Chapter 32: Fractures of the Distal Radius and Ulna

Margaret M. McQueen

Chapter Outline

Introduction to Fractures of the Distal Radius and Ulna

Fracture of the distal radius and ulna is the most common fracture encountered by orthopedic trauma surgeons with around 120,000 fractures per year in the United Kingdom and 607,000 annually in the United States.60,73 
The history of fractures of the distal radius reflects the evolution of the understanding of many conditions in orthopedic trauma. The credit for recognition of the true nature of the injury is shared between Petit, Pouteau, and Colles, prior to whose writings it was believed that the injury was a carpal or distal radioulnar joint dislocation. Petit first suggested in the early 18th century that these injuries might be fractures rather than dislocations but it was Pouteau291 who first recognized that injuries to the wrist from a fall on to the outstretched hand were usually fractures of the distal radius with “outward” or dorsal displacement. He recognized “inward” or volar displacement but attributed it to ulnar fracture. His meticulous observations demonstrate the knowledge that can be accrued from clinical examination. Pouteau could not defend his opinion from the scepticism of his colleagues as this article was published posthumously. Added to this little attention was paid to his views outside France. 
Fractures of the distal radius were brought to the attention of the English speaking literature in 1814 when Abraham Colles published his views “On the fracture of the carpal extremity of the radius” in 1814. Colles was the Professor of surgery at the Royal College of Surgeons in Ireland from 1804 to 1836. He was renowned for his truthfulness and honesty having on one occasion informed his students: “Gentleman, it is no use mincing the matter; I caused the patient’s death.” Colles wrote: “This fracture takes place about an inch and a half above the carpal extremity of the radius …. the posterior surface of the limb presents a considerable deformity; for a depression is seen in the forearm, about an inch and a half above the end of this bone, while a considerable swelling occupies the wrist and metacarpus. Indeed, the carpus and base of metacarpus appear to be thrown backward so much as on first view to excite a suspicion that the carpus has been dislocated forward. On viewing the anterior surface of the limb we observe a considerable fullness, as if caused by the flexor tendons being thrown forwards…. On the posterior surface (the surgeon) will discover, by the touch, that the swelling on the wrist and metacarpus is not caused entirely by an effusion among the softer parts; he will perceive that the ends of the metacarpal and second row of the carpal bones form no small part of it… …If the surgeon lock his hand in that of the patient and makes extension…he restores the limb to its natural form, but the distortion of the limb instantly returns on the extension being removed…. Or, should he mistake the case for a dislocation of the wrist and attempt to retain the parts in situ by tight bandages and splints, the pain caused by the pressure on the back of the wrist will force him to unbind them in a few hours; and if they be applied more loosely, he will find, at the expiration of a few weeks, that the deformity still exists in its fullest extent…. By such mistakes the patient is doomed to endure for many months considerable lameness and stiffness of the limb, accompanied by severe pains on attempting to bend the hand and fingers…. The hard swelling which appears on the back of the hand is caused by the carpal surface of the radius being directed slightly backwards instead of looking directly downwards. The carpus and metacarpus, retaining their connections with this bone, must follow it in its derangement, and cause the convexity above alluded to. The broken extremity of the radius being thus drawn backwards causes the ulna to appear prominent toward the palmar surface… …”66 These observations were made more extraordinary by the fact that they were made without the benefit of anatomical dissection or x-rays. 
With the publication of his “Leçons Orales,” in 1841, Guillaume Dupuytren, the chief surgeon of L’Hôtel Dieu in Paris, brought the subject to the attention of a wider audience. Dupuytren was renowned not only for being an absolute perfectionist combined with intelligence, drive, and boundless energy but also for a complete disregard for the sensibilities of his colleagues about whom he is quoted as saying “nothing should be feared as much for a man as mediocrity.” Most of his vast knowledge was imparted by lectures attended by hundreds from near and far and eventually published by his students as Leçons Orales de Clinique Chirurgicale. On fracture of the distal radius he acknowledged Petit and Pouteau’s contributions and went on to state “one would have thought … that the observations of these writers would have raised some doubts in the minds of modern surgeons on this obscure point of doctrine: but not so; … … …. I have for a long time publicly taught that fractures of the carpal end of the radius are extremely common; that I had always found that these supposed dislocations turn out to be fractures; and that, in spite of all which has been said on the subject, I have never met with or heard of one single well authenticated and convincing case of the dislocation in question.”86 
In 1847 Malgaigne237 defined the injury further and stated that most fractures of the distal radius were caused by a fall on the palm of the hand and fewer by a fall on the back of the hand. He identified extra- and intra-articular fractures, including undisplaced fractures. He recognized the sequelae of untreated fracture: deformity, reduction of pronation, supination and flexion, weakness of the hand, long-term swelling and pain, and permanent finger stiffness. He recorded that the prognosis is favorable if there is only dorsal displacement and the fracture is recognized early but with radial shortening and radial deviation it is “almost impossible to overcome it entirely.” He also recognized the poorer prognosis for articular fractures. 
The concept of a variety of types of distal radius fractures was developed by John Rhea Barton24 from Philadelphia, who in 1838 described “a subluxation of the wrist consequent to a fracture through the articular surface of the carpal extremity of the radius.” He described dorsal displacement of the wrist and the partial articular fracture. He also recognized the morbidity of distal radius fracture: “I do not know any subject on which I have been more frequently consulted than on deformities, rigid joints, inflexible fingers, loss of the pronating and supinating motions and on neuralgic complaints resulting from injuries of the wrist and of the carpal extremity of the forearm—one or more of these evils having been left, not merely as a temporary inconvenience but as a permanent consequence.” 
Robert William Smith, who was Professor of surgery in Dublin (and also performed Colles’ postmortem) described “fracture of the lower extremity of the radius with displacement of the lower fragment forward” and stated that it was generally the result of a fall on the back of the hand.337 This was the first description of volar displacement of distal radius fractures. 
The next major step forward was the discovery of x-rays in 1895. Carl Beck,26 a surgeon from New York City, concluded in 1901 that “in no fracture type were the Röntgen rays more urgently needed to realize how often we have erred in its true recognition” and he described eight different types of distal radius fracture. 
Frederick Cotton70,71 from Boston described his findings in distal radius fractures using a combination of postmortems and x-rays. He described comminution of the metaphysis, which he considered frequent and most common on the dorsum, and in two articles gives a clear and comprehensive review of the knowledge of the time. 
During this time the main debate about treatment centered around the mechanics of reduction, the position of immobilization, and the types of splint used. Poor results and amputation were recorded because of tight bandages and splints. Lucas-Champonnière227 described his new ideas in the management of fractures using massage and early mobilization, which were revolutionary in their time. He considered that distal radius fracture was best suited to this form of treatment. 
Further contributions to the management of distal radius fractures were in the realms of fixation of the distal radius with the development of methods of stabilization, although the biggest influence was the advent of anesthesia and asepsis. External fixation of the distal radius was first reported by Ombredanne,270 a Parisian surgeon in 1929. It is of interest that this was a nonbridging external fixator and was used in pediatric cases. Ombredanne concluded that “temporary osteosynthesis with external connections permits a mathematical adjustment of the surgical correction ….. and guarantees further retention with ample and sufficient precision.” 
Bridging external fixation was introduced by Roger Anderson and Gordon O’Neill from Seattle in 1944 because of the poor results of nonoperative management. 
They recognized the difficulty of maintaining a reduction particularly of radial length and attributed this to “crushing of the cancellous bone.” The authors named the technique “castless fixation.”13 Meanwhile Raoul Hoffman of Geneva was designing his external fixator, which had universal clamps allowing reduction of the fracture by closed manipulation while the fixator was in place. Jacques Vidal et al.380 introduced the concept of ligamentotaxis: “the device is placed beyond the involved joint in the unaffected bone, tension is applied and by means of distraction forces working through capsuloligamentous structures, reduction is obtained.” The Hoffmann fixator, although modified, remains in use today. 
Internal fixation of distal radius fractures has long been dominated by percutaneous pinning, which was first suggested for distal radius fracture treatment by Lambotte in 1907 with the use of one radial styloid pin.295 This was followed by reports of many other techniques of multiple pinning in the middle to late 20th century.295 Plating was first popularized by Ellis93 in 1965. Since then, the development of initially dorsal plating and then volar locked plating has extended its indications. 

Epidemiology of Fractures of the Distal Radius and Ulna

Fractures of the distal radius are the most frequent fractures encountered by orthopedic trauma surgeons accounting for 17.5% of all adult fractures.73 A variety of incidences are reported (Table 32-1), but these are difficult to interpret because of varying ages of the populations and methods of recording the information. The most recent information comes from Edinburgh in 2010 to 2011(unpublished data) and Finland in 2008105 with similar incidences being reported from each country (23.6 and 25.8 per 10,000 per year respectively) for adult distal radius fractures. In all studies the incidences in females are higher than males by a factor of two to three. 
 
Table 32-1
The Reported Incidences of Fracture of the Distal Radius
Area Date Incidence/105/yr Male Incidence/105/yr Female Incidence/105/yr Age Groups (yrs)
UK
Dundee/Oxford43
Edinburgh72 (see text and Chapter 3)
Dorset368
Scotland/England271
1954–1958
1991–1993
2000
2007–2008
2010–2011
1996–1997
1997–1998
20
17.2
19.3
20.6
23.6
26.1
23.6
7.2
7.7
11.7
12.9
13.9
11.4
9
29.9
25.7
26
27.8
32.2
35.9
36.8
≥15
>25
>35
Denmark
Frederiksborg342
Hvidovre212
1981
1976–1984
21.9
19.7
8.9
N/A
34.6
39.7
>20
≥20
Sweden
Stockholm324
Uppsala238
Malmo28
SE Sweden41
1981–1982
1989–1990
1953–1957
1980–1981
1991–1992
2001
36.5
29
17.6
42.2
31.3
26
13.4
14.3
9.6
19.6
16.5
12
54.6
43.2
24.8
62.4
44.4
39
>15
>15
≥10
>18
Iceland304,332 1985
2004
26
27
14
17
34
37
>15
Finland
Oulu105 2008 25.8 14.7 36.3 ≥16
USA
Rochester, MN278
All emergency rooms272
1945–1974
2001–2007
17.6
26.5
7.8
8.8
25.7
40.9
≥50
≥35
X
Men who sustain distal radius fractures are significantly younger than women. The average age of all distal radius fractures in adults has been reported to be between 57 and 66 years with females being on average in their 60s and men in their 40s. This is reflected in the age- and gender-specific distribution curves, which are type A (see Chapter 3). Low-energy injury is the cause of the majority of distal radius fractures with 66% to 77% of fractures being related to a fall from standing height41,105,304,332 and increased numbers in winter conditions.105 The Edinburgh data show that high-energy injury accounts for around 10% of all wrist fractures. 
The majority (57% to 66%) of fractures are extra-articular (AO type A). Of the remainder between 9% and 16% are reported as partial articular (AO type B) and 25% to 35% as complete articular fractures (type C). From the Edinburgh data there were 51 type C3 or complex articular fractures (4.5%), whereas there were 543 fractures (48.3%) with metaphyseal comminution but without severe articular involvement. Thus a potentially unstable metaphyseal fracture is 10 times more common than a severe articular fracture. Using the Mackenney formula234 the median risk of instability is 39.4%. 
There is some evidence emerging from Scandinavia and the United Kingdom that the epidemiology of distal radius fractures is changing. In Iceland, between 1985 and 2004, the overall incidence of distal radius fractures did not change significantly, but there were changes within the age- and gender-specific incidences.332 The incidence reduced in women aged 50 to 70 years over this time period, which the author speculated was because of the increased use of hormone replacement therapy (HRT). In men there was a trend showing an increase in incidence, which the author suggested was related to the increase in longevity of men whose mean age at fracture had risen by 8 years to 50 years over the 19-year period. 
In contrast, data from Edinburgh shows an increase in the incidence of distal radius fractures over a 17-year period (Table 32-1), mainly attributable to an increase in incidence in both younger and older men (Fig. 32-1). In women there was a reduction in incidence in the 45- to 59-year-old age group, but an increase in the incidence in women over 75 years of age. It is of interest however that the percentage of patients who were independent for the activities of daily living increased significantly over the period confirming that although getting older, individuals were also getting fitter. In the fragility fractures there was an increase in extra-articular and partial articular fractures and a corresponding decrease in complete articular fractures. In the whole group there was no difference detected in the radiographic severity of the fractures. 
Figure 32-1
 
A, B: The incidence of distal radius fractures in men and women with 95% confidence intervals. Group 1 data were collected from 1991 to 1993 inclusive and group 2 data were collected in the year from 2007 to 2008. The increases in both younger and older men largely account for the overall increase in incidence of distal radius fractures.
A, B: The incidence of distal radius fractures in men and women with 95% confidence intervals. Group 1 data were collected from 1991 to 1993 inclusive and group 2 data were collected in the year from 2007 to 2008. The increases in both younger and older men largely account for the overall increase in incidence of distal radius fractures.
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Figure 32-1
A, B: The incidence of distal radius fractures in men and women with 95% confidence intervals. Group 1 data were collected from 1991 to 1993 inclusive and group 2 data were collected in the year from 2007 to 2008. The increases in both younger and older men largely account for the overall increase in incidence of distal radius fractures.
A, B: The incidence of distal radius fractures in men and women with 95% confidence intervals. Group 1 data were collected from 1991 to 1993 inclusive and group 2 data were collected in the year from 2007 to 2008. The increases in both younger and older men largely account for the overall increase in incidence of distal radius fractures.
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However, when fragility fractures (defined as those in patients aged 50 years or more) are examined, there are significant increases in the likelihood of metaphyseal instability in the extra-articular and complete articular fractures. 
It would seem therefore that fractures of the distal radius are increasing in men and older women but remain most common in older women. Reducing numbers have been observed in middle-aged women, which may be the effect of successful programs to detect and treat osteoporosis. The Edinburgh data confirms that patients are becoming more independent for their activities of daily living but the fractures in the older age group are becoming more severe. If the population projections are accurate for westernized countries and the proportion of the elderly continues to rise, there will be an increasing burden on orthopedic trauma services for the treatment of more unstable distal radius fractures in older but more active patients. This increases the urgency of coming to a consensus on the recommended method of treatment for those fractures. 

Risk Factors for Distal Radius Fractures

There are a number of methods of predicting the risk of an osteoporotic fracture and many published risk fractures. These are dealt with in more detail in Chapter 3. There are, however, some studies that consider the risk factors specific to distal radius fractures. 
Reported lifetime risks of distal radius fractures from the age of 50 onward range from 12% to 52.7% for women and 2.4% to 6.2% for men (Table 32-2). These may be real differences in risk from country to country although it may be that the difficulties in fracture ascertainment account for some of the differences. 
Table 32-2
The Estimated Percentage Lifetime Risk of Sustaining a Distal Radius Fracture over the Age of 50 Years for Men and Women
Females Males Dates
Norway7 32.7 6.2 1994–2004
Sweden181 20.8 4.6 1987–1993
UK376 16.6 2.9 1988–1998
USA74 15 2.4 1979–1981
Tasmania67 12 5 1997–1999
S Korea283 21.7 4.9 2005–2008
Denmark212 18 N/A 1976–1984
X
As is the case with all osteoporotic fractures, distal radius fractures occur because of a combination of a fall and low bone mineral density (BMD). Not surprisingly, low BMD is an important predictor of future fracture risk,186,216,265,267 but there is also evidence that increasing falls, especially with aging, are a significant risk factor.265,267 Some authors have found that the risk of distal radius fracture increases with a higher level of activity127,168,333 implying that individuals who sustain distal radius fractures are in the fitter cohort of older people. 

