Management of Distal Radial Fractures

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2007;89:2051-2062. doi:10.2106/JBJS.G.00020 J Bone Joint Surg Am.Neal C. Chen and Jesse B. Jupiter

Management of Distal Radial Fractures

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2051

Current Concepts Review

Management of Distal Radial FracturesBy Neal C. Chen, MD, and Jesse B. Jupiter, MD

The older population continues to grow and, at the same time, live more active lives; as a consequence, theincidence of distal radial fractures can be expected to increase.

There is no Level-I clinical evidence suggesting a superior modality for treatment of distal radial fractures.

The lunate facet has a considerable volar extension at the distal extent of the pronator quadratus and subse-quently has an important role in fracture pathomechanics and stability.

Application of a volar plate with angular stable fixation has been used successfully in a number of cohortstudies but needs to be examined in stringent trials to determine if there is any benefit when compared withother treatment modalities.

Irritation of the flexor pollicis longus and irritation of extensor tendons are possible complications of fixationwith a locked volar plate.

Interest in one of the most common injuries to the muscu-loskeletal systemthe distal radial fracturehas been re-newed. Literature over the past two centuries had even ledsome to believe that the distal radial fracture was a solvedproblem. In contrast, we are now confronted with a markedswing toward stable internal fixation being touted by some au-thors as the treatment of choice for all but the most stable,aligned fractures. Instructional courses, symposia, and skillscourses worldwide are now oversubscribed, bearing witness tothese changing perspectives.

It is surprising that, despite this aggressive push towardinternal fixation, there is no convincing evidence that sup-ports this approach in the contemporary literature. To whatcan we attribute this dramatic shift in the management of thedistal radial fracture? In this review, we will attempt to answerthis question by looking in depth at a number of contributingfactorschanging epidemiologic patterns; a growing under-standing of the injury mechanism; the development of en-hanced imaging techniques; novel plate designs, especiallythose featuring locked screw fixation; and the impact of pa-tient-rated outcome assessments.

Scope of ImpactOur basic understanding of the epidemiology of the distal ra-dial fracture and its relationship to general health is matur-ing. The authors of a prospective, multicenter epidemiologicstudy estimated the incidence of distal radial fractures to be36.8/10,000 person-years in women and 9.0/10,000 person-years in men over the age of thirty-five1. Examination of a 5%sample of Medicare claims data from 1986 to 1990 identified15,000 distal forearm fractures in a cohort of 1.4 millionpersons2. As life expectancy increases, the incidence of distalradial fractures can be expected to increase as well. On thebasis of actuarial risk calculations from Medicare data, therisk of a white woman sustaining a distal forearm fracturewas estimated to be 6% by the age of eighty years and 9% bythe age of ninety years2.

There appears to be a bimodal distribution of distal ra-dial fractures consisting of a younger group who sustains rela-tively high-energy trauma to the upper extremity and anelderly group who sustains both high-energy injuries and in-sufficiency fractures. New research has improved our under-standing of this second group. According to the 2000 United

Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor amember of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercialentity. In support of their research fund, one or more of the authors received, in any one year, outside funding or grants of in excess of $10,000from the AO Foundation, Smith and Nephew, Wright Medical, Small Bone Innovations, Joint Active Systems, Orthopaedic Trauma Association, andAmerican Foundation for Surgery of the Hand/American Society for Surgery of the Hand.

J Bone Joint Surg Am. 2007;89:2051-62 doi:10.2106/JBJS.G.00020

Chen_CCR.fm Page 2051 Thursday, August 16, 2007 12:29 PM

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THE JOU R N A L OF BO N E & JO I N T SU RG ER Y JB JS .ORGVOLU M E 89-A NU M B E R 9 SEP TEM BE R 2007

MA N AG E M EN T OF DI ST A L RA D I AL FR A C TU RE S

States Census data, individuals who are sixty-five years of ageor older account for 12% of our population. This percentage isexpected to balloon to almost 20%, representing 70 millioncitizens, by 20303. Along with growth of the elderly populationis a trend for more individuals in this age segment to livehealthier and more active lives4.

