfixator device to treat comminuted fractures of the distalradius: report of a technique. Am J Orthop 1998;27:619-623.

46. Fischer T, Koch P, Saager C, Kohut GN. The radio-radialexternal fixator in the treatment of fractures of the distalradius. J Hand Surg [Br] 1999;24B:604-609.

47. McQueen MM, Simpson D, Court-Brown CM. Use of theHoffman 2 compact external fixator in the treatment of

redisplaced unstable distal radial fracture. J Orthop Trauma1999;13:501-505.

48. Krishnan J, Chipchase LS, Slavotinek J. Intraarticular frac-tures of the distal radius treated with metaphyseal externalfixation. J Hand Surg [Br] 1998;23B:396-399.

49. McQueen MM. Redisplaced unstable fractures of the distalradius: a randomized, prospective study of bridging versusnon-bridging external fixation. J Bone Joint Surg Br 1998;80B:665-669.

50. Leung KS, Shen WY, Leung PC. Ligamentotaxis and bonegrafting for comminuted fractures of the distal end of theradius. J Bone Joint Surg Br 1989;71B:838-842.

51. Ladd AL. Use of bone-graft substitutes in distal radius frac-tures. J Am Acad Orthop Surg 1999;7:279-290.

52. Carter PR, Frederick HA, Laseter GF. Open reduction andinternal fixation of unstable distal radius fractures with alow-profile plate: a multicenter study of 73 fractures. J HandSurg [Am] 1998;23A:300-307.

53. Ring D, Jupiter JB, Brennwald J, Buchler U, Hastings H.Prospective multicenter trial of a plate for dorsal fixation ofdistal radius fractures. J Hand Surg [Am] 1997;22A:777-784.

54. Dao KD, Venn-Watson E, Shin AY. Radial artery psuedo-aneurysm complication from use of AO/ASIF volar distalradius plate: a case report. J Hand Surg [Am] 2001;26A:448-452.

55. Gesensway D, Putnam MD, Mente PL, Lewis JL. Design andbiomechanics of a plate for the distal radius. J Hand Surg[Am] 1995;20A:1021-1027.

56. Orbay JL. The treatment of unstable distal radius fractureswith volar fixation. Hand Surgery 2000;5:103-112.

57. Finsen V, Aasheim T. Initial experience with the Forte platefor dorsally displaced distal radius fractures. Injury 2000;31:445-448.

58. Fernandez DL, Geissler WB. Treatment of displaced articularfractures of the radius. J Hand Surg [Am] 1991;16A:375-384.

59. Heim U, Pfeiffer KM. Internal fixation of small fractures. 3rded. Berlin: Springer-Verlag, 1988.

60. Terral TG, Freeland AE. Early salvage reconstruction of se-vere distal radius fractures. Clin Orthop 1996;327:147-151.

61. Rogachefsky RA, Lipson SR, Applegate B, Ouellette EA,Savenor AM, McAuliffe JA. Treatment of severely commi-nuted intra-articular fractures of the distal end of the radiusby open reduction and combined internal and external fixa-tion. J Bone Joint Surg Am 2001;83A:509-519.

62. Cooney WP, Bussey R, Dobyns JH, Linscheid R. Difficultwrist fractures. Perilunate fracture-dislocations of the wrist.Clin Orthop 1987;214:136-147.


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