Assessment of Fractures of the Distal Radius and Ulna

Injury Mechanisms for distal radius and ulna fractures

The common injury mechanism that results in a fracture of the distal radius is a fall on to the outstretched hand from standing height, although a small proportion of patients will experience high-energy injury. Palvanen et al.281 demonstrated that the typical osteoporotic upper extremity fractures in older adults have specific injury mechanisms with individuals with distal radius fractures significantly more frequently breaking their fall with an outstretched hand compared to those sustaining proximal humerus or elbow fractures. This suggests that patients with distal radius fractures have better preserved reflexes and are generally fitter than those with proximal humerus fractures. 
The different characteristics of fractures of the distal radius are generally agreed to be influenced by the position of the hand at the time of impact, the type of surface with which it makes contact, and the velocity of the force. Added to this the quality and strength of the bone of the distal radius will influence the severity of the fracture. 
Most attention has been focused on the position of the hand at the time of impact. In the late 19th century Lilienfeldt220 used cadaver arms to show that both the position of the hand and the angle at which the forearm strikes the ground determine the type of fracture. Fracture of the distal radius resulted if the angle was between 60 and 90 degrees with a radial styloid fracture resulting from a hand in ulnar deviation and an ulnar styloid fracture from radial deviation. Lilienfeldt also reproduced a volar displaced fracture with the hand in flexion. Frykman114 refined these experiments and concluded that clinical types of distal radius fractures occurred, provided dorsiflexion of the wrist was between 40 and 90 degrees. If less, a proximal forearm fracture resulted and if more, a carpal bone fracture. More force was required to produce a fracture with increasing dorsiflexion. He produced volar fractures when the hand was loaded in volar flexion. Frykman also noted that more force was required to fracture a male compared to a female specimen. 
Fernandez and Jupiter97 divided distal radius fractures into five types depending on the mechanism of the injury and this forms the basis for the Fernandez classification (see below). They believe that bending fractures occur because at impact the proximal carpal row transmits the force to the dorsal aspect of the radius and the volar cortex fails because of tensile stresses. As the radius bends dorsally, the dorsal cortex compresses producing dorsal comminution and a metaphyseal defect especially in an osteopenic patient. If the forearm is supinated and the elbow is extended, the force is applied with the wrist in flexion and the displacement is reversed producing compression of the volar lip and an extra-articular volar displaced bending fracture. 
Partial articular or shearing fractures of the volar lip of the distal radius probably occur in the same way as extra-articular volar displaced fractures in younger patients. In these cases the compression of the volar lip results in an articular fracture with volar subluxation of the carpus. The fracture line is often vertical and usually unstable. 
The severity of distal radius fractures is related to the quality of the bone. Clayton et al.64 examined 37 distal radius fractures and showed that there was a linear correlation between dual energy x-ray absorptiometry T scores and early instability and malunion. Patients with osteoporosis had a 43% probability of having a metaphyseal unstable distal radius fracture and a 66% probability of malunion compared with patients with normal T-scores who had a 28% probability of instability and a 48% probability of malunion. Xie and Barenholdt396 used multilayer peripheral quantitative CT scans and showed that cross-sectional volumetric density and geometric properties of cortical bone may be essential in determining the severity of a distal radius fracture. 

Injures associated with distal radius and ulna fractures

The main injuries associated with distal radius fractures are those to the interosseous ligaments of the carpus and to the triangular fibrocartilage complex (TFCC). Chondral lesions have also been reported in 32% of patients. Their significance is unknown although it has been suggested that they may be precursors of degenerative change.222 

Interosseous Ligament Injury

Interosseous ligament injury associated with fractures of the distal radius is predominantly scapholunate and lunatotriquetral injury. The severity of these injuries has been graded arthroscopically by Geissler from grade 1 to grade 4. Grade 1 injuries are the least severe with attenuation or hemorrhage, grades 2 and 3 are increasing incongruity of the ligament, and grade 4 is gross instability with sufficient disruption to allow passage of an arthroscope from radiocarpal to midcarpal joints. 
Scapholunate injury has been reported to occur in between 4.7% and 46% of distal radius fractures,121,222,298,330,365 but it is difficult to estimate the true figure as most studies report highly selected series of young patients with predominantly intra-articular fractures which have been treated arthroscopically. The figure of 4.7% is derived from the least selective series of distal radius fractures and is likely to be closest to the true figure.365 Lunatotriquetral injury is less common with prevalences between 12% and 34% being reported.121,222,298,330 
The diagnosis of ligament injury can be made from static radiographs of the distal radius in the more severe cases (see Chapter 31). However, the diagnosis can be difficult when associated with a distal radius fracture. Arthroscopy is probably the best method but is expensive and may subject the patient to an unnecessary procedure. This can be minimized by the carpal stretch test when traction is applied to the wrist to emphasize disruption of Gilula’s lines. This test has been reported to have a sensitivity of 78% and a specificity of 72% in cases with distal radius fracture. The authors concluded that it is a useful screening test to rule out the more severe grade 3 and 4 tears.209 An increased risk of interosseous ligament injury has been demonstrated where there is more than 2 mm of positive ulnar variance and in intra-articular fractures.109 
The significance of interosseous ligament tears to the outcome of distal radius fractures is unclear. It has been suggested that undetected lesions are a cause of ongoing pain, but in a series of 51 patients with displaced distal radius fractures reviewed at 11 to 27 months after injury there were no differences in patient-reported outcome measures (PROMs) between the grade 3 and 4 ligament injuries and those with grade 0 to 2 ligament injuries. There was increased pain in the more severe injuries but only when the Watson shift test was performed and not at rest or with use of the hand.109 However, Tang et al.365 reported worse function in 20 patients with radiographically obvious scapholunate instability compared to cases with normal carpal alignment. 

Triangular Fibrocartilage Complex (TFCC) Injury

TFCC injury is commoner than interosseous ligament injury being reported in 39% to 82% of cases.121,222,298,330 The majority are peripheral avulsions and may be associated with ulnar styloid fractures, the presence of which increases the risk of a TFCC tear by a factor of 5.1.222 The natural history of these lesions remains unclear but in a long-term review at 13 to 15 years after injury there were no differences in any outcome measure including the Disabilities of Arm, Shoulder and Hand (DASH) score between patients with and without complete TFCC tears or between those with or without detectable laxity at the distal radioulnar joint (DRUJ) barring a reduction of grip strength to 83% in the patients with laxity.260 It is debatable if this is clinically significant. Surgery to repair TFCC tears has good reported results although similar to nonoperatively managed patients with average grip strength of 78% and a DASH score of 13 at 2 years after surgery.315 The indications for surgical treatment of these injuries have not yet been clearly defined. 

Signs and Symptoms of Fractures of the Distal Radius and Ulna

Eliciting the symptoms of a fracture of the distal radius is usually straightforward with a history of a fall on to the outstretched hand or occasionally a higher-energy injury. Pain and swelling around the wrist are invariable features and where there is displacement the patient may also complain of a visible deformity. Specific questioning should include any paresthesia or numbness in the fingers to exclude any median or ulnar nerve injury. Evidence of pain elsewhere in the limb should be sought to diagnose an ipsilateral injury. 
On examination swelling is usually evident around the wrist. In cases with displacement, the deformity can be seen. The classical dinner fork or silver fork deformity is caused by dorsal displacement of the carpus secondary to dorsal angulation of the distal radius (Fig. 32-2). The reverse deformity is seen in volar displaced fractures. The hand may be radially deviated and if there is shortening of the radius the ulna will be prominent. The skin should be inspected to rule out any open wounds, which most commonly occur on the ulnar side. 
Figure 32-2
A sagittal section of a distal radius fracture.
 
There is dorsal angulation with comminution of the metaphysis producing the classic dinner fork deformity which is caused by the malalignment of the carpus.
There is dorsal angulation with comminution of the metaphysis producing the classic dinner fork deformity which is caused by the malalignment of the carpus.
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Figure 32-2
A sagittal section of a distal radius fracture.
There is dorsal angulation with comminution of the metaphysis producing the classic dinner fork deformity which is caused by the malalignment of the carpus.
There is dorsal angulation with comminution of the metaphysis producing the classic dinner fork deformity which is caused by the malalignment of the carpus.
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Palpation will elicit tenderness at the area of the fracture and is more useful in raising clinical suspicion where there is no obvious deformity. A thorough neurologic examination of the hand should be performed as acute carpal tunnel syndrome (CTS) may require prompt treatment. It is also important to remember that distal radius fractures may be complicated by acute compartment syndrome and the symptoms and signs of this condition should also be sought (see Chapter 29). 

Imaging and Other Diagnostic Studies for Fractures of the Distal Radius and Ulna

The standard series of posteroanterior (PA), lateral, and oblique x-ray views is useful to visualize a suspected fracture of the distal radius. Additional views may be obtained as needed to assess for displacement or additional injuries. 
A number of radiologic measurements quantifying the orientation of the distal radius are in common use and it is important to understand these to reduce interobserver error. Significant discrepancy regarding intra- and interobserver reliability has been demonstrated in the measurement of standard radiographic criteria. For extra-articular fractures the mean standard deviation between surgeons was 3.2 degrees for radial angle, 3.6 degrees for conventional lateral palmar tilt, and 2.1 degrees for 15 degrees of lateral palmar tilt.175 
Dorsal/palmar tilt: On a true lateral view a line is drawn connecting the most distal points of the volar and dorsal lips of the radius. The dorsal or palmar tilt is the angle created with a line drawn along the longitudinal axis of the radius (Fig. 32-3A). 
Figure 32-3
 
A: The dorsal angle (DA) is measured by finding the angle between a line (CD) perpendicular to the long axis of the radius (AB) and a line joining the dorsal and volar extremities of the radiocarpal joint (EF). Carpal alignment is assessed by the point of intersection of the line parallel to the long axis of the radius (AB) and a line parallel to the long axis of the capitate (GH). If these intersect outwith the carpus or do not intersect as in this illustration, then the carpus is malaligned. B: Ulnar variance (UV) is the distance between two lines perpendicular to the long axis of the radius (AB). The first is tangential to the ulnar corner of the radius (CD) and the second tangential to the ulnar head (EF). Radial length is the distance between line EF and a line tangential to the radial styloid (GH). (From Court-Brown C, McQueen M, Tornetta P. Orthopaedic Surgery Essentials: Trauma. Philadelphia, PA: Lippincott Williams & Wilkins; 2006, with permission.)
A: The dorsal angle (DA) is measured by finding the angle between a line (CD) perpendicular to the long axis of the radius (AB) and a line joining the dorsal and volar extremities of the radiocarpal joint (EF). Carpal alignment is assessed by the point of intersection of the line parallel to the long axis of the radius (AB) and a line parallel to the long axis of the capitate (GH). If these intersect outwith the carpus or do not intersect as in this illustration, then the carpus is malaligned. B: Ulnar variance (UV) is the distance between two lines perpendicular to the long axis of the radius (AB). The first is tangential to the ulnar corner of the radius (CD) and the second tangential to the ulnar head (EF). Radial length is the distance between line EF and a line tangential to the radial styloid (GH). (From Court-Brown C, McQueen M, Tornetta P. Orthopaedic Surgery Essentials: Trauma. Philadelphia, PA: Lippincott Williams & Wilkins; 2006, with permission.)
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Figure 32-3
A: The dorsal angle (DA) is measured by finding the angle between a line (CD) perpendicular to the long axis of the radius (AB) and a line joining the dorsal and volar extremities of the radiocarpal joint (EF). Carpal alignment is assessed by the point of intersection of the line parallel to the long axis of the radius (AB) and a line parallel to the long axis of the capitate (GH). If these intersect outwith the carpus or do not intersect as in this illustration, then the carpus is malaligned. B: Ulnar variance (UV) is the distance between two lines perpendicular to the long axis of the radius (AB). The first is tangential to the ulnar corner of the radius (CD) and the second tangential to the ulnar head (EF). Radial length is the distance between line EF and a line tangential to the radial styloid (GH). (From Court-Brown C, McQueen M, Tornetta P. Orthopaedic Surgery Essentials: Trauma. Philadelphia, PA: Lippincott Williams & Wilkins; 2006, with permission.)
A: The dorsal angle (DA) is measured by finding the angle between a line (CD) perpendicular to the long axis of the radius (AB) and a line joining the dorsal and volar extremities of the radiocarpal joint (EF). Carpal alignment is assessed by the point of intersection of the line parallel to the long axis of the radius (AB) and a line parallel to the long axis of the capitate (GH). If these intersect outwith the carpus or do not intersect as in this illustration, then the carpus is malaligned. B: Ulnar variance (UV) is the distance between two lines perpendicular to the long axis of the radius (AB). The first is tangential to the ulnar corner of the radius (CD) and the second tangential to the ulnar head (EF). Radial length is the distance between line EF and a line tangential to the radial styloid (GH). (From Court-Brown C, McQueen M, Tornetta P. Orthopaedic Surgery Essentials: Trauma. Philadelphia, PA: Lippincott Williams & Wilkins; 2006, with permission.)
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Radial length: This is measured on the PA radiograph. It is the distance in millimeters between a line drawn perpendicular to the long axis of the radius and tangential to the most distal point of the ulnar head and a line drawn perpendicular to the long axis of the radius and at the level of the tip of the radial styloid (Fig. 32-3B). 
Ulnar variance: This is a measure of radial shortening and should not be confused with the measurement of radial length. Ulnar variance is the vertical distance between a line parallel to the medial corner of the articular surface of the radius and a line parallel to the most distal point of the articular surface of the ulnar head, both of which are perpendicular to the long axis of the radius (Fig. 32-3B). 
Radial inclination: On the PA view the radius inclines toward the ulna. This is measured by the angle between a line drawn from the tip of the radial styloid to the medial corner of the articular surface of the radius and a line drawn perpendicular to the long axis of the radius. 
Carpal malalignment: There are two types of carpal malalignment associated with fracture of the distal radius. The commonest is malalignment which compensates for the tilt of the distal radius and is extrinsic to the carpus. On a lateral view one line is drawn along the long axis of the capitate and one down the long axis of the radius. If the carpus is aligned the lines will intersect within the carpus. If not they will intersect outwith the carpus (Fig. 32-3A). Carpal malalignment can also be caused by associated carpal ligament disruption. The radiologic diagnosis of this condition is detailed in Chapter 31
Teardrop angle and anteroposterior (AP) distance: More recently, attention has been drawn to examination of the teardrop angle and AP distance, as measured on a lateral radiograph.254 The teardrop of the distal radius articular surface refers to the U-shaped outline of the volar rim of the lunate facet. The teardrop angle refers to the angle between the central axis of the teardrop and the central axis of the radial shaft. Depression of the teardrop angle to less than 45 degrees indicates displacement of the lunate facet (Fig. 32-4). A depressed teardrop angle may be the only evidence that reduction is incomplete and articular incongruity remains. The AP distance is also a measure of articular incongruity and is defined by the distance between the apices of the dorsal and volar rims of the lunate facet. The normal AP distance averages 19 mm on a true lateral view,254 but is probably best assessed by comparison with the contralateral normal wrist. 
Figure 32-4
 
A: A lateral view of a displaced intra-articular distal radius fracture showing a depressed teardrop angle of just over 10 degrees. B: The fracture has been reduced and the teardrop angle is restored to just under 54 degrees.
A: A lateral view of a displaced intra-articular distal radius fracture showing a depressed teardrop angle of just over 10 degrees. B: The fracture has been reduced and the teardrop angle is restored to just under 54 degrees.
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Figure 32-4
A: A lateral view of a displaced intra-articular distal radius fracture showing a depressed teardrop angle of just over 10 degrees. B: The fracture has been reduced and the teardrop angle is restored to just under 54 degrees.
A: A lateral view of a displaced intra-articular distal radius fracture showing a depressed teardrop angle of just over 10 degrees. B: The fracture has been reduced and the teardrop angle is restored to just under 54 degrees.
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Specific features should be assessed on each view of the distal radius as follows. 