In a large patient cohort, the mortality of persons whohad sustained a distal radial fracture was either the same as orless than that of the local population. One interpretation ofthis finding is that individuals who sustain a distal radial frac-ture are more active and healthier than their age-matchedcounterparts5. The self-perception of elderly people plays animportant role in this increased activity. Many elderly individ-uals view themselves as being in good health and notdisabled4,6. In addition, the proportion of older citizens livingindependently is growing. A report by the United States Cen-sus Bureau stated that 23% of persons sixty-five to seventy-four years of age and 41% of those older than seventy-fivelived alone7.

Distal radial fracture is also frequently associated withlow bone mineral density. Some recent studies have moreclearly defined our previous knowledge of this association,especially the relationship of a prior wrist fracture with sub-sequent osteoporotic fractures at other sites8-10. In women,the risk of a hip fracture increases 1.4 to 1.8-fold if there wasa previous wrist fracture. In older men, the risk of hip frac-ture increases 2.3 to 2.7-fold8,11. Numerous studies have dem-onstrated increases in mortality after hip fracture12-14. In asimilar vein, some have hypothesized that distal radial frac-

ture in an osteoporotic patient could be associated with de-creased survival. The existence of such a subpopulation issupported by a study demonstrating increased mortality in asmall cohort of patients, greater than sixty-five years of age,who sustained a distal radial fracture15. These patients had anaverage of more than three comorbidities, with two of themost frequent three being musculoskeletal and cardiac.Thus, while many older individuals are leading more activelives, the high prevalence of osteopenia and osteoporosisplaces this segment of the population at a particularly highrisk for distal radial fracture.

With todays active elderly, it can be expected that bothhigh-energy injuries and insufficiency fractures will occur, andresults of treatment will be confounded by the presence of age-related osteopenia or frank osteoporosis. The impact of distalradial fractures on society can be anticipated to increase overtime; as a result, considerable scientific, clinical, and economicinterest in the treatment of these fractures has developed.

Understanding of the InjuryPart of the trend toward internal fixation is due to an im-proved understanding of the structural anatomy of the distalpart of the radius and the kinematics of the wrist and distal ra-dioulnar joint. In addition, a greater understanding of the pat-terns of injury is leading to treatment based on the specifics ofeach individual injury.

Historical studies emphasized quantitative parametersthat define an acceptable reduction of a distal radial fracture.In 1951, Gartland and Werley reported a landmark study on

Fig. 1

Computed tomography scans demonstrating hyperextension injury to the distal part of the radius. (Reprinted,

with permission of Georg Thieme , from: Pechlaner S, Kathrein A, Gabl M, Lutz M, Angermann P, Zimmermann

R, Peer R, Peer S, Rieger M, Freund M, Rudisch A. Distal radius fractures and concomitant lesions. Experimen-

tal studies concerning the pathomechanism. Handchir Mikrochir Plast Chir. 2002;34:150-7. Figs. 6-A and 6-B.)


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the evaluation of healed Colles fractures that emphasized res-toration of volar tilt to 11 and radial inclination to 23 tocompensate adequately for the loss of correction which willoccur when Colles fractures are treated with closed means16.They defined a Colles fracture as a dorsally displaced meta-physeal fracture of the distal part of the radius with or withoutarticular involvement. Fractures that settled tended to be asso-ciated with a worse functional outcome. A subsequent studyof malunited distal radial fractures compared with anatomi-cally healed distal radial fractures demonstrated that gripstrength, range of motion, and the ability to perform activitiesof daily living were significantly worse (p < 0.05) in patientswith dorsal angulation of >12 than in those with dorsal angu-lation of 1017.

Biomechanical studies of simulated distal radial mal-unions have been performed in an attempt to explain whythese parameters have clinical importance. Studies of cadav-ers have demonstrated an increase in radiocarpal contact areasand pressures with radial shortening; dorsoulnar migration ofcontact pressures with increased dorsal inclination; and shiftsin the instant center of rotation during pronation and supina-tion with changes in radial height, inclination, and dorsalangulation18-20. In the past, the principles of management ofdistal radial fractures have focused on restoring these parame-ters, and restoration of global alignment is heavily weighted inmany physician-rated outcome assessments. Contemporaryinvestigations have focused in greater depth on the mecha-nism of the fracture and its relationship to various articularinjury patterns, the impact of the fracture on carpal kinemat-ics and the function of the distal radioulnar joint, and the bio-mechanics of angular stable fixation21-26.