PA View

For extra-articular fractures assess the following: 
  •  
    Radial length/ulnar variance
  •  
    Extent of metaphyseal comminution
  •  
    Ulnar styloid fracture location (tip/waist/base)
In addition, for intra-articular fractures assess the following: 
  •  
    Presence and orientation of articular fractures
  •  
    Depression of the lunate facet
  •  
    Gap between scaphoid and lunate facet
  •  
    Central impaction fragments
  •  
    Carpal bone assessment—Gilula’s carpal arc 1 or evidence of a scaphoid fracture
Lateral View.
For extra-articular fractures assess the following: 
  •  
    Dorsal/palmar tilt
  •  
    Extent of metaphyseal comminution
  •  
    Carpal alignment
  •  
    Displacement of the volar cortex
  •  
    Position of the DRUJ
For intra-articular fractures assess the following: 
  •  
    Depression of the palmar lunate facet
  •  
    Depression of the central fragment
  •  
    Gap between palmar and dorsal fragments
  •  
    Scapholunate angle for possible associated carpal injury
  •  
    Teardrop angle
  •  
    AP distance
Measurement of dorsal and volar tilt should be made on a true lateral view of the distal radius when the ulna is completely superimposed on the radius. Pronation of the forearm reduces the apparent volar tilt and supination increases it although it does not affect the measurement of radiolunate or carpal alignment.46 Johnson and Szabo175 found that a 5-degree rotational change produces a 1.6-degree change in palmar tilt on the conventional lateral view and a 1-degree change on the 15-degree lateral view. 
Oblique Views.
The pronated oblique view demonstrates the radial side of the distal radius and is particularly useful for assessing radial comminution, a split or depression of the radial styloid, and for confirming the position of screws on the radial side of the distal radius (Fig. 32-5A).335 
Figure 32-5
 
A: A pronated oblique view of the distal radius. This allows assessment of the radial side of the joint. In this case a volar plate is being inserted and it can be seen that the screws are outwith the radiocarpal joint. B: A supinated oblique view of the distal radius allowing assessment of the ulnar side of the joint. C, D: The forearm is elevated 20 degrees off the table to provide a tilted lateral view of the distal radius which captures a tangential view of the radiocarpal joint.
A: A pronated oblique view of the distal radius. This allows assessment of the radial side of the joint. In this case a volar plate is being inserted and it can be seen that the screws are outwith the radiocarpal joint. B: A supinated oblique view of the distal radius allowing assessment of the ulnar side of the joint. C, D: The forearm is elevated 20 degrees off the table to provide a tilted lateral view of the distal radius which captures a tangential view of the radiocarpal joint.
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Figure 32-5
A: A pronated oblique view of the distal radius. This allows assessment of the radial side of the joint. In this case a volar plate is being inserted and it can be seen that the screws are outwith the radiocarpal joint. B: A supinated oblique view of the distal radius allowing assessment of the ulnar side of the joint. C, D: The forearm is elevated 20 degrees off the table to provide a tilted lateral view of the distal radius which captures a tangential view of the radiocarpal joint.
A: A pronated oblique view of the distal radius. This allows assessment of the radial side of the joint. In this case a volar plate is being inserted and it can be seen that the screws are outwith the radiocarpal joint. B: A supinated oblique view of the distal radius allowing assessment of the ulnar side of the joint. C, D: The forearm is elevated 20 degrees off the table to provide a tilted lateral view of the distal radius which captures a tangential view of the radiocarpal joint.
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The supinated oblique view demonstrates the ulnar side of the distal radius and is useful for assessing depression of the dorsal lunate facet and the position of ulnar-sided screws (Fig. 32-5B). 
Tilted Lateral View.
This is a lateral view taken with a pad under the hand to incline the radius 22 degrees toward the beam.229 It provides a tangential view of the lunate facet and allows more accurate measurement of lunate facet depression and possible screw penetration into the radiocarpal joint (Fig. 32-5C, D). 
Traction Views (AP and Lateral).
These views are taken with manual traction or finger traps applied after reduction and under anesthetic. They are most useful in articular fractures and allow the surgeon to plan whether closed techniques will be sufficient for treatment or whether open reduction will be necessary. A traction view also helps to identify fracture fragments that may be obscured by the displacement of the fracture and emphasizes any disruption of Gilula’s arc in the proximal carpal row in associated interosseous ligament injury. 
Contralateral Wrist (AP and Lateral).
These x-rays may be indicated prior to surgery to assess the patient’s normal ulnar variance, scapholunate angle, and AP distance, all of which vary between patients. 

Computerized Tomography

Computerized tomography (CT) scanning is used to improve the visualization and accuracy of measurement of articular fractures in the distal radius. Clinical data suggest that CT demonstrates intra-articular fracture lines and measures intra-articular displacement more accurately than plain radiographs,176 and in particular demonstrates the presence and displacement of sigmoid notch fractures more accurately than plain radiographs. In one study comparing plain radiographs to CT, the authors found that in 20 consecutive fractures plain x-rays documented sigmoid notch involvement in only 35% of the fractures compared with 65% found on CT.312 A more recent study found that in 95 articular fractures there was 77% involvement of the sigmoid notch, 71% involvement of the dorsoulnar segment, 57% of the dorsoradial segment, and only 13% involvement of the volar ulnar segment.364 
Three-dimensional CT scans are now commonly used in assessing intra-articular fractures of the distal radius. Their use has been shown to improve intraobserver but not interobserver agreement and to allow a reliable determination of fracture characteristics which may influence treatment such as coronal fracture lines, central articular depression, and articular comminution. The use of this technique has been shown to increase the perceived need for open exposure of displaced articular segments when compared to conventional CT,149 but the influence of this on functional outcome has yet to be determined. 

Classification of Fractures of the Distal Radius and Ulna

Many classification systems have been proposed for fractures of the distal radius and ulna over the years, the majority of which are morphologic and consider in varying degrees the presence or absence of displacement, comminution, and articular involvement. 

Previous Classifications

Of the older classification systems the most common still quoted are Gartland and Werley,117 Older,269 and the Frykman114 classification, with the Melone classification for intra-articular fractures.257 In 1951, Gartland and Werley described a classification system, which included articular involvement, comminution, and displacement. They described three groups: 
Group 1—Simple Colles fracture with no involvement of the articular surface. 
Group 2—Comminuted Colles fracture with fractures of the radial articular surface in which the fragments were not displaced. 
Group 3—Comminuted Colles fracture with fractures of the radial articular surface in which the fragments were displaced. 
Group 4—Gartland and Werley did not specify whether group 1 fractures were displaced but Solgaard339 added a fourth group of extra-articular undisplaced fractures. 
The Older classification was published in 1965 and aimed to assist the inexperienced resident in selecting treatment. It is based on severity of displacement and comminution. There are four types: 
Type 1—Undisplaced: 
  1.  
    Loss of some volar angulation up to 5 degrees dorsal angulation.
  2.  
    No significant radial shortening—2 mm or more above the distal ulna.
Type 2—Displaced with minimal comminution: 
  1.  
    Loss of volar angulation or dorsal displacement of distal fragment.
  2.  
    Shortening—usually not below the distal ulna, occasionally up to 3 mm below it.
  3.  
    Minimal comminution of dorsal radius.
Type 3—Displaced with comminution of distal radius: 
  1.  
    Comminution of dorsal radius.
  2.  
    Shortening—below distal ulna.
  3.  
    Comminution of distal radial fragment—usually not marked, often characterized by pieces.
Type 4—Displaced with severe comminution of distal radius: 
  1.  
    Marked comminution of dorsal radius.
  2.  
    Comminution of distal radial fragment—shattered with fractures into the joint.
  3.  
    Shortening—usually 2 to 8 mm below the distal ulna.
  4.  
    Poor volar cortex in some cases.
Older et al. correlated their end results to the classification system and found that anatomical and functional results were worse with increasing severity of the fracture. 
Frykman classified fractures of the distal radius concentrating on articular and ulnar (styloid or shaft) involvement. He specifically differentiated between radiocarpal and distal radioulnar joint involvement, as he believed that intra-articular involvement and ulnar involvement were the most prognostic factors: 
 
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Type I Extra-articular, no ulnar fracture
Type II Extra-articular, ulnar fracture
Type III Radiocarpal articular, no ulnar fracture
Type IV Radiocarpal articular, ulnar fracture
Type V DRUJ articular, no ulnar fracture
Type VI DRUJ articular, ulnar fracture
Type VII Radiocarpal and DRUJ, no ulnar fracture
Type VIII Radiocarpal and DRUJ, ulnar fracture
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Melone classified intra-articular fractures of the distal radius by considering that each fracture consisted of four parts: radial styloid, dorsal medial fragment, volar medial fragment, and the radial shaft. He termed the two medial fragments, which make up the lunate fossa the medial complex and based his classification on the position of the medial complex (Fig. 32-6). 
Figure 32-6
The Melone classification for intra-articular fractures of the distal radius.
 
Four parts of the fractures are illustrated—the shaft, the radial styloid, the volar ulnar, and the volar dorsal components.
Four parts of the fractures are illustrated—the shaft, the radial styloid, the volar ulnar, and the volar dorsal components.
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Figure 32-6
The Melone classification for intra-articular fractures of the distal radius.
Four parts of the fractures are illustrated—the shaft, the radial styloid, the volar ulnar, and the volar dorsal components.
Four parts of the fractures are illustrated—the shaft, the radial styloid, the volar ulnar, and the volar dorsal components.
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Type 1—Undisplaced or variable displacement of the medial complex as a unit. No comminution. Stable after closed reduction. 
Type 2—Unstable, die punch. Moderate or severe displacement of the medial complex as a unit with comminution of dorsal and volar cortices. 
A—Irreducible, closed. 
B—Irreducible, closed because of impaction. 
Type 3—As type 2 but with a spike of the radius on the volar side, which may compromise the median nerve. 
Type 4—Split fracture, unstable. The medial complex fragments are severely comminuted with rotation of the fragments. 
Type 5—Explosion injury. Severe displacement and comminution often with diaphyseal comminution. 

Current Classifications

Probably the most widely used classification system in current use is the AO classification (Fig. 32-7), which has been adopted by the Orthopaedic Trauma Association and has been renamed the AO/OTA classification.241 This is an inclusive, alphanumeric classification and has 27 different subgroups. Three different types (A—extra-articular, B—partial articular, and C—complete articular) are divided into 9 main groups and 27 different subtypes depending on comminution and direction of displacement. 
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Figure 32-7
The AO/OTA classification.
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In response to the AO classification, Fernandez and Jupiter97 published a simplified classification intended to be more treatment-oriented and based on the mechanism of injury. There are five basic types—bending fracture of the metaphysis, shearing and compression fractures of the joint surface, avulsion fractures, and combined fractures from high-velocity injury (Fig. 32-8). The system is presented with the likely risk of instability and associated injuries and gives treatment recommendations. It has not as yet been validated in terms of the treatment recommendations. 
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Figure 32-8
The Fernandez classification.
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Reliability of Classification Systems

Although classification systems are widely used for distal radius fractures, their reliability has not been established. A reliable classification system should be able to define and quantify the severity of a fracture and assist the surgeon in predicting the outcome of a fracture. The dilemma in constructing a classification system is that the more complex the system, the less reliable it becomes both within and between observers. 
A number of studies have investigated the reliability of classification system for distal radius fractures. At best, inter- or intraobserver reliability has been demonstrated for the AO/OTA system205,375 when only types A, B, or C are considered. Other studies considering both the AO/OTA and other classifications fail to demonstrate reliability11,102,288 except for the Older classification in which Anderson et al. showed high inter- and intraobserver reproducibility. Solgaard339 demonstrated the prognostic value of this system. However, undue reliance should not be placed on classification systems especially in considering treatment and prognosis. For research purposes it is preferable to classify distal radius fractures by consensus amongst authors. 

Classification of Associated Ulnar Injury

Both the AO/OTA classification241 and Fernandez classification97 have constructed a system of classifying ulnar injury associated with distal radius fractures. The Fernandez classification concentrates on the residual stability of the DRUJ after the distal radius fracture has been reduced. There are three types. 
Type 1—The distal radioulnar joint is clinically stable and congruous. The primary stabilizers of the joint are intact. Includes avulsion of the tip of the ulnar styloid and stable fractures of the ulnar neck. 
Type 2—The distal radioulnar joint is subluxed or dislocated in association with a TFCC tear or fracture at the base of the ulnar styloid. 
Type 3—Potentially unstable lesions. Displaced fracture involving sigmoid notch or ulnar head. 
The AO/OTA classification system applies a qualification (Q) modifier to classify associated ulnar injuries as follows: 
Q1—Distal radioulnar joint dislocation (base of styloid process fracture). 
Q2—Simple neck fracture. 
Q3—Multifragmentary neck fracture. 
Q4—Ulnar head fracture. 
Q5—Ulnar head and neck fracture. 
Q6—Ulnar fracture proximal to neck. 

Outcome Measures for Fractures of the Distal Radius and Ulna

Evaluation of the outcome of a fracture or its treatment is essential to the practice of modern surgery, but any system used for this purpose must be reliable, reproducible, and validated. The World Health Organization (WHO) developed a framework to measure health and disease, the International Classification of Impairments, Disabilities and Handicaps (ICIDH) which distinguishes between impairment, disability, and handicap. Impairment is abnormal physical function, for example, lack of forearm rotation following distal radius fracture, which is generally measured by clinical methods. Disability is the lack of ability to perform daily activities because of the impairment such as inability to open a tight jar because of the lack of forearm rotation. Disability is usually measured by patient reported outcome measures (PROMs). However the patient’s perception of disability may be heavily influenced by psychosocial factors,300 which surgical intervention will not influence. This suggests that those methods measured by clinicians (which treatment may influence) which can be correlated with PROMs may be the best method of measuring outcomes. 
Initially, outcome measures for distal radius fracture concentrated on a combination of objective and subjective factors including pain, range of motion, grip strength, ability to undertake the activities of daily living, and radiologic measurements which mainly measure impairment. In recent years however, more emphasis has been placed on self-reported measures of symptoms and function after injury which measure perceived disability. 

Clinician-Rated Outcome Measures

Clinician-measured outcomes depend on the measurement of grip strength, ranges of motion, and specialized grip strengths and may contain an element of assessment of the ability to undertake the normal activities of daily living. Although not patient related, it should be noted that although these measurements are theoretically objective the effort applied can be influenced by the patient’s psychological state.346 
The most frequently used physician-based scores for distal radius fractures are the Mayo wrist score,68 the Gartland and Werley score,117 and the Green and O’Brien134 score. None have been examined to determine their reliability, responsiveness, or validity. 
Mayo Wrist Score.
This was developed for assessment of perilunate fracture dislocations68 and includes four measures of outcome: pain intensity (25 points), functional status (25 points) based purely on work ability, range of motion (25 points), and grip strength (25 points). The resultant score (maximum 100) is then rated as excellent (90 to 100), good (80 to 90), satisfactory (60 to 80), and poor (below 60). It is based on the Green and O’Brien score, which was modified by Cooney et al.68 in 1987 by removing any scoring for radiographic appearances. 
Green and O’Brien Score.
This was developed for assessment of carpal dislocations and includes assessment of pain (five categories, 25 points), occupation (five categories, 25 points), range of motion (five categories, 25 points), grip strength (three categories, 10 points), and radiology (five categories, 20 points).135 The radiology can only be scored for carpal dislocation. The total score out of 100 was considered satisfactory if it was greater than 70. 
Gartland and Werley Score.
In 1951, Gartland and Werley117 constructed an outcome score to evaluate the results of distal radius fractures. It is a demerit score with an excellent result being 0 to 2 points, good 3 to 8 points, fair 9 to 20 points, and poor greater than 20 points. Points are allocated for residual deformity, subjective (i.e., patient) evaluation of pain, disability and limitation of motion, objective (i.e., surgeon) evaluation of loss of movement and distal radioulnar joint pain, and complications of arthritic change, CTS, and stiff fingers. Radiologic results were reported separately. 