Radiocarpal StabilityBiomechanical investigations have demonstrated how fracturesoccur and the association of these fractures with intercarpalligament injury. A cadaver study21 in which a hyperextensionload was applied to the distal part of the radius demonstratedthe following sequence of events: (1) the flexor tendons aretensed, leading to increased pressure over the carpus; (2) thepalmar radiocarpal and ulnocarpal ligaments and variable in-tercarpal ligaments are tensed and rupture; (3) there is dorsalimpingement of the carpus on the radial joint surface; and (4)the dorsal aspect of the metaphysis reaches its yield point andfractures. A separate finding was that the scaphoid impinges onthe carpus primarily with hyperextension, but there may be aconsiderable load on the lunate facet (Fig. 1). In twenty-eightof forty cadavers, the investigators identified a number of inter-carpal ligament injuries as well as different intra-articular frac-ture patterns due in part to the differential impact of thescaphoid and lunate with hyperextension.

These findings must be interpreted with caution. Be-cause the mechanism of injury occurs through the radio-scaphoid articulation, this articulation is not necessarily themajor contributor to stability. Previous in vitro studies sug-gested that radioscaphoid contact is greater than radiolunatecontact18, but subsequent in vivo studies suggested that the ra-diolunate articulation accepts a greater amount of contactthan had been previously acknowledged27.

This renewed emphasis on the importance of the radiol-unate articulation coincides with the development of a struc-tural concept that the distal part of the radius consists of amedial, an intermediate, and a lateral column (Figs. 2-A and2-B)28. This theory emphasizes that (1) the lateral, or radial,

Fig. 2-A

Fig. 2-B

Three-column model of the distal part of the radius. The lateral, or radial, column (lc)

is an osseous buttress for the carpus and is an attachment point for the intracapsular

ligaments. The intermediate column (ic) functions in primary load transmission. The

medial, or ulnar, column (mc) serves as an axis for forearm and wrist rotation as well

as a post for secondary load transmission. TFCC = triangular fibrocartilage complex.

(Reproduced, with permission and copyright of the British Editorial Society of Bone

and Joint Surgery, from: Rikli DA, Regazzoni P. Fractures of the distal end of the radius

treated by internal fixation and early function. A preliminary report of 20 cases. J Bone

Joint Surg Br. 1996;78:588-92.)


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column is an osseous buttress for the carpus and is an attach-ment point for the intracapsular ligaments; (2) the intermediatecolumn functions in primary load transmission; and (3) themedial, or ulnar, column serves as an axis for forearm and wristrotation as well as a post for secondary load transmission.

Clinical failures of volar plate fixation of the distal partof the radius have also provided some insight into the subtle-ties of distal radial anatomy29. The volar surface of the distalpart of the radius is flat until the distal end of the pronatorquadratus, where the distal rim of the radius is more anteriorin the region of both the radial styloid and the lunate facet(Fig. 3)30. Because of the difficulties with supporting the verydistal lunate facet fragments in the treatment of some frac-tures, changes have been made in a number of volar lockingplate designs.

Carpal KinematicsIt is still not clear why posttraumatic radiocarpal arthritis devel-ops in some patients and not in others. Residual intra-articularincongruity has been accepted as a predictor of the develop-ment of radiographically evident arthritis31. However, studieswith seven and fifteen-year durations of follow-up of patientswith an intra-articular fracture have demonstrated that func-

tion is well-preserved as evaluated with validated outcome mea-sures, despite evidence of arthritic changes on radiographs32,33.

The alignment of the carpus in relation to the distal ra-dial articular surface after healing may also be an importantfactor in the outcomes of treatment of distal radial fractures32.In a prospective study of distal radial fractures treated withclosed reduction, external fixation, or open reduction and in-ternal fixation, the authors found that carpal alignmentthedisplacement of the capitate relative to the longitudinal axis ofthe radiuswas the most important predictor of function. Itis likely that the interplay between carpal kinematics and lon-gitudinal alignment has an important influence on fractureoutcomes.

Another potential contributor to altered radiocarpal ki-nematics is intercarpal ligament injury. In a study in which ahyperextension force was applied to sixty-three cadavericwrists until a distal radial fracture occurred, an injury to thetriangular fibrocartilage complex occurred in 63% (forty) ofthe specimens, an injury to the scapholunate interosseousligament occurred in 32% (twenty), and an injury to thelunotriquetral ligament occurred in 17% (eleven)21. These invitro observations have been validated clinically: tears of thescapholunate ligament, lunotriquetral ligament, and triangu-lar fibrocartilage complex are commonly noted during arthro-scopically assisted reduction and internal fixation of distalradial fractures34,35.

As our understanding of carpal kinematics has ad-vanced, it has become evident that the carpal bones interact inan elegant and intricate pattern and it has been suggested thatthese kinematics may be disrupted by articular step-off, radio-carpal malalignment, or intercarpal ligament injury. Recogni-tion of these factors is an additional explanation for a growingtrend toward operative treatment of displaced fractures.

Distal Radioulnar JointProblems related to the distal radioulnar joint can take theform of instability, incongruity, or late arthrosis. Studies sug-gest a statistical correlation between instability of the distal ra-dioulnar joint and worse clinical outcomes36,37. In vitro modelshave demonstrated that radial deformity affects the distal ra-dioulnar joint38. Increasing dorsal angulation results in an in-creased torque, especially at the extremes of supination andpronation. In addition, a 5.5-mm shift of the instant center ofrotation occurs when the radius is shortened 5 mm. Investiga-tors using computer models based on these data estimated in-creased strains in the triangular fibrocartilage ranging from11% to 13% with radial shortening20. Another in vitro studydemonstrated that increases in dorsal malangulation of thedistal part of the radius result in progressive incongruity of thedistal radioulnar joint and tightness of the interosseous mem-brane39. An in vivo study, however, did not demonstrate thesame change in the axis of rotation with malunion40. One ex-planation for this discrepancy is the role of soft-tissue stabiliz-ers about the distal radioulnar joint and their attenuation orcontracture over time. These soft-tissue changes are generallynot incorporated into biomechanical models.

Fig. 3

Volar extension of the lunate facet. The arrow delineates the length of

the lunate facet on this lateral view of a computer reconstruction of the

distal part of the radius. (Reprinted, with permission [for non-exclusive

world English rights only] of The American Society for Surgery of the

Hand, from: Andermahr J, Lozano-Calderon S, Trafton T, Crisco JJ, Ring

D. The volar extension of the lunate facet of the distal radius: a quanti-

tative anatomic study. J Hand Surg [Am]. 2006;31:892-5.)


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While not yet supported by adequate scientific data, ithas been evident clinically to many that instability of the distalradioulnar joint is uncommon when the radial fracture hasbeen reduced anatomically and supported by stable plate fixa-tion. When the distal interosseous membrane was divided in acadaver model, stability of the distal radioulnar joint wascompromised41. Some believe that the distal radioulnar jointbecomes unstable only when the distal interosseous mem-brane is injured42. Future research is needed to determine howmuch influence injury to the distal interosseous membranehas on the outcome of treatment of a distal radial fracture.

ImagingImproved understanding of the morphology of displaced in-tra-articular distal radial fractures has been a direct result ofnewer imaging techniques. Oblique standard radiographsmore clearly define the dorsal lunate facet, while measurementof the volar teardrop angle can alert the surgeon to rotationaldisplacement of the volar lunate facet43. The volar teardrop an-gle is formed by the intersection of the central axis of the ra-dial shaft and a line through the central axis of the teardrop.This angle typically measures 70. When the volar and dorsalarticular surfaces are injured during axial load, the volar rimhyperextends, resulting in a decrease in this angle.

These oblique radiographic views as well as computedtomography and three-dimensional computed tomographyreconstructions have had a major impact on decision-making,with a move toward creative intervention and internal platefixation, especially when the volar lunate facet is rotated (Figs.

4-A and 4-B)44-46. When four independent observers reviewedthirty different intra-articular fractures on two separate occa-sions, the addition of a computed tomography scan and athree-dimensional computed tomography reconstruction tothe standard radiographs led to the observers recommendingoperative treatment in 50% of the cases23. Although computedtomography scanning is costly and certainly not routine ingeneral practice, it has become more affordable and available.Orthopaedic surgeons in the future may find that advancedimaging studies are further encouraging them to perform op-erative intervention for distal radial fractures.