Patient-Reported Outcome Measures

In recent years there have been a number of PROMs developed ranging from generic measures assessing the impact of injury on the patient’s health and well-being (e.g., Short Form 36 [SF-36], sickness impact profile [SIP]) to more specific measures of outcome focused on anatomical regions or specific conditions. 
There are two scoring systems in common usage which focus on the upper extremity or wrist. 
The Disabilities of Hand, Arm and Shoulder (DASH) Score.
The DASH score was first described in 1996165 as a joint initiative of the American Academy of Orthopaedic Surgeons (AAOS), the Council of Musculoskeletal Research Societies, and the Institute for Work & Health in Toronto. The authors wished to produce a brief self-administered measure of symptoms and mainly physical functional status. The result was the DASH score, which is a 30-item disability/symptom score from 0 (no disability) to 100 (severe disability). Questions are asked about the degree of difficulty in performing tasks because of the upper extremity problem (21 items); the severity of pain; pain with use, tingling, weakness, or stiffness (five items); and the problems’ effect on social activities, work, sleep, and self-image (four items). The normal DASH score is less than 15.119 
Studies of the validity, reliability, and responsiveness of the use of the DASH score in upper limb disorders have demonstrated good validity, reliability, and responsiveness for upper extremity conditions53,78,141 and specifically for distal radius fractures.232 A 10-point difference in the mean DASH score is considered the minimal clinically important change.141 A shorter form, the QuickDASH, is also available and consists of 11 items with similar results for validity and reliability for a variety of upper extremity conditions141 although not specifically for distal radius fractures. 
The Patient-Related Wrist Evaluation (PRWE) Score.
The PRWE is a 15-item questionnaire, which examines the severity and frequency of pain in 5 questions and the ability to undertake activities of daily living in 10 questions.233 It was developed and tested on patients with distal radius fractures and is therefore specific to the wrist rather than to the whole upper extremity. The developers reported excellent reliability and the ability to detect changes over time and concluded that the PRWE provides a brief, reliable, and valid measure of patient-related pain and disability. The responsiveness (or the ability to detect change) of the PRWE was rated highest in a comparison between SF-36, DASH, and PRWE.232 Changulani et al.53 summarized the validity, reliability, and responsiveness of four outcome measures, three of which (Gartland and Werley, DASH, and PRWE) are used for assessment of outcome in distal radius fractures and concluded that the PRWE validity was fair, but its reliability and responsiveness was good. The system has also been found to be reliable and valid when translated into different languages.394 

Pathoanatomy and applied anatomy of fractures of the distal radius and ulna

The distal end of the radius and ulna is an integral part of the wrist joint and preservation of its normal anatomy is essential for the mobility of the wrist and its ability to transmit axial load. The prime function of the wrist joint is to position the hand in space and allow full hand function. Fractures of the distal radius that malunite are therefore likely to have a significant effect on hand function. 
The articular surface of the distal radius has two concavities, one for articulation with the scaphoid and one for the lunate. The two facets are divided by a ridge running from dorsal to volar. The surface is triangular in shape with the base formed by the sigmoid notch and the apex by the tip of the radial styloid. The articular surface is inclined both in a volar and an ulnar direction. 
The palmar surface of the radius forms a curve concave from proximal to distal. It is relatively smooth, which allows easy contouring of plates in this area. It also allows attachment of stout radiocarpal ligaments, which act as restraints to the normal tendency of the carpus to slide in an ulnar and palmar direction. The curve is covered by the transverse fibers of pronator quadratus, which is attached to the radial side of the bone. 
The dorsal surface is convex and much more irregular with Lister’s tubercle, around which the extensor pollicis longus (EPL) tendon passes, being the most prominent area. There are grooves that form the floors of extensor compartments (Fig. 32-9). A knowledge of their anatomy is essential in approaching the dorsum of the distal radius surgically or in applying any form of fixation to the distal radius dorsally (Table 32-3). 
Figure 32-9
The cross-sectional anatomy of the radius immediately below the radiocarpal joint.
 
The extensor tendons lie in their compartments in immediate contact with the bone whilst on the palmar surface the flexor tendons are protected by a layer of fat.
The extensor tendons lie in their compartments in immediate contact with the bone whilst on the palmar surface the flexor tendons are protected by a layer of fat.
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Figure 32-9
The cross-sectional anatomy of the radius immediately below the radiocarpal joint.
The extensor tendons lie in their compartments in immediate contact with the bone whilst on the palmar surface the flexor tendons are protected by a layer of fat.
The extensor tendons lie in their compartments in immediate contact with the bone whilst on the palmar surface the flexor tendons are protected by a layer of fat.
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Table 32-3
The Extensor Compartments of the Wrist and Their Contents
Extensor Compartment Contents Comments
1 Abductor pollicis longus
Extensor pollicis brevis
Form the radial border of the anatomical snuff box
2 Extensor carpi radialis longus
Extensor carpi radialis brevis
3 Extensor pollicis longus Ulnar to Lister’s tubercle
4 Extensor digitorum
Extensor indicis
5 Extensor digiti minimi Dorsal to the distal radioulnar joint
6 Extensor carpi ulnaris Runs in groove between the ulnar head and styloid
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As well as the radiocarpal articulation the distal radius forms one half of the distal radioulnar joint, the sigmoid notch, which is a uniform curve semicylindrical in shape allowing rotation of the radius around the ulnar head. As rotation occurs the ulnar head moves in a volar direction with supination and a dorsal direction with pronation. The ulnar head is largely covered in cartilage even on its inferior surface. However, it does not articulate with the carpus as the TFCC extends from the ulnar aspect of the radius to the base of the ulnar styloid and articulates with the triquetrum. The TFCC acts as a stabilizer of the distal radioulnar joint along with extensor carpi ulnaris and flexor carpi ulnaris, the pronator quadratus, and the interosseous membrane of the forearm. 

Treatment Options

There are numerous treatment options for the management of distal radius fractures including nonoperative, external fixation, and internal fixation. The indications for each differ depending on the patient, their demands, and the type of fracture. As the main goal of treatment is to maximize function in the hand and wrist it is essential in planning treatment to consider the factors that may predict fracture instability or functional outcome. 

Prediction of Instability

Several factors have been associated with re-displacement following closed manipulation of a distal radius fracture. 

Age

Patients over 80 years of age with a displaced fracture of the distal radius are three times more likely to have instability than those under 30 years of age. This is even more striking in patients with minimally or undisplaced fractures when the risk of instability increases tenfold in older patients.234 Fractures in elderly patients with osteopenic bones may also displace at a later stage. 

Initial Fracture Displacement340

The greater the degree of initial displacement (particularly radial shortening), the more energy is imparted to the fracture resulting in a higher likelihood that closed treatment will be unsuccessful. 

Metaphyseal Comminution

The presence of a metaphyseal defect as evidenced by either plain radiographs or computerized tomography increases the chance of instability.340 

Displacement Following Closed Treatment

This is a predictor of instability as repeat manipulation is unlikely to result in a successful radiographic outcome.104,250,251 
Mackenney and his co-authors234 examined the natural history of over 3,500 distal radius fractures and detailed the independently significant predictors of early instability (redisplacement before two weeks), late instability (redisplacement between two weeks and fracture union) and malunion for both undisplaced and displaced fractures. Mathematical formulae were constructed to give a percentage chance of redisplacement or malunion for individual patients. The authors give an example of an independent 85 year old lady with a dorsally displaced fracture of the distal radius with metaphyseal comminution and a positive ulnar variance of 2 mm. The calculated probability of malunion is 82%. Clinical application of these formulae is likely to encourage early treatment in appropriate cases and reduce the prevalence of malunion. 

Prediction of Function

Patient Factors

Age.
The main consideration influencing a decision about the treatment of a patient with a distal radius fracture is the demand which an individual places on their wrist. The purpose of treatment is to maintain normal strength, mobility, and function in the hand and wrist. These factors are influenced by the age and psychological state, both of which may alter the demands placed on the wrist. Treatment methods usually serve to restore the normal anatomy, failing which malunion results. As demands upon the wrist become less, the symptoms from a malunion are likely to reduce and the importance of normal anatomy declines. 
However, there is as yet no consensus on how patients should be treated as the definition of an elderly patient is not clear. Physiologic and actual age may vary greatly but the surgeon usually makes a judgment on a subjective impression. The use of more objective measures available in the geriatric and epidemiologic literature such as the Physical Activity Scale of the Elderly (PASE) score may be of value.387 The PASE is a brief instrument designed to assess physical activity in older persons and includes assessment of participation in normal daily and leisure activities. It has been validated as a measure of physical activity, health, and physical function in older people.327,386 
Lessening demands may account for reports of malunion of the distal radius in older people being compatible with good function. Jaremko et al.170 reviewed 74 older patients with distal radius fractures treated nonoperatively. Seventy-one percent had at least one unacceptable radiographic deformity, but at review 6 months after fracture the authors reported that self-reported disability was low and patient satisfaction high despite a mean DASH score of 24 and a patient dissatisfaction rate of 28%. Mean DASH scores were higher if the radiologic deformity was outside the acceptable range but this was not statistically significant. The outcome scores could not be predicted by radiologic deformity possibly because the age range was wide from 50 years upward. Young and Rayan399 studied 25 low-demand patients over 60 years of age. Thirty-two percent of patients had fair or poor radiographic results but only 12% had fair or poor functional outcomes. The most difficult task was jar opening. The authors concluded that nonoperative treatment yields satisfactory results in low-demand patients. No relationship between anatomy and function was found in a group of 74 older patients with conservatively managed distal radius fractures 6 months after injury, although only 59% of patients were satisfied with the outcome.14 Grewal and MacDermid136 found that the relative risk of a poor outcome with malalignment of the distal radius showed a decreasing trend with increasing age. In a comparison of operative versus nonoperative treatment in elderly patients despite better anatomical results in the operatively treated group there were no differences in DASH scores or pain scores between the groups up to a year after injury.92 
In contrast to these studies Brogren et al.40 examined 143 patients 1 year after distal radius fracture and classified them into three groups: No malunion, single malunion (either dorsal tilt of 10 degrees or positive ulnar variance) and combined malunion (both dorsal tilt of 10 degrees and positive ulnar variance). The average age was 65 years. The mean DASH score was 10.5 points worse than the no malunion group if there was single malunion (p = 0.015) and 8.7 points worse if there was a combined malunion (p = 0.034). With regression analysis the relative risk of higher disability was 2.5 with single malunion and 3.7 with a combined malunion. There was no difference in these results when adjusted for age or gender. The authors concluded that malunion with a dorsal angle greater than 10 degrees or a positive ulnar variance leads to higher arm-related disability after distal radius fracture, regardless of age or gender. 
Other Factors.
A number of other factors have been linked to outcome after fractures of the distal radius. Work-related injury or compensation claims have been shown to have a negative influence on outcomes.138,231 Poorer socioeconomic status,58 lower education levels138 and low bone density158 have also been implicated in poorer outcomes. 

Fracture Factors

There remains little consensus on what constitutes an “acceptable” radiologic result after distal radius fracture. This should be defined as a radiologic position which will predict satisfactory function in the substantial majority of cases. A number of authors have examined the influence of radiologic position on function, considering both metaphyseal and articular alignment. 
Metaphyseal Alignment.
All of the radiologic indices of anatomy detail earlier in this chapter have been examined in attempts to detect any correlation with function. 
Radial Height.
After retrospectively reviewing 269 distal radial fractures in adults, Solgaard340 found that shortening had the most impact on the result and recommended restoration of the radial length to be the primary goal of surgery. Batra and Gupta,25 in a retrospective review of 69 patients at 1 year after the injury that had been treated with various techniques, echoed the above findings by highlighting radial length as the most important determinant of functional outcome. Jenkins et al.173 in a prospective study of 61 consecutive patients presenting with distal radial fractures treated by plaster immobilization showed that shortening of more than 4 mm was associated with wrist pain at a mean follow-up of 23 months. Trumble et al.369 also concluded that the degree of surgical correction of the shortening was strongly associated with an improved outcome. 
Ulnar Variance.
Displacement and impaction of the distal fragment leads to relative shortening of the radius compared to the ulna (Fig. 32-10) or ulnar variance, which can be ascertained by comparison with the contralateral normal wrist. The ulna could appear longer (ulnar plus), shorter (ulnar minus), or level (ulnar neutral) with the radius in the normal population.21 Hence the extent of radial shortening as a result of fracture cannot be determined by simply measuring the distance between the radius and ulna, without a preinjury or contralateral radiograph for comparison. 
Figure 32-10
A fracture of the distal radius with an ulnar positive variance, dorsal angulation, and carpal malalignment.
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Adams3 in a cadaveric experiment showed that positive ulnar variance caused the greatest alteration in the kinematics of the DRUJ and the most distortion of the triangular fibrocartilage, compared with loss of radial inclination and palmar tilt. In a prospective randomized trial involving 120 patients with redisplaced distal radial fractures, McQueen et al.250 showed that radial shortening (more than 3 mm compared to the contralateral wrist) resulted in diminished grip strengths. More recently in 118 patients with distal radius fractures treated with locked plating positive ulnar variance at presentation or at final review predicted ulnar-sided wrist pain at final review.401 Brogren et al.40 reported significantly worse DASH and SF-12 scores and weaker grip strength with positive ulnar variance 1 year after fracture. 
Radial Inclination.
Radial inclination is closely correlated with radial height and both are indications of axial compression.374 At 1 to 3 years after a distal radial fracture, Jenkins and Mintowt-Czyz173 showed a correlation between the loss of radial inclination and decreased grip strength. Axial compression predicted the presence of degenerative changes in the radiocarpal joint and the DRUJ in a study of 76 young patients after a mean of 30 years although no patient had altered his occupation or leisure activities as a result.200 Wilcke et al.392 highlighted the association between a loss of radial inclination of >10 degrees and a worse DASH score in a retrospective review of 78 healed distal radial fractures after a mean of 22 months. 
Dorsal/Palmar Tilt.
Cadaveric studies have provided some evidence of the mechanical effects of loss of palmar tilt. The pressure distribution on the ulnar and radial articular surfaces has been shown to change and become more concentrated as dorsal tilt increases.331 In another study the effects of increasing dorsal tilt resulted in worsening incongruence of the distal radioulnar joint, increased tightness of the interosseous membrane, and limited rotation.189 In addition, loss of the normal palmar tilt positions the carpus in a dorsal collapse alignment, leading to midcarpal instability, which may be corrected by a distal radial osteotomy.362 
There has been conflicting evidence on the impact of loss of the normal palmar tilt on functional outcome, which may be because of different measurements and definitions of function or the difficulty in obtaining standard radiographs and a consequent wide margin of error in measurement. Some authors failed to find any relationship between radiology and function.369 Forward et al.108 observed that measurements of extra-articular malunion were not related to the Patient Evaluation Measure. However, in the same study, they noted that dorsal angulation was associated with worse narrowing of joint space and reduced grip strength when compared to the contralateral uninjured site. 
In contrast, radiologic position has been shown to influence a number of individual surgeon-rated measures of function. Van der Linden and Ericson,374 in a study of 250 consecutive cases of extra-articular distal radial fractures, noted that the better the reduction of the dorsal tilt, the better the range of movement, grip strength, and residual pain. In a study of 115 patients being followed up for 2 years post injury, Porter and Stockley290 demonstrated that grip strength diminished significantly when the dorsal tilt exceeded 20 degrees. Gartland and Werley,117 in a study of 60 cases after a mean follow-up of 18 months, showed that residual dorsal tilt of 11 degrees or more was associated with significant loss of wrist flexion. McQueen and Caspers248 performed comprehensive functional assessment on 30 patients with extra-articular fractures after a mean of 5 years. They showed that malunion (dorsal tilt of 12 degrees or more and more than 2 mm of radial shift) was clearly associated with significant functional limitation. 
A more recent study using DASH scores as the primary outcome demonstrated statistically and clinically significantly worse DASH scores with dorsal angle of 10 degrees or more 1 year after fracture.40 The same effect was seen with SF-12 scores and grip strength. 
Carpal Alignment.
It is important to appreciate that most cases of carpal malalignment after distal radius fractures are caused by residual dorsal or volar tilt of the distal radius and not by intrinsic instability of the carpus. As the radius tilts, for example dorsally, the lunate tilts with it. The position of the hand is corrected at the midcarpal joint resulting in carpal malalignment (Fig. 32-10). 
This was first appreciated by Linscheid et al.223 in 1972. They described two cases of distal radius malunion and carpal malalignment and demonstrated correction of the malalignment and improvement in function with corrective osteotomy of the distal radius. Bickerstaff and Bell described carpal malalignment as the inevitable response of the carpus to the altered mechanics caused by dorsal tilt of the distal radius and believed that it explained the morbidity caused by the fracture. They examined 32 patients and concluded that the most significant indication of a poor result was the degree of carpal malalignment.30 In a prospective randomized study of 120 patients with unstable fractures of the distal radius there was poorer recovery of grip strength and forearm rotation in those with carpal malalignment.250 The authors concluded that carpal malalignment had the strongest negative influence on function. Gupta et al. differentiated between two types of carpal alignment, one where the lunate dorsiflexes with the distal radius displacement and one where the lunate remains colinear with the capitate. They believe that the latter is associated with radiocarpal ligament damage and carries a worse prognosis.143 
Articular Alignment.
The relationships between the initial insults to the cartilage, the effects of residual incongruity, and the subsequent development of degenerative changes remain debatable.240 There are no robust data to guide the surgeon on the amount of residual articular displacement which can be accepted with a reasonable guarantee of a satisfactory outcome. This is likely to be caused by the many other factors which influence outcome and its measurement such as age, injury severity, inter- and intraobserver reliability, and difficulty in obtaining accurate measurements of the articular surface.124 
Articular incongruity appears to adversely affect the biomechanics of the joint, and three separate cadaveric experiments using pressure-sensitive films have shown significant increases in contact stresses with articular step-offs varying between 1 and 3 mm.23,383 
However, although radiologic degeneration can be demonstrated with articular displacement, it has been more difficult for investigators to show consistent relationships between articular incongruity, osteoarthrosis, and significant functional compromise. In 1986, Knirk and Jupiter correlated patient outcome with residual intra-articular incongruity. They found a 91% incidence of radiographically apparent arthrosis with any measurable intra-articular step-off and a 100% incidence with over 2 mm of articular step-off, of which 93% (26 of 28) were said to be symptomatic. However, only one patient with bilateral fractures had to stop working as a direct result of the injuries. Overall, 61% reported an excellent or good outcome.196 
Subsequent authors also emphasized the relationship of as little as 1 mm or more of articular incongruity with a worse clinical outcome.120,200 Although these studies indicate the importance of restoring articular congruity, other authors question the ability of plain radiographs to consistently demonstrate incongruity of less than 2 mm. Data on healed fractures indicate that clinicians measuring step and gap deformity on a random x-ray film will differ by more than 3 mm at least 10% of the time. Repeat step or gap measurements by the same observer are also expected to differ by more than 2 mm at least 10% of the time.206 
In another retrospective review, 21 young patients were examined at a mean follow-up of 7.1 years following open reduction and internal fixation (ORIF) of a displaced intra-articular fracture. There was a 76% prevalence of radiocarpal arthritis, but no patient reported a poor functional outcome. Radiocarpal degenerative changes were noted to deteriorate over time, but the patients maintained a high level of function.50 
More recently, Forward et al. reviewed 108 patients at a mean follow-up of 38 years after distal radial fracture. The majority was treated nonoperatively and only one patient underwent internal fixation. The mean age of the patients at the latest review was 64 years. Around two-thirds of the fractures were malunited although none of the patients reported any limitation of activity as a result of the injuries, and none had required a salvage procedure. Intra-articular injury was found to be a strong predictor of radiologic degenerative changes and worse Patient Evaluation Measure and DASH scores.108 

Can We Predict Outcome?

Prediction of outcome is made difficult by the numerous factors which have been shown to have an influence on the final result but would be useful in aiding the surgeon to make a management decision in individual patients. For example, one of the most difficult decisions is in treatment of the elderly patient where biologic and chronologic age may vary significantly and it is difficult to know whether age, level of comorbidity, and preinjury function, or combination of those are the most important factors in deciding whether there will be benefit in correcting the anatomical position. 
In an attempt to predict the threshold above or below which correction of the anatomy should be undertaken, 642 patients treated for distal radius fractures in Edinburgh were examined. Poorer functional outcome was predicted by age, pain, residual dorsal angulation, positive ulnar variance, and carpal malalignment. Weighted equations are being developed which can be applied in individual cases to predict the outcome and assist the surgeon in making a treatment decision. Other authors have also examined the influence of multiple factors on functional outcome. In a prospective study of 96 patients with distal radius fractures treated nonoperatively, Wakefield and McQueen384 found that malunion, the severity of the initial fracture displacement, and a high level of pain 6 weeks after fracture were independent predictors of a poor outcome. Finsen et al. found a highly statistically significant relationship between radiographic displacement and clinical outcome scores including the PRWE and DASH scores. With multiple regression analysis they found that complications, ulnar variance, dorsal angulation, and time since fracture significantly contributed to outcome scores, but that they only contributed 11% to 16% of the variability of the scores.99 
In a recent study osteoporosis has been demonstrated to result in poorer outcomes after distal radius fracture.101 In a cohort of 64 patients treated with ORIF, 20 were osteoporotic and 44 osteopenic on BMD scanning. At 1 year after injury the osteoporotic group had a mean DASH score 15 points higher than the osteopenic group. Using multivariate analysis the authors showed that osteoporosis was a strong independent predictor of a higher DASH score and a higher rate of major complications. This study used a comorbidity index to assess the patients’ general state of health and also demonstrated that more comorbidity was a strong predictor of a poorer DASH score. A similar study published in the same year failed to demonstrate a relationship between osteoporosis and the DASH score, but showed a trend to more complications in the osteoporotic patients.381 
As present knowledge stands we cannot predict the outcome of a distal radius fracture with any degree of confidence but can only recommend levels of displacement which can be accepted in the fit, active, and fully functioning patient. These are detailed in Table 32-4. They are more stringent than those recommended by the AAOS, as the AAOS publication does not consider the effect of carpal malalignment. If the carpus is malaligned and the dorsal tilt is beyond neutral then correction should be undertaken. Some dorsal tilt can be accepted if the carpus is aligned.264 Palmar tilt can be accepted provided the carpus is aligned. 
Table 32-4
The Radiologic Limits Beyond Which Correction is Recommended
Radiologic Measurement Recommended Limits
Positive ulnar variance (mm) 2–3
Carpal malalignment None
Dorsal tilt (degrees) Neutral if carpus malaligned
<10 degrees if carpus aligned
Palmar tilt (degrees) No limit if carpus aligned
Gap or step in joint (mm) 2
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Indications for Treatment

There are numerous treatment options for the management of distal radius fractures including nonoperative treatment, external fixation, and internal fixation. The indications for each differ depending on the patient, their demands, and the type of fracture. 
The main factor influencing a decision about treatment of a distal radius fracture is the demand that an individual patient places on their wrist. The purpose of treatment of a distal radius fracture is to maintain normal strength, mobility, and function in the hand and wrist. These factors are influenced by the age and physiologic state of a patient, both of which may reduce the demands placed on the wrist. Treatment methods usually aim to restore normal anatomy and if this is not achieved malunion will result, which may cause difficulty with activities requiring strength in the hand and wrist. As demands on the wrist become less, the symptoms from a malunion become less thus reducing the need for treatment to maintain normal alignment. 

Nonoperative Treatment of Fractures of the Distal Radius and Ulna

Nonoperative treatment remains the mainstay for fractures of the distal radius and consists of plaster or splint management with or without closed reduction. Rates of nonoperative treatment are probably around 70%,72 with a range in the United States varying from 60% to 96% with geographic location.60,96 Nonoperative treatment of distal radius fractures increases with increasing age and comorbidities59,96 in males and in black patients.60 It was postulated that this was the case because males and black patients were less likely to be osteoporotic and were therefore likely to have more stable fractures.60 Nonoperative treatment is also less likely to be employed by hand surgeons compared to orthopedic trauma surgeons.59,60 
Trends in the use of nonoperative treatment of distal radius fractures have changed over the years. In the early 1950s just over 95% were treated nonoperatively in an urban practice in Southwest USA94 in comparison to as few as 60% in some areas of the United States in this millennium.96 Recent trends have shown an increase from 3% to 16% in the use of ORIF and an accompanying decrease from 82% to 70% in nonoperative management in the elderly since 2000.60 The authors attribute the change to the introduction of volar locked plating systems around 2000. A striking shift has been recorded in fixation techniques amongst younger surgeons between 1999 and 2007 but not in response to improved surgeon-related outcomes.201 This suggests vulnerability in the profession to marketing of new devices and emphasizes the importance of making management decisions based on scientific evidence. 

Indications for Nonoperative Treatment

Nonoperative treatment is indicated for undisplaced stable fractures or displaced fractures which are stable after reduction (Fig. 32-11). Stability after reduction may be assessed by observation over time or by predictive algorithms.234 
Figure 32-11
Management of the undisplaced distal radius fracture.
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Manipulative reduction is indicated where the radiologic position falls outwith acceptable limits (Table 32-4) and nonoperative treatment is predicted to be successful, that is, if the fracture is likely to be stable (Fig. 32-12). It is also used when there is an impending complication which may be averted by early reduction even if further treatment may be necessary. In some situations manipulative treatment is not necessary. These include fracture with a high risk of instability where more definitive primary treatment should be used. Manipulative reduction should not be used where the fracture is displaced and unstable, but the patient is not considered suitable for surgical treatment, for example, in a low-demand patient. In a series of 59 low-demand patients who had undergone manipulative reduction and who had a mean age of 82 years, 53 patients ultimately had a malunion. The authors concluded that primary reduction was ineffective in elderly frail patients and recommend that it should only be performed where there is a specific indication such as median nerve symptoms.29 
Figure 32-12
Nonoperative management of the displaced distal radius fracture.
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Technique of Manipulative Reduction

Reduction of a displaced distal radius fracture requires adequate analgesia or pain relief, which can be achieved by hematoma block, regional or general anesthesia, or intravenous sedation. General anesthesia and intravenous sedation are used in smaller proportions130,348 and the majority of patients are treated with either regional anesthesia or hematoma block. A number of randomized controlled trials (RCTs) have been published, all of which agree that regional anesthesia in the form of a Bier’s block provides superior pain relief and reduction without a significant risk of complications. Hematoma block is cited as being more efficient because it requires only one doctor in attendance, although transit times in the emergency department are similar for both methods.187 However, there is a consensus that Bier’s block is a safe, effective, and practical procedure and superior to hematoma block.1,65,187,385 Despite this it is reported that hematoma block remains a common procedure348 and is used in up to half of the cases. 
Once adequate analgesia or anesthesia has been established, reduction of distal radius fractures is usually straightforward. The surgeon applies longitudinal traction to the forearm with an assistant providing countertraction above the elbow. This usually disengages the fracture and allows direct pressure to be applied to the distal radial fragment from dorsal to volar if dorsally displaced and volar to dorsal if volar displaced. Flexion of the wrist may assist in producing some restoration of volar tilt. However, dorsal ligaments only tighten with maximal wrist flexion.4 This position cannot be maintained in a cast because excessive flexion, the Cotton-Loder position, increases carpal tunnel pressures122,198 and therefore the risk of acute CTS. In recalcitrant cases with dorsal displacement, for example late reduction, Agee technique4 of applying palmar translation of the hand in relation to the forearm is often successful (Fig. 32-13). Finger traps can also be used to apply longitudinal traction, which may be useful when no assistant is available but have not been demonstrated to improve reduction.88 
Figure 32-13
 
To apply the Agee maneuver, traction is first applied either manually or with fingertraps (A). A volar translation force (F) is applied to the distal fragment of the radius (B). The lunate translates on the distal radius, causing the distal fragment to tilt in a volar direction (C). (From Court-Brown C, McQueen M, Tornetta P. Orthopaedic Surgery Essentials: Trauma. Philadelphia, PA: Lippincott Williams & Wilkins; 2006, with permission.)
To apply the Agee maneuver, traction is first applied either manually or with fingertraps (A). A volar translation force (F) is applied to the distal fragment of the radius (B). The lunate translates on the distal radius, causing the distal fragment to tilt in a volar direction (C). (From Court-Brown C, McQueen M, Tornetta P. Orthopaedic Surgery Essentials: Trauma. Philadelphia, PA: Lippincott Williams & Wilkins; 2006, with permission.)
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Figure 32-13
To apply the Agee maneuver, traction is first applied either manually or with fingertraps (A). A volar translation force (F) is applied to the distal fragment of the radius (B). The lunate translates on the distal radius, causing the distal fragment to tilt in a volar direction (C). (From Court-Brown C, McQueen M, Tornetta P. Orthopaedic Surgery Essentials: Trauma. Philadelphia, PA: Lippincott Williams & Wilkins; 2006, with permission.)
To apply the Agee maneuver, traction is first applied either manually or with fingertraps (A). A volar translation force (F) is applied to the distal fragment of the radius (B). The lunate translates on the distal radius, causing the distal fragment to tilt in a volar direction (C). (From Court-Brown C, McQueen M, Tornetta P. Orthopaedic Surgery Essentials: Trauma. Philadelphia, PA: Lippincott Williams & Wilkins; 2006, with permission.)
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Cast Immobilization

Once the reduction maneuvers have been performed, a plaster cast is applied. There are a number of controversies around the use of plaster casts including the type of cast, the use of bracing, the position of immobilization, and the length of time required in cast. 
Type of Cast.
The initial cast is usually a back slab or sugar tong splint. These theoretically allow for swelling to occur in the cast but this has not been demonstrated by pressure measurements within casts which indicate that splitting a circumferential cast is the only method which allows for swelling after reduction.400 The cast is then completed when swelling has reduced. It is important to allow free finger movement within a cast by ensuring that the cast ends proximal to the metacarpophalangeal joints. 
Both forearm and above-elbow casts have been used for distal radius fractures. Above-elbow casts were used because it was believed that holding the forearm in supination prevented redisplacement from the deforming force of brachioradialis.322 However, randomized studies have shown no benefit of above-elbow immobilization compared to forearm casts in maintaining the fracture reduction,36,129,289,352,374 with some showing a disadvantage because of long-term rotational contracture with above-elbow casts.289 No advantage has been demonstrated by the use of braces rather than casts.371 
Position of Immobilization.
Extreme positions of the wrist such as the Cotton-Loder position of extreme flexion and ulnar deviation should be avoided because of their potential complications. Traditionally, slight flexion and ulnar deviation have been recommended but neutral or even dorsiflexed positions do not seem to affect the final radiologic position.142,374 It is likely that fracture and patient factors rather than the wrist position determine the stability of a distal radius fracture.234,374 
Length of Time in Cast.
Undisplaced fractures need a very limited immobilization time with some evidence that no or minimal immobilization is required with functional recovery faster than when conventional cast immobilization is used.76,80,355 If immobilization is used, removable wrist splints may be more acceptable to the patient than a cast.268 
In displaced fractures, which have required manipulative reduction, the accepted length of time in a cast is 5 to 6 weeks. However, in an RCT, McAuliffe et al. found no significant anatomical differences but less pain in patients over 60 years of age whose casts were retained for 3 rather than 5 weeks. They recommended that casts be removed after 3 weeks and active mobilization encouraged.244 
Radiologic and clinical review following fracture reduction should be undertaken at regular intervals. All fractures should be reviewed at 1 week as even minimally displaced fractures which have not required initial reduction may displace. Mackenney et al. reported that 10% of minimally displaced fractures and 43% of displaced fractures were unstable within 2 weeks and would have malunited without further treatment. Late instability, defined as loss of position after 2 weeks of injury, occurred in 22% of the remaining minimally displaced fractures and 47% of the remaining displaced fractures after the fractures with early instability were excluded.234 These data indicate that fracture review should also be undertaken at 2 and 3 weeks after injury. 