Angular Stable Fixation of the Distal Radial FractureIt has been long recognized that there is a correlation betweenthe functional outcome following a distal radial fracture andthe restoration of both the radiocarpal and the radioulnarrelationships24,31. What has been less predictable has been themaintenance of the reduction of fractures in osteopenic boneor fractures considered to be unstable. The development of an-gular stable fixation techniques with use of implants designedspecifically for the anatomy of the distal end of the radius theo-retically improves our ability to manage these problems (Figs.5-A through 5-D).

The important aspects of angular stable fixation are: (1)stability is not achieved by the creation of friction between theplate and bone as in traditional screw-plate fixation, butrather mechanical bridging of the bone and load-bearing areallowed through the locked screw-plate construct; (2) locking-

Fig. 4-A

Three-dimensional computed tomography scans of a distal radial fracture, demonstrating fracture characteristics that are often not well appreci-

ated: (1) the volar lunate facet has rotated and is now parallel with the volar face of the radial shaft, (2) comminution extends into the dorsal rim of

the lunate facet, and (3) the distal part of the radius is pronated in relation with the radial shaft.

Fig. 4-B


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head screws do not rely on the bone thread for purchase; and(3) screws that lock into the plate prevent loosening within theimplant, so early failure of fixation with an angular stable im-plant will occur only if the entire screw-plate construct pullsout from the bone or there is material failure of the implant25.

The concept of angular stable fixation of distal radialfractures is actually not new as a number of different implantsused over the past two decades have involved this technology26.Contemporary enthusiasm for the application of these im-plants can be attributed in part to the angular stable fixationbut perhaps more so to the recognition that the more preva-lent dorsally displaced fractures can be internally fixed fromthe palmar side.

Theorized benefits of volar plate fixation, especially formore simple dorsally displaced fractures, include (1) ease ofanatomic reduction because the volar cortex is often less com-minuted than the dorsal side of the injury, (2) early return ofhand and upper-limb function, (3) diminished frequency andduration of formal occupational therapy, (4) potentially lessoverall pain, (5) a decreased risk of displacement, and (6) po-tential cost savings secondary to a diminished need for radio-graphs47,48. Many of these benefits would be derived from theinherent stability of the fixed-angle plate-screw construct.

Biomechanical studies have emphasized the need forplacement of the distalmost screws or pegs just beneath thesubchondral bone of the articular surface to achieve the maxi-mum benefit of volar fixed-angle plate fixation. In a cadavermodel, when distal screw fixation was placed 4 mm proximalto the subchondral bone, fracture displacement with cyclicloading of the specimens doubled and rigidity at load-to-failure was reduced by half49.

Currently, more than thirty different implant designsare produced worldwide. The growing popularity of internalfixation has yielded numerous options with regard to platematerial, contour, and shape; locking and nonlocking features;and cost. An estimated $2 billion in medical costs are incurredas a result of distal radial fractures, and this is associated witha $250 million market in medical devices aimed toward treat-ment of these injuries50. A large portion of this cost is due tofact that fixation with locked volar plates involves machiningof threaded holes in the plate and matching threaded screwheads. This rapidly evolving industry requires careful scrutinyas these changes are based on a limited amount of stringentclinical evidence. Case series documenting these new technol-ogies continue to be published and represent possible trendsin the future; however, Level-I and II evidence is required todelineate the true benefits that these new technologies andtheir additional costs confer to patients.

Outcome MeasuresOver the past decade, a deliberate and profound philosophicalchange in orthopaedics has redirected evaluation measures to-ward the patients self-reporting of treatment outcomes. In thelate 1980s and early 1990s, a global health survey called theShort Form-36 (SF-36) was created to collect large cross-sectional pools of normative data with which comparisonscan be made51. Although this scale is aimed toward measuringgeneral health and chronic disease, it seems to have some va-lidity for evaluating wrist injuries. The SF-36 consists of sub-scales evaluating physical role, bodily pain, social functioning,and other components of general health. One study showedthat the physical role and mental health domains were respon-

Fig. 5-A

Figs. 5-A through 5-D Radiographs of a sixty-four-year-old female librarian who sustained a dorsally displaced intra-articular distal radial fracture

with marked metaphyseal comminution. After ten days, closed reduction failed. Surgery improved hand function and restored independent upper-

limb activity sooner and more predictably than closed treatment. Figs. 5-A and 5-B Preoperative radiographs.

Fig. 5-B


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sive indices three months following treatment of Colles frac-tures with closed reduction52. A subsequent study demonstratedthat the physical component and mental component summaryscores were significantly lower (p < 0.01) for patients who hadintra-articular displacement of 1 mm on the most recentradiographs53. The findings in the latter study most likely reflectthe development of arthrosis in the wrist, as the most recent ra-diographs were made about two years postinjury.

Other patient-rated evaluations have been developed.The Disabilities of the Arm, Shoulder and Hand (DASH)questionnaire is intended to evaluate upper-extremity out-comes, and the Patient-Rated Wrist Evaluation (PRWE) is aimedtoward disorders of the wrist54,55. Modified self-reporting sys-tems such as the QuickDASH and the visual QuickDASH re-cently have been validated56,57. In a prospective evaluation ofthe SF-36, DASH, and PRWE along with standard physicalperformance measures for assessing recovery after distal radialfractures treated with a variety of methods, the PRWE wasfound to be a more responsive measure than the DASH andboth indices were more responsive than the SF-36. Notably,the function subscales of the PRWE were the most responsivebetween the time of the initial injury and the three-month fol-low-up examination, and grip strength was the most respon-sive physical performance measure. The association betweengrip strength and the PRWE was reaffirmed by independentstudies58.

There are important caveats with regard to the interpre-tation of the results of evaluations performed with these sys-tems. The DASH scores may be confounded by concomitant

lower-extremity injury59. The inability of a patient to reach adoor or an inability to stabilize the trunk and shoulder girdlemay affect DASH items such as turning a key or carrying ashopping bag. In addition, the DASH and SF-36 scores may beheavily influenced by pain60. When applied to disorders of theelbow, the DASH as well as the physical and mental com-ponent scores of the SF-36 were statistically correlated (p or = 65 years of age: the study of os-teoporotic fractures. J Bone Miner Res. 2005;20:131-40.

11. Jaglal SB, Weller I, Mamdani M, Hawker G, Kreder H, Jaakkimainen L, Adachi JD. Population trends in BMD testing, treatment, and hip and wrist fracture rates: are the hip fracture projections wrong? J Bone Miner Res. 2005;20:898-905.

12. Magaziner J, Simonsick EM, Kashner TM, Hebel JR, Kenzora JE. Survival experience of aged hip fracture patients. Am J Public Health. 1989;79:274-8.

13. Aharonoff GB, Koval KJ, Skovron ML, Zuckerman JD. Hip fractures in the elderly: predictors of one year mortality. J Orthop Trauma. 1997;11:162-5.

14. Richmond J, Aharonoff GB, Zuckerman JD, Koval KJ. Mortality risk after hip fracture. J Orthop Trauma. 2003;17:53-6.

15. Rozental TD, Branas CC, Bozentka DJ, Beredjiklian PK. Survival among elderly patients after fractures of the distal radius. J Hand Surg [Am]. 2002;27:948-52.

16. Gartland JJ, Werley CW. Evaluation of healed Colles fractures. J Bone Joint Surg Am. 1951;33:895-907.

17. McQueen M, Caspers J. Colles fracture: does the anatomical result affect the final function? J Bone Joint Surg Br. 1988;70:649-51.

18. Pogue DJ, Viegas SF, Patterson RM, Peterson PD, Jenkins DK, Sweo TD, Hokanson JA. Effects of distal radius fracture malunion on wrist joint mechanics. J Hand Surg [Am]. 1990;15:721-7.

19. Short WH, Werner FW, Fortino MD, Palmer AK. Distribution of pressures and forces on the wrist after simulated intercarpal fusion and Kienbcks disease. J Hand Surg [Am]. 1992;17:443-9.

20. Adams BD. Effects of radial deformity on distal radioulnar joint mechanics. J Hand Surg [Am]. 1993;18:492-8.

21. Pechlaner S, Kathrein A, Gabl M, Lutz M, Angermann P, Zimmermann R, Peer R, Peer S, Rieger M, Freund M, Rudisch A. Distal radius fractures and concomi-tant lesions. Experimental studies concerning the pathomechanism. Handchir Mikrochir Plast Chir. 2002;34:150-7.

22. McQueen MM, Hajducka C, Court-Brown CM. Redisplaced unstable fractures of the distal radius: a prospective randomised comparison of four methods of treatment. J Bone Joint Surg Br. 1996;78:404-9.