Outcome of Nonoperative Treatment

Cohort Studies.
The majority of reports of outcomes after nonoperative treatment are in cohorts of older patients. One study has presented the results of nonoperative treatment at a review period of 9 to 13 years. The patients’ ages ranged from 19 to 78 at the time of injury. There was a high rate of radiologic deformity with a mean dorsal angle of 13 degrees in patients less than 60 years of age and 18 degrees in the older patients. Fifty-two of sixty-six patients’ outcomes were rated as excellent or good according to the modified Green and O’Brien score. The authors noted a slower recovery in the over 60 group and concluded that some patients with nonoperatively treated distal radius fractures still experience some impairment a decade after injury.106 
Other reports concentrate on older patients and those who had access to radiographs after healing report a significant proportion of malunited fractures.14,170,360,399 Mean DASH scores range from 15.7 to 24.10,170,360 Patient satisfaction is rated from 59% to 92%.14,170,399 
Randomized Controlled Trials.
A number of RCTs have compared nonoperative treatment with percutaneous pinning. Most report no or minimal radiologic advantage with percutaneous pinning but no functional advantage.20,357,395 The only study to report anatomical and functional advantages of percutaneous pinning compared to cast management was in patients under 65 years of age.305 
There seems to be a consensus amongst authors of RCTs or pseudo-RCTs which compare nonoperative management with bridging external fixation that bridging external fixation results in a better anatomical position than nonoperative management,8,57,160,164,203,250,308,341 but most reported no differences in the functional results.160,203,250,308,341 The only series that reported DASH scores showed no differences,8 whereas Christensen et al.57 reported improvement in the Gartland and Werley scores for external fixation at 3 and 9 months after injury. Some authors reported either a trend toward poorer function164,203 or worse results for nonoperative management in a small number of objective surgeon-orientated outcomes.8 However, a lower rate of complications is reported for nonoperative management.160,341 Only one study has reported on a randomized comparison of nonbridging external fixation and cast management. Jenkins et al. compared 26 cases treated in plaster with 30 cases treated with nonbridging external fixation. All of their patients were under 60 years of age. There was a mean loss of reduction of 10.5 degrees of dorsal angulation and 3.7 mm of radial length in the plaster group with the fixator group maintaining the reduced position. The authors concluded that a nonbridging external fixator was more effective in maintaining the reduced position of distal radial fractures.171 The following year the same group published functional results in 106 patients under the age of 60 years with displaced distal radial fractures randomized between cast and nonbridging external fixation and confirmed the superiority of the external fixator in maintaining the reduced position. They reported better grip strength and a higher proportion of excellent results both subjectively and objectively in the external fixation group, although each group achieved similar proportions of satisfactory results.172 
There is only one RCT comparing volar locked plating and nonoperative management. Arora et al. reported on 90 patients over 65 years with unstable distal radius fractures treated with a volar locked plate or manipulation under anesthetic and plaster management. Radiologic results were superior in the plated group, which was reflected by better grip strength in this group. The DASH and PRWE scores showed early advantages in the plated group but this was not sustained at later follow-up. The operative group had a higher complication rate (36% vs. 11%) with a 22 % tendon complication rate and a 31% secondary surgery rate.16 
One study compared both external fixation and ORIF as a combined operative group with nonoperative management in patients over the age of 65 years with displaced distal radius fractures. Not surprisingly, the operative group not only had better radiologic results but also had improved grip strength and supination. There were no significant differences in the mean DASH scores which were 12.1 for the nonoperative group and 10 for the operative group. The nonoperative group were significantly older which may have had an impact on the results.92 

Author’s Preferred Treatment for Non-Operative Management of Fractures of the Distal Radius and Ulna

 
 

Undisplaced or minimally displaced fractures are treated without manipulative reduction. I define minimal displacement as fractures without carpal malalignment, less than 10 degrees of dorsal tilt and less than 3 mm of ulnar variance. Undisplaced or minimally displaced fractures are treated in either a forearm cast or removable splint with radiologic review at 1 week. If the fracture is undisplaced, the risk of metaphyseal instability is calculated at less than 70%, and the position has not changed, the patient is reviewed at 3 weeks and if x-rays are satisfactory the wrist is mobilized.

 

For minimally displaced fractures, the risk of instability is calculated and if this is less than 70%, review is undertaken at 1 week. I recommend further radiologic review at 2 weeks and immobilization in a forearm cast for a total of 4 weeks from injury. In a low-demand patient who is not considered suitable for fracture fixation, immobilization is required only for pain relief. Radiologic review is only required at cast or splint removal to confirm union.

 

Displaced distal radius fractures are carefully assessed for risk of instability and articular malalignment. If there is articular displacement of more than 2 mm gap or step or if the risk of metaphyseal instability is greater than 70%, I recommend early operative reduction and stabilization. Calculation of the instability risk234 is easily performed online (www.trauma.co.uk/wristcalc).

 

If there is acceptable articular alignment and the risk of instability is less than 70%, manual manipulative reduction is performed under regional anesthesia. Agee’s technique is used if necessary to restore volar tilt (Fig. 32-13). If an acceptable reduction (Table 32-4) is obtained then the wrist is immobilized in the neutral position in a forearm back slab. If the reduction maneuvers fail then surgery is planned. Reduced fractures are reviewed at 1, 2, and 3 weeks with the back slab being completed or replaced with a full forearm cast at 1 week. Cast immobilization is maintained for 4 to 6 weeks depending on the evidence of radiologic healing and the patient’s symptoms.

Operative Treatment

There are a number of methods of operative treatment available for distal radius fractures including closed reduction and percutaneous pinning, ORIF, different types of external fixation, or combinations of each type of treatment. The indications for each are complex and relative and are to some extent guided by the type of fracture. 
As indicated in this chapter on the section on epidemiology, around 60% of distal radius fractures are extra-articular and almost one-half of almost all distal radius fractures are likely to have metaphyseal instability. Of the total, one-third are articular fractures but fewer than 5% are complex articular fractures. A small proportion is volar displaced fractures including volar shearing fractures. For the purposes of making decisions about surgical treatment, three groups should be considered: metaphyseal unstable extra- or minimal articular fractures, displaced articular fractures, and partial articular fractures. 

Metaphyseal Unstable, Extra- or Minimal Articular Fractures

These are the most common fractures requiring surgical treatment. Metaphyseal instability may be predicted or actual. A minimal articular fracture is one that has an articular component and that does not require articular reduction; most are undisplaced articular fractures (Fig. 32-14). In fit active patients with these fractures, reduction and stabilization is indicated to maximize the chance of good recovery. Metaphyseal unstable fractures can be stabilized by closed reduction and percutaneous pinning, ORIF, or external fixation. Closed remanipulation and plaster management was popular a number of years ago but has been shown to be ineffective by a number of authors.250,251,324 This practice should be abandoned in favor of more stable fixation techniques. 
Figure 32-14
 
A: A minimal articular fracture of the distal radius. B: Despite initially successful manipulative reduction the fracture has lost position because of metaphyseal instability but the articular alignment is maintained.
A: A minimal articular fracture of the distal radius. B: Despite initially successful manipulative reduction the fracture has lost position because of metaphyseal instability but the articular alignment is maintained.
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Figure 32-14
A: A minimal articular fracture of the distal radius. B: Despite initially successful manipulative reduction the fracture has lost position because of metaphyseal instability but the articular alignment is maintained.
A: A minimal articular fracture of the distal radius. B: Despite initially successful manipulative reduction the fracture has lost position because of metaphyseal instability but the articular alignment is maintained.
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Percutaneous Pinning.
Percutaneous pinning of fractures of the distal radius was first suggested in the early 20th century and many different constructs of pins have been described.295 The technique is appealing as it is minimally invasive and it has been widely used for the treatment of unstable extra-articular or minimal articular distal radius fractures as well as for intra-articular fractures. 
Technique.
Percutaneous pinning is performed under sterile conditions with the arm abducted on an arm board. The fracture should first be reduced and held either by an assistant or by finger traps. If intrafocal pinning is planned, complete reduction is not necessary as the pins are used as reduction tools. It can be of assistance to place the wrist in flexion over towels as this gives easier access for the dorsal ulnar pins. 
There are three basic constructs for percutaneous pinning: 
  1.  
    Distal radius pinning where pins are placed across the fracture in the distal radius. These may be only radial styloid pins or may also include a pin from the dorsal ulnar aspect to the volar aspect of the radius.
  2.  
    Ulnar radial pinning where the pins are placed from the radius across the ulna.
  3.  
    Intrafocal pinning or the Kapandji technique where the pins are inserted into the fracture, used as reduction tools, and then driven into the proximal radius.
Whichever technique is used it is important to avoid damage to the dorsal sensory branch of the radial nerve or tendons which are close to the insertion points of both radial styloid and dorsal ulnar wires. A small incision should be made at the proposed point of pin entry with blunt dissection down to the bone to protect nerves and tendons.56 Fluoroscopic control is used to confirm the correct placement of the K-wires. The styloid wire fixes the radial styloid to the radius and is usually placed first from a starting point on the lateral cortex of the radius either on or within 1 cm of the tip of the radial styloid.55 The pin is then driven diagonally in an ulnar direction to engage the cortex proximal to the fracture on the ulnar side of the radius (Fig. 32-15). The dorsal ulnar pin is placed from the dorsal ulnar corner of the radius and driven across the fracture to the volar radial cortex. Biomechanically, the use of two radial styloid and one dorsal ulnar pin is the most rigid construct.262 These authors also recommend that at least a 0.062-in pin should be used. 
Figure 32-15
 
A–C: Comminuted radius fracture in a polytrauma patient treated with percutaneous pinning technique.
A–C: Comminuted radius fracture in a polytrauma patient treated with percutaneous pinning technique.
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Figure 32-15
A–C: Comminuted radius fracture in a polytrauma patient treated with percutaneous pinning technique.
A–C: Comminuted radius fracture in a polytrauma patient treated with percutaneous pinning technique.
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For intrafocal pinning, pins are driven into the fracture site and used as levers to reduce the fracture (Fig. 32-16). Kapandji recommends three wires placed laterally, posterolaterally, and posteromedially. He describes making a small incision in the skin and using blunt dissection to avoid tendons and nerves.182 A small vertical incision is made at the fracture site. On the radial side the pin is inserted in the plane between the tendons of extensor pollicis brevis (EPB) and abductor pollicis longus (APL) and the wrist extensors. The posterolateral incision is placed slightly lateral to and above Lister’s tubercle and the pin is placed between the EPL and the tendons of EPB and APL. The posteromedial placement is in the fourth extensor compartment usually between the extensors of the ring and little fingers. The pins are introduced perpendicularly in the line of the fracture and then inclined obliquely upward thus buttressing the cortex of the distal fragment. The pin is then driven into the opposite cortex of the radius. 
Figure 32-16
 
The Kapandji Technique: Metaphyseal fracture with redisplacement after reduction (A).A pin is inserted into the fracture site, manipulated to elevate the fragment distally (B), and then driven into the opposite cortex (C).The fragments are thus trapped and prevented from dorsal displacement.
The Kapandji Technique: Metaphyseal fracture with redisplacement after reduction (A).A pin is inserted into the fracture site, manipulated to elevate the fragment distally (B), and then driven into the opposite cortex (C).The fragments are thus trapped and prevented from dorsal displacement.
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Figure 32-16
The Kapandji Technique: Metaphyseal fracture with redisplacement after reduction (A).A pin is inserted into the fracture site, manipulated to elevate the fragment distally (B), and then driven into the opposite cortex (C).The fragments are thus trapped and prevented from dorsal displacement.
The Kapandji Technique: Metaphyseal fracture with redisplacement after reduction (A).A pin is inserted into the fracture site, manipulated to elevate the fragment distally (B), and then driven into the opposite cortex (C).The fragments are thus trapped and prevented from dorsal displacement.
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Pins may be left protruding from the skin for ease of removal but a small RCT demonstrated lower pin track infection rates in wires buried below the skin.147 This has the disadvantage of requiring a further minor procedure to remove the wires. 
There are a number of controversies centered around percutaneous pinning for distal radius fractures. These include the best configuration of the pins, whether the pins should be buried, whether immobilization is required, and if so for how long. 
Postoperative Immobilization.
Although Kapandji stated, “plaster is strictly forbidden,”182 most authors utilize a short arm cast for varying periods of up to 6 weeks after percutaneous pinning.9,20,188,357 Allain performed an RCT of 60 patients using transstyloid pinning and compared 1 and 6 weeks in a cast. No difference was found between the groups, but only 24 patients had metaphyseal comminution, so the likelihood is that the majority were stable fractures. The author concluded that no plaster was required after percutaneous pinning but recognized that there was more loss of volar tilt in comminuted fractures.9 
Type of Percutaneous Pinning.
Neither intrafocal nor any type of extra-focal pinning has been shown to be superior. Lenoble215 compared Kapandji fixation to transstyloid fixation with two pins in 96 patients with dorsally displaced distal radius fractures. No immobilization was used postoperatively for Kapandji pinning but a plaster was applied for over 6 weeks for the group treated with styloid pinning. Loss of reduction occurred in both groups with a worse loss of ulnar variance in the Kapandji group. There was better initial reduction in terms of volar tilt in the Kapandji group but some were overreduced in a volar direction. More complications occurred in the Kapandji group with sensory radial nerve symptoms and complex regional pain syndrome predominating. The Kapandji group had better movement at 6 weeks, which is not surprising as they were not immobilized, but they had more pain. Overall, there were disadvantages to Kapandji pinning but neither method performed particularly well considering that over half of the fractures had no comminution. A similar study was performed by Strohm et al.358 comparing modified Kapandji pinning with two transstyloid pins. Radiologic results were not reported but 82% of the fractures had no comminution. The authors found better results in the Kapandji group but review times were not standardized and a significant number of patients were lost to follow-up leading to a recommendation that these results should not be considered as proven.146 In a radiologic comparison of traditional Kapandji pinning versus modified Kapandji pinning with one transfocal radial styloid pin the latter gave better results.131 
Outcome of Percutaneous Pinning
Cohort Studies.
There have been a number of cohort studies examining the outcome of percutaneous pinning for distal radius fractures. Although some earlier papers were optimistic about the outcome of the technique235,351 more recent papers have reported significant loss of position at final review.38,188 This is particularly prevalent in older patients and patients with poor bone stock and comminuted fractures.9,38,84,276 
Randomized Controlled Trials.
There have been a number of studies comparing percutaneous pinning with other methods. Stoffelen and Broos examined 98 patients with distal radius fractures randomized to Kapandji pinning and cast for 1 week or plaster cast for 6 weeks after closed reduction. The authors found no significant differences in the two groups for either functional or radiologic outcome.357 Azzopardi et al.20 found marginal radiographic advantage and no functional advantage in the use of percutaneous pinning. Wong et al. studied older patients and found small radiologic advantages in dorsal angulation but not in ulnar variance with the use of percutaneous pinning. They found no functional differences.395 The only study to report anatomical and functional advantages of percutaneous pinning compared to cast management was in patients under 65 years of age.305 
Three studies have compared the outcome of external fixation to percutaneous pinning. Ludvigsen228 examined 60 patients with distal radius fractures with metaphyseal comminution randomized to bridging external fixation (average age 61 years) or percutaneous pinning (average age 58 years) reviewed at 6 months after injury. There were no significant differences in radiologic outcome, complication rates, or function as measured by the modified Gartland and Werley score. In a series of 50 younger patients aged less than 65 years and randomized to augmented bridging external fixation or percutaneous pinning, there were no differences in the radiologic outcome or DASH scores except for better articular surface reduction in the external fixation group.148 Nonbridging external fixation allowed more rapid early rehabilitation than percutaneous pinning in a randomized study of 40 patients but no longer-term advantages.111 
In the last few years there have been two retrospective comparisons and a number of prospective randomized comparisons of percutaneous pinning and ORIF with volar locking plates. The two retrospective studies found a greater loss of reduction with percutaneous pinning,214,274 particularly ulnar variance, in patients with lower bone density measurements.274 Locked plating demonstrated a faster recovery time and a better final grip strength in one study274 but no significant differences in function in the other.214 Two of the randomized studies showed no significant differences in the radiologic outcomes,239,310 but one warned against overreduction with pinning in the presence of volar comminution.239 All showed a consistent advantage in DASH scores for plating up to 6 months after injury. 
There seems to be little advantage in the use of percutaneous pinning over plaster cast in older patients. Kapandji’s published indications were primarily for younger patients with good bone stock and the use of this technique in older patients results in a significant secondary instability rate. This may be higher than is realized, as the definition of instability in most studies is vague. A number of studies use fractures without metaphyseal comminution, which suggest that many are stable fractures which would do well with minimal treatment. Comparison with external fixation or ORIF seems to show advantages in terms of earlier function in the external fixation and ORIF groups, but this may be because of earlier mobilization. 
Complications of Percutaneous Pinning.
The most common complication of this technique is damage to the superficial branch of the radial nerve which although poorly reported in some papers occurs in up to 15% of cases.9,55,144,215 A number of authors note that it occurs after pin removal.9,215 Placement of the pins should be done under direct visualization using small skin incisions and blunt dissection down to the bone. Care should be taken when removing pins that the incisions are large enough to ensure protection of the nerve. 
Pin track infection is an often ignored complication of percutaneous pinning and is often poorly defined. Classification systems defining pin track infection are available147 and should be used for research purposes, but in practice it is important to differentiate between minor and major pin track infections. Major pin track infection occurs when further surgery is required to eradicate the problem or the pins have to be removed early. The majority of pin track infections are minor after percutaneous pinning with rates recorded from 1.7% to 70%.9,38,144,147,215,305 Major pin track infection occurs rarely with most authors reporting none. Burial of pins subcutaneously may contribute to avoidance of pin track infection, especially if the pins are in place for prolonged periods.147 
External Fixation.
External fixation for distal radius fractures was first used over 80 years ago and the first large series was reported by Anderson and O’Neill in 1944. The authors used K-wires into the metacarpal and the radius and described their technique as “castless fixation allowing full finger function.”13 The technique was not popularized until the late 1970s when Vidal et al.380 described the principal of tension on the ligaments and capsule allowing reduction and coined the term “ligamentotaxis.” 
There are two different methods of utilizing external fixation, bridging or spanning fixation and nonbridging or nonspanning fixation (Fig. 32-17). Bridging external fixation employs pins in the second metacarpal and the radial shaft thus bridging the radiocarpal, intercarpal, and carpometacarpal joints and depends on ligamentotaxis. It may be static, dynamic, or augmented. Nonbridging external fixation employs pins in the distal fragment of the fracture and in the radial shaft and allows direct fixation of the fracture. 
Figure 32-17
 
A: A bridging external fixator. The distal pins are fixed in the second metacarpal and the proximal pins in the radius immobilizing the radiocarpal, intercarpal, and carpometacarpal joints. B: Augmentation of a bridging external fixator with K-wires. C: A nonbridging external fixator with the distal pins proximal to the radiocarpal joint allowing early mobilization of the wrist (D–G).
A: A bridging external fixator. The distal pins are fixed in the second metacarpal and the proximal pins in the radius immobilizing the radiocarpal, intercarpal, and carpometacarpal joints. B: Augmentation of a bridging external fixator with K-wires. C: A nonbridging external fixator with the distal pins proximal to the radiocarpal joint allowing early mobilization of the wrist (D–G).
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Figure 32-17
A: A bridging external fixator. The distal pins are fixed in the second metacarpal and the proximal pins in the radius immobilizing the radiocarpal, intercarpal, and carpometacarpal joints. B: Augmentation of a bridging external fixator with K-wires. C: A nonbridging external fixator with the distal pins proximal to the radiocarpal joint allowing early mobilization of the wrist (D–G).
A: A bridging external fixator. The distal pins are fixed in the second metacarpal and the proximal pins in the radius immobilizing the radiocarpal, intercarpal, and carpometacarpal joints. B: Augmentation of a bridging external fixator with K-wires. C: A nonbridging external fixator with the distal pins proximal to the radiocarpal joint allowing early mobilization of the wrist (D–G).
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Bridging External Fixation
Indications.
The most common indication for bridging external fixation is actual or predicted instability in the dorsally displaced extra-articular or minimal articular fracture of the distal radius, especially where the distal fragment is too small to allow nonbridging external fixation. It can also be used for severe articular fractures (see below) and open injuries. 
Technique.
The patient is placed supine on the operating table with the arm abducted to 90 degrees and placed on an arm table. A tourniquet is used on the upper arm. The surgeon sits in the axilla and the C-arm is brought in from the opposite side and diagonally to allow room for an assistant. 
The technique is similar regardless of whether the fixator is to be used as a static, dynamic, or augmented device. Two pins are first placed in the second metacarpal, the proximal of which should be close to the second carpometacarpal joint, which can be easily palpated. Either one or two incisions may be used depending on surgeon preference and are placed on the lateral side of the metacarpal in the gap between the extensor tendon and the first dorsal interosseous muscle. The incision is made down to bone and the pin track is first drilled using a drill diameter which is narrower than the thread diameter of the pin to be used. The drill should be placed at about 45 degrees to the frontal plane. A pin is then inserted by hand and should engage both cortices. A second pin is then placed more proximally in the same manner, using a template if necessary. 
The proximal pins are placed in the radial diaphysis. A 2- to 3-cm longitudinal skin incision is made at the level of the junction of the middle and distal thirds of the radius. This is then deepened using blunt dissection to protect the superficial branch of the radial nerve. The radius is exposed by retraction of the brachioradialis muscle and superficial radial nerve allowing the proximal pins to be placed in the midlateral position. Clamps are then applied to the pins. There should be sufficient room to allow access for cleaning of the pin tracks. This can be ensured by placing a finger between the clamp and the skin as the clamp is tightened. A bar is then placed between the clamps. 
The fracture is then reduced using the techniques described above and the fixator tightened. Care must be taken not to overdistract the wrist, which can be recognized by widening of the radiocarpal joint (Fig. 32-18) or by measuring the carpal height ratio. In cadaveric work it has been shown that wrist distraction of more than 5 mm increases the load required to generate metacarpophalangeal joint flexion,282 although the results of clinical studies are conflicting, with some showing adverse effects of distraction180 and others finding no disadvantage in distraction provided the distal radioulnar relationship is maintained33 or provided the distraction is moderate.48 At the end of the procedure the pin incisions should be examined to ensure that there is no tension on the skin edges and should be extended if necessary. Sutures are not required and may lead to skin tension around the pins. 
Figure 32-18
A bridging external fixation which has caused distraction of the wrist joint.
 
There is regional osteoporosis raising the possibility of complex regional pain syndrome.
There is regional osteoporosis raising the possibility of complex regional pain syndrome.
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Figure 32-18
A bridging external fixation which has caused distraction of the wrist joint.
There is regional osteoporosis raising the possibility of complex regional pain syndrome.
There is regional osteoporosis raising the possibility of complex regional pain syndrome.
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Augmentation.
Bridging external fixation can be augmented by percutaneous K-wires, limited ORIF with plates, bone graft, or bone substitute. The commonest method is with K-wires, which are inserted in a similar manner to percutaneous pinning (Fig. 32-17B). Bone graft or bone substitute may also be used where there is a large metaphyseal defect and are usually introduced through a small dorsal incision. Augmentation by using a fifth pin inserted dorsally into the distal fragment has been described39,389 and is placed in a similar fashion to distal pins for nonbridging external fixation. 
Postoperative Care.
The presence of external fixation pins requires regular dressings to prevent pin track infection. A simple dry dressing is sufficient, changed twice weekly with cleansing of the pin sites with sterile saline if necessary. No benefit has been demonstrated by the use of hydrogen peroxide for cleaning or antiseptic dressings.91 
The patient should be instructed to mobilize the hand, elbow, and shoulder. Physiotherapy is required if any finger stiffness is detected. The fixator is usually removed at around 6 weeks. Removal does not usually require anesthetic. 
Outcome
Cohort Studies.
Most authors agree that with bridging external fixation alone unstable fractures of the distal radius will redisplace by varying degrees. Significant loss of reduction was reported by McQueen et al.250 in 14 of 60 cases; furthermore, 10 of the 60 cases did not fully reduce with closed reduction. Twenty-four of sixty patients were considered to have malunion. At 1-year grip strength was around two-thirds of the opposite normal side, although recovery of movement was an average of 89% of the opposite wrist. Although the anatomical results were better with bridging external fixation than cast management, the functional results did not show clear benefit. The authors attributed this to the failure of either technique to restore volar tilt and therefore carpal alignment, which was significantly related to function. 
In a series of 641 distal radius fractures treated with external fixation, 230 patients were treated in bridging fixators. Twenty-four percent had a malunion at final review despite successful initial reduction.151 Similar findings of improved radiologic outcomes, but similar functional outcomes to those treated in a cast, have been reported by others.8,203,250 Other authors have found that bridging external fixation fails to regain or maintain the volar tilt.194,392 Wilcke et al. treated 30 patients with distal radius fractures with bridging external fixation but excluded those with severe comminution, which are the most likely to be unstable. Even so nine patients had residual dorsal angulation after healing.392 
Augmentation of bridging external fixation has been suggested to reduce loss of reduction. Dicpinigaitis et al. reported that in a series of 70 cases treated with bridging external fixation augmented with percutaneous pins, half of the fractures lost more than 5 degrees of initially reduced volar tilt. However, no cases deteriorated sufficiently to be considered radiologically unacceptable.82 Lin et al. reported a retrospective comparison of 20 cases treated with bridging external fixation without augmentation and 36 cases with augmentation of the bridging external fixator using percutaneous pins. They demonstrated that bridging external fixation alone did not regain volar tilt and that augmentation was better at retaining the initial reduction and provided a better range of movement and grip strength.221 
Augmentation of bridging external fixation with a fifth pin inserted dorsally in the distal fragment and attached to the fixator was first described in 1994.39 In 10 cases in which volar tilt could not be restored by closed reduction, volar tilt was regained and maintained by the addition of a fifth pin. Improvement in both radiographic and functional results using the five-pin technique was demonstrated in an RCT in 2003.389 This technique combines the advantage of nonbridging external fixation with a disadvantage of bridging external fixation and probably does not have any advantages over the nonbridging technique. 
Bone grafting or insertion of bone substitutes into the metaphyseal defect after reduction and bridging external fixation can assist in maintenance of the reduction318,372 and may allow earlier removal of the fixator at 3 weeks without loss of reduction.218 Bone substitutes seem to be equally effective to autograft318,372 and are probably preferable to avoid graft donor site complications. 
Randomized Controlled Trials.
Since the late 1980s, there have been a number of RCTs comparing bridging external fixation with other methods of treatment for distal radius fractures. Analysis of any RCT for the treatment of distal radius fractures is frequently hampered by varying definitions of instability, with widely varying inclusion and exclusion criteria, which makes comparisons difficult. Instability for these purposes should be defined as a fracture which has redisplaced in plaster or which can be predicted to have a chance of instability of more than 70%.234 
Despite this, there largely seems to be a consensus amongst authors of RCTs or pseudo-RCTs, which compare bridging external fixation with cast management. All authors agree that bridging external fixation results in a better anatomical position than nonoperative management,8,57,160,164,203,250,308,341 but most reported that improvement is not reflected in the functional results.160,203,250,308,341 For patient-orientated measures the only series that reported DASH scores showed no differences,8 whereas Christensen reported improvement in the Gartland and Werley scores for external fixation at 3 and 9 months after injury.57 Some authors reported either a trend toward better function164,203 or improvement in a small number of objective surgeon-orientated outcomes.8 However, these advantages in anatomy and function were usually accompanied by an increase in early complications,160,341 usually because of minor pin track infection or radial nerve irritation. 
Augmented bridging external fixation has not been compared in a prospective RCT with cast management. The only reported RCT on the subject is a comparison of standard nonaugmented bridging external fixation with bridging external fixation augmented by a fifth pin in the distal fragment.389 Fifty patients with an unstable dorsally angulated distal radius fracture were randomized. Restoration and retention of reduction was better in the five-pin group as was the range of movement and grip strength. The authors concluded that their clinical findings supported the concept of augmentation of bridging external fixation of unstable distal radius fractures. 
Dynamic bridging external fixation for unstable distal radius fractures was popular in the 1990s and was achieved by using bridging external fixators with a built-in hinge, which was released at 2 to 3 weeks after application of the fixator. No advantage has been identified with the use of this technique.163,250,343 
Bridging external fixation has been compared with open reduction and plating for distal radius fractures in a number of randomized studies in the last 5 years.2,90,137,174,211,388,393 Four of these studies showed no differences in the patient-orientated scores (DASH and PRWE) at any time period,2,90,137,211 and three showed subjective improvement for the first few months after surgery, which was not sustained by 6 months.174,388,393 Early improvement in the recovery of the range of movement with plates was reported by some authors,2,90,388,393 but in all of these studies, the patients treated with plates were allowed to mobilize their wrist early in the postoperative period whereas the external fixation device immobilized the wrist until its removal. Landgren et al.211 extended the outcome studies on a previously reported study2 to 5 years and found no differences in function between external fixation and plating. 
Radiologic results were equivalent between plating and augmented external fixation in most studies.2,90,137,174,388 When poorer radiologic results were reported, the bridging external fixator was not augmented in all cases.393 Only two studies reported malunion rates. Jeudy et al.174 reported a 31% malunion rate for external fixation and 30% for ORIF, with both methods allowing loss of reduction after surgery. Loss of correction in both groups was also reported by Abramo et al.2 
Complication rates were similar for the two methods of treatment in most studies.2,90,137,388,393 Egol et al.90 reported a higher reoperation rate for plates, with most reoperations being caused by hardware problems. Grewal et al. found more tendon complications in their ORIF group, a number of which would be deemed major complications. All but one complication (acute compartment syndrome) in the external fixation group were minor, mainly minor pin track infections.137 
Esposito et al. undertook a meta-analysis of nine studies and concluded that overall there was very little clinical difference between the two methods of treatment. They cite lower DASH scores for plates but the difference did not reach the acknowledged clinically important difference of 10. They found that overall complication rates were similar but that external fixation had a higher rate of infection, although this was minor.95 
Overall, therefore ORIF seems to allow earlier recovery than bridging external fixation in the first few months after fracture, probably because of the earlier mobilization the technique allows. Both Egol et al.90 and Abramo et al.2 allude to the better results for nonbridging external fixation compared with bridging external fixation because of direct fixation of the distal fragment, which may remove this advantage of plating. The rate of major complications or reoperation when plating is used is a disadvantage of the technique and may be a reason to use external fixation to limit the severity of complications when treating extra-articular or minimal articular unstable fractures of the distal radius. 
Nonbridging External Fixation
Indications.
The main indication for nonbridging external fixation is in fractures of the distal radius with actual or predicted instability, which are extra-articular or have an articular extension, which is undisplaced or reducible closed. There must be sufficient space in the distal fragment to site the pins. This usually requires 1 cm of intact volar cortex. The technique can also be used for displaced articular fractures if there is sufficient space for pins once the joint surface has been reduced and fixed. Nonbridging external fixation can also be used for distal radial osteotomy for dorsal malunion. 
Technique.
Positioning is similar to that for bridging external fixation except that the surgeon sits at the head end of the patient, as the distal pins are placed from dorsal to volar. 
The distal pins are placed first usually from dorsal to volar, although some fixators use radial-sided pins. For dorsal to volar placement, a marker is placed on the skin at the estimated point of entry of the pin into the distal fragment. With the forearm in the lateral position, an image is obtained. The proximal end of the pin track incision should be level with the point of entry of the pin into the bone. The ulnar pin is placed first and should be on the ulnar side of Lister’s tubercle in the ulnar corner of the radius (Fig. 32-19A); care should be taken not to penetrate the distal radioulnar joint. A 1-cm longitudinal incision is made in the skin at the appropriate point and deepened until the extensor retinaculum is visualized. A longitudinal incision is then made in the retinaculum taking care to avoid damage to any underlying extensor tendons. Using blunt dissection, the tendons are retracted until the bone is palpated. A pin is then placed on the bone, half way between the fracture and the radiocarpal joint on the lateral view (Fig. 32-19B) and its starting point is checked with the fluoroscope. The pin is adjusted until it is parallel to the radiocarpal joint on the lateral view and is then inserted by hand without predrilling into the distal fragment. The pin should penetrate the volar cortex (Fig. 32-19C). The forearm is then rotated to confirm free rotation and exclude penetration of the distal radioulnar joint. A second pin is then inserted in a similar manner on the radial side of Lister’s tubercle using the clamp of the fixator as a template if necessary. 
Figure 32-19
 
A: Placement of the distal pins for a nonbridging external fixator. On the AP view the ulnar pin starting point is shown. B: A marker on the starting point on the lateral view which should be halfway between the fracture and the joint. C: The pin is parallel to the radiocarpal joint and engages the volar cortex D: Reduction has been achieved by using the distal pins as a joystick E: Where there is volar comminution or bayoneting it is possible to overreduce the fracture in the volar direction.
A: Placement of the distal pins for a nonbridging external fixator. On the AP view the ulnar pin starting point is shown. B: A marker on the starting point on the lateral view which should be halfway between the fracture and the joint. C: The pin is parallel to the radiocarpal joint and engages the volar cortex D: Reduction has been achieved by using the distal pins as a joystick E: Where there is volar comminution or bayoneting it is possible to overreduce the fracture in the volar direction.
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Figure 32-19
A: Placement of the distal pins for a nonbridging external fixator. On the AP view the ulnar pin starting point is shown. B: A marker on the starting point on the lateral view which should be halfway between the fracture and the joint. C: The pin is parallel to the radiocarpal joint and engages the volar cortex D: Reduction has been achieved by using the distal pins as a joystick E: Where there is volar comminution or bayoneting it is possible to overreduce the fracture in the volar direction.
A: Placement of the distal pins for a nonbridging external fixator. On the AP view the ulnar pin starting point is shown. B: A marker on the starting point on the lateral view which should be halfway between the fracture and the joint. C: The pin is parallel to the radiocarpal joint and engages the volar cortex D: Reduction has been achieved by using the distal pins as a joystick E: Where there is volar comminution or bayoneting it is possible to overreduce the fracture in the volar direction.
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Two proximal pins are then placed in the radius proximal to the fracture in a similar fashion to that used for bridging external fixation except that their position is usually more dorsal to volar than midlateral. Once the skin and subcutaneous tissues are opened, the interval between the flat tendons of extensor carpi radialis longus and extensor carpi radialis brevis can be seen. This interval is developed and the radius is exposed (Fig. 32-20). These pins are usually predrilled as it is more difficult to control their path in cortical bone. 
Figure 32-20
Pin position between the extensor carpi radialis longus and brevis.
 
Note the proximity of the dorsal sensory branch of the radial nerve. Iatrogenic injury to this nerve is a frequent cause of neurogenic pain after external fixation and may be minimized by open rather than percutaneous pin insertion.
Note the proximity of the dorsal sensory branch of the radial nerve. Iatrogenic injury to this nerve is a frequent cause of neurogenic pain after external fixation and may be minimized by open rather than percutaneous pin insertion.
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Figure 32-20
Pin position between the extensor carpi radialis longus and brevis.
Note the proximity of the dorsal sensory branch of the radial nerve. Iatrogenic injury to this nerve is a frequent cause of neurogenic pain after external fixation and may be minimized by open rather than percutaneous pin insertion.
Note the proximity of the dorsal sensory branch of the radial nerve. Iatrogenic injury to this nerve is a frequent cause of neurogenic pain after external fixation and may be minimized by open rather than percutaneous pin insertion.
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The fixator is then assembled maintaining adequate space between the clamps and the skin to allow access for pin track dressings. The fracture is reduced by using the distal pins as a “joystick” to control the position of the distal fragment (Fig. 32-19D). Care should be taken to avoid overreduction where there is volar comminution (Fig. 32-19E). As the distal pins move with the reduction, they should move into the centre of correctly placed skin incisions, but each pin track should be released if there is any residual tension. Sutures should not be used on the pin tracks to avoid tension on the skin, which may lead to pin track infection. 
Postoperative Care.
Pin track care is carried out as for bridging external fixation. No other form of immobilization is necessary and the patient is encouraged to move the hand and wrist fully. Physiotherapy is not usually required unless finger stiffness develops. The fixator is usually removed after 5 to 6 weeks. Anesthesia is not required for removal. 
Outcome of Nonbridging External Fixation
Cohort Studies.
There are a number of cohort studies which report the outcome of nonbridging external fixator for extra- or minimal articular unstable fractures of the distal radius. The first study of the technique was published in 1981 in 22 cases of redisplaced distal radius fractures with an average age of 64 years. The authors reported 21 good or excellent results and concluded that the nonbridging external fixator maintained the reduced position and allowed rapid restoration of good function in the wrist and hand.107 
Since then, a consensus has developed that nonbridging external fixation restores and maintains volar tilt12,100,104,151,249,252,259 and carpal alignment104,151,249,252 in patients of varying ages. Radial length is restored with a small increase in ulnar variance after removal of the fixator.12,100,104,151,249,252 In a retrospective radiologic comparison of 588 bridging or nonbridging external fixators Hayes et al.151 reported a 6.2 times increased chance of dorsal malunion in bridging external fixation compared with nonbridging external fixation and a 2.5 times increased chance of radial shortening in the bridging group. 
Functional results in cohort studies are equally good. Andersen et al.12 reported 88% excellent or good results with the Gartland and Werley score and concluded that nonbridging external fixation is a reliable method of maintaining radiologic reduction with a good functional outcome after 1 year. Flinkkila et al. reported 90% restoration of grip strength and up to 97% restoration of movement at a mean of 16 months after fracture and concluded that nonbridging external fixation is an easy, minimally invasive, and reliable method that restores the anatomy and function after unstable fracture of the distal forearm. The authors consider it their treatment of choice for these fractures.104 
The ease of the technique was demonstrated by Hayes et al.151 who reported on the success of the technique in the hands of surgeons in training thus confirming its generalizability. 
Randomized Controlled Trials.
The first randomized study to include nonbridging external fixation was reported in the late 1980s. Jenkins et al. initially reported radiologic results of external fixation versus cast management with their first two cases utilizing pins in the second metacarpal. The authors then concluded that “it seemed unnecessary to cross the wrist joint with a frame if a satisfactory hold could be obtained in the distal fracture fragments” and used nonbridging external fixation for their next 30 cases. They compared these with 26 cases treated in plaster. All of their patients were under 60 years of age. There was a mean loss of reduction of 10.5 degrees of dorsal angulation and 3.7 mm of radial length in the plaster group with the fixator group maintaining the reduced position. The authors concluded that a nonbridging external fixator was highly effective in maintaining the reduced position of distal radial fractures.171 The following year the same group published functional results in 106 patients under the age of 60 years with displaced distal radial fractures randomized between cast and nonbridging external fixation and confirmed the superiority of the external fixator in maintaining the reduced position. They reported better grip strength and a higher proportion of excellent results both subjectively and objectively in the external fixation groups although each group achieved similar proportions of satisfactory results.172 
McQueen reported on an RCT of nonbridging versus bridging external fixation in 60 patients with redisplaced fractures of the distal radius and an average age of 61 years. Because they had all redisplaced and all had metaphyseal comminution, there was little heterogeneity in the fractures. Both extra- and intra-articular fractures were randomized but displaced intra-articular fractures were excluded. Anatomical studies were statistically significantly better in the nonbridging group throughout the period of review. Nonbridging external fixation restored and maintained the volar tilt whereas bridging external fixation failed to restore volar tilt after reduction and had lost a mean of 8.6 degrees of tilt during and after the period of fixation. Nonbridging external fixation lost some radial length after removal of the fixator but at 1 year radial shortening was still only half that of the bridging group. Carpal alignment was restored in 28 of 30 patients in the nonbridging group but in only 13 of 30 patients in the bridging group at 1 year. There were 14 cases in the bridging group with malunion but none in the nonbridging group. It should be noted however that augmentation of the bridging group was not used in this study.249 All ranges of movement were significantly better in the early rehabilitation period in the nonbridging external fixation group, which was likely to be related to the freedom of wrist movement which the technique allows. Only the range of flexion showed sustained superiority with nonbridging external fixation possibly because volar tilt was retained. Pain scores were low at 1 year and the groups did not differ significantly in this respect. The author concluded that nonbridging external fixation was significantly better than bridging external fixation and should be the treatment of choice for unstable distal radius fractures where external fixation is contemplated and where there is space for pins in the distal fragment.249 
Since then, three further RCTs comparing bridging and nonbridging external fixation in patients with extra-articular or minimal articular fractures of the distal radius have been reported.19,208,373 All demonstrated better reduction in the nonbridging groups. The DASH score was used in two studies with no differences in one19 and better DASH scores in the nonbridging group in the other.208 The former study reported better early SF-12 physical health scores for the nonbridging group but no differences in pain scores. 
There is only one RCT comparing nonbridging external fixation with percutaneous pinning. Similar ranges of movement and grip strength were found in each group but there was a higher proportion of excellent and good results with nonbridging external fixation. The study concluded that nonbridging external fixation had the advantages of early restoration of function, easy reduction, and free use of the hand during the treatment period.111 
There has been one report of an RCT comparing nonbridging external fixation to volar locked plating.128 One hundred and two patients with an average age of 63 years were recruited. Fractures were dorsally displaced by more than 20 degrees and 93 were either extra-articular (AO/OTA A3) or minimal articular (AO/OTA C2). The authors found that the surgery time was significantly less in the nonbridging external fixation group. Restoration of volar tilt was achieved in all cases in the nonbridging external fixation group but in none of the volar locked plating group. One year after surgery there were no differences in range of movement, grip strength, or pain. Although volar flexion was significantly better in the external fixation group at 6 months (p < 0.03) the difference of 7 degrees is unlikely to be clinically significant. The Garland and Werley, Castaing, and SF-36 scores were similar between the groups barring social functioning in the volar locked plate group at 8 weeks only. More differences are evident in the analysis of complications. There was a 10% prevalence of minor pin track infection in the external fixation group. There were two EPL ruptures in the external fixation group requiring reconstruction and four tendon problems in the volar locked plate group requiring further surgery. The overall complication rate was similar in each group (20% external fixation vs. 21% volar locked plate) but the more serious nature of the complications in the volar locked plate group is reflected in the reoperation rate of 36.5% in that group compared to 6% in the external fixation group.128 
The main complication of nonbridging external fixation reported in cohort studies is minor pin track infection or irritation, defined as requiring antibiotic treatment and increased dressings but not compromising the final outcome. Rates range from 17% to 31% in cohort studies.12,100,104,151 In a comparison between bridging and nonbridging fixation Hayes et al.151 reported a three times increase of minor pin track infection with nonbridging compared with bridging external fixation, although this is not confirmed by RCTs despite some demonstrating a trend to more minor pin track infections in nonbridging external fixation.19,249 No other complications occur more in either type of external fixation. 
Complications of External Fixation
Pin Track Infection.
The most common complication of external fixation is pin track infection. There are a number of classification systems for the assessment of the severity of pin track infections,54,147,319 but practically it is important to differentiate between those which compromise the final outcome by early removal of the fixator or added surgical procedure (major pin track infections) and those which do not, merely requiring treatment with antibiotics and increased frequency of dressing changes (minor pin track infection).151 
Rates of pin track infection reported in the literature vary from 0% to 39% for minor pin track infections.2,6,12,19,91,104,163,208,249,259,390,393 Major pin track infections are rare in external fixation of the distal radius with none in most reports12,19,91,104,163,208,390 and sporadic single cases in others.100,249,250,393 In the biggest series of external fixation of distal radius fractures reported in the literature, minor pin track infection occurred in 126 of 588 cases (21%). Major pin track infection requiring early removal of the fixator or further surgery occurred in only 12 cases (2%).151 
Other Pin Track Complications.
Other pin track complications including pin track fracture, pin pull-out, and skin adherence are rare. The largest prevalence of pin track fracture was reported by Ahlborg with 11 pin track fractures in 314 cases of bridging external fixation, 5 in the radius, and 6 in the second metacarpal. Two of these were related to added trauma, one occurred during surgery, seven during the fixation period, and three after removal of the fixator. The authors found no relationship with pin track infection.6 In 588 cases, Hayes et al.151 reported only three pin track fractures (0.5%), all in the second metacarpal. Pin track fractures that occur during treatment can be managed by resiting the pin; those occurring outwith this time should be treated by standard methods for the specific fracture. 
 
Table 32-5
Pitfalls and Prevention External Fixation
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Table 32-5
Pitfalls and Prevention External Fixation
Pitfall Prevention
Bridging External Fixation
Pin track infection Ensure no skin tension
Insert pins by hand, not power
Overdistraction Examine fluoroscopic views for radiocarpal gap and carpal height ratio
Loss of reduction/malunion Always augment
Use mini open reduction if closed reduction fails
Hand stiffness Refer for physiotherapy at first signs
Radial nerve injury Open pin placement
Nonbridging External Fixation
Overreduction Be wary if volar comminution, bayoneting volar cortex
Tendon injury Open distal pin placement
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Pin pull-out was originally cited as a potential problem for pins placed in the distal fragment with nonbridging external fixation but these fears have proven to be unfounded with only occasional cases occurring in both bridging and nonbridging external fixators.151 
Tethering of the skin can occur after healing of the pin tracks but is poorly documented. Ahlborg and Josefsson6 reported a 1% rate of surgery to correct skin tethering. This procedure is simple and can be done using local anesthetic. 
Radial Nerve Damage.
The superficial branch of the radial nerve runs deep to the brachial radialis muscle in the forearm and around 5 cm proximal to the radial styloid it emerges dorsally from beneath the brachioradialis tendon. At this point it is vulnerable to damage with insertion of the proximal pins of an external fixator. This is a preventable complication if care is taken to place pins using open incisions and the nerve is protected (Fig. 32-20). 
The rate of damage to the radial nerve is reported to occur in between 0% and 13% of cases.2,6,19,137,151,174,208,388,390,393 In one series there was a five-time increased prevalence with ORIF compared to bridging external fixation but this was with the use of a radial approach.2 No study reports any difference in the rate of radial nerve injury between different types of external fixation with Hayes et al.151 reporting a 1% rate in a large series of both bridging and nonbridging external fixations. Theoretically there may be an increased risk where percutaneous pins are used to augment a bridging external fixator but this has not been reported. 
Joint Distraction.
There is a risk that bridging external fixation will cause overdistraction of the radiocarpal and midcarpal joints with excessive force being applied in attempts to reduce a fracture (Fig. 32-18). This is usually measured by measuring the distance from the distal radius to the base of the third metacarpal and dividing that value by the length of the third metacarpal (carpal height ratio). The standard carpal height ratio is 0.54.398 
Initial reports raised concerns that distraction of the wrist might lead to complex regional pain syndrome180 or hand stiffness180,282 and that outcome was compromised more with a longer duration of distraction. Biyani et al.33 reported that distraction alone did not cause functional problems in seven patients with carpal distraction from 5 to 8 mm but if the distraction was sufficient to cause a negative ulnar variance then the result could be impaired. More recently, in a larger study of 42 patients with augmented external fixation for unstable distal radial fractures, Capo et al. found that the mean carpal height ratio in the group of patients with excellent results was 0.63 and of those with good or fair results was 0.58. The authors concluded that moderately increased distraction resulted in improved clinical outcome and did not cause subsequent joint stiffness but cautioned against extreme distraction, which could induce carpal malalignment, worsen intercarpal ligament injury, and induce finger stiffness.48 
Plating.
ORIF with plating is an alternative technique for stabilizing an extra-articular or minimal articular fracture of the distal radius. Plating was first popularized for volar displaced distal radial fractures by Ellis in 1965 with a plate which was placed on the volar surface of the radius and acted as a buttress to prevent volar displacement of the distal fragment.93 Variations of the Ellis buttress plate were used for a number of years but only for volar displaced fractures. 
The problem of maintaining the reduced position of a dorsally displaced distal radius fracture was first tackled with dorsal