23. Harness NG, Ring D, Zurakowski D, Harris GJ, Jupiter JB. The influence of three-dimensional computed tomography reconstructions on the characterization and treatment of distal radial fractures. J Bone Joint Surg Am. 2006;88:1315-23.

24. Gartland JJ, Werley CW. Evaluation of healed Colles fractures. J Bone Joint Surg Am. 1951;33:895-907.

25. Wagner M, Frigg R. Internal fixators: concepts and cases using LCP and LISS. AO manual of fracture management. New York: Thieme; 2006.

26. Ring D, Jupiter JB, Brennwald J, Bchler U, Hastings H. Prospective multi-center trial of a plate for dorsal fixation of distal radius fractures. J Hand Surg [Am]. 1997;22:777-84.

27. Rikli DA: Personal communication, 2006.

28. Rikli DA, Regazzoni P. Fractures of the distal end of the radius treated by inter-nal fixation and early function. A preliminary report of 20 cases. J Bone Joint Surg Br. 1996;78:588-92.

29. Harness NG, Jupiter JB, Orbay JL, Raskin KB, Fernandez DL. Loss of fixation of the volar lunate facet fragment in fractures of the distal part of the radius. J Bone Joint Surg Am. 2004;86:1900-8.

30. Andermahr J, Lozano-Calderon S, Trafton T, Crisco JJ, Ring D. The volar exten-sion of the lunate facet of the distal radius: a quantitative anatomic study. J Hand Surg [Am]. 2006;31:892-5.

31. Knirk JL, Jupiter JB. Intra-articular fractures of the distal end of the radius in young adults. J Bone Joint Surg Am. 1986;68:647-59.


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32. Catalano LW, Cole RJ, Gelberman RH, Evanoff BA, Gilula LA, Borrelli J. Dis-placed intra-articular fractures of the distal aspect of the radius. Long-term results in young adults after open reduction and internal fixation. J Bone Joint Surg Am. 1997;79:1290-1302.

33. Goldfarb CA, Rudzki JR, Catalano LW, Hughes M, Borrelli J. Fifteen-year out-come of displaced intra-articular fractures of the distal radius. J Hand Surg [Am]. 2006;31:633-9.

34. Geissler WB, Freeland AE, Savoie FH, McIntyre LW, Whipple TL. Intracarpal soft-tissue lesions associated with an intra-articular fracture of the distal end of the radius. J Bone Joint Surg Am. 1996;78:357-65.

35. Doi K, Hattori Y, Otsuka, K, Abe Y, Yamamoto H. Intra-articular fractures of the distal aspect of the radius: arthroscopically assisted reduction com-pared with open reduction and internal fixation. J Bone Joint Surg Am. 1999;81:1093-110.

36. Lindau T, Hagberg L, Adlercreutz C, Jonsson K, Aspenberg P. Distal radioulnar instability is an independent worsening factor in distal radial fractures. Clin Or-thop Relat Res. 2000;376:229-35.

37. Lindau T, Runnquist K, Aspenberg P. Patients with laxity of the distal radioul-nar joint after distal radial fractures have impaired function, but no loss of strength. Acta Orthop Scand. 2002;73:151-6.

38. Hirahara H, Neale PG, Lin YT, Cooney WP, An KN. Kinematic and torque-related effects of dorsally angulated distal radius fractures and the distal radial ulnar joint. J Hand Surg [Am]. 2003;28:614-21.

39. Kihara H, Palmer AK, Werner FW, Short WH, Fortino MD. The effect of dorsally angulated distal radius fractures on distal radioulnar joint congruency and fore-arm rotation. J Hand Surg [Am]. 1996;21:40-7.

40. Moore DC, Hogan KA, Crisco JJ, Akelman E, Dasilva MF, Weiss AP. Three-dimensional in vivo kinematics of the distal radioulnar joint in malunited distal radius fractures. J Hand Surg [Am]. 2002;27:233-42.

41. Watanabe H, Berger RA, Berglund LJ, Zobitz ME, An KN. Contribution of the interosseous membrane to distal radioulnar joint constraint. J Hand Surg [Am]. 2005;30:1164-71.

42. Orbay JL. Personal communication.

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Management of Distal Radial Fractures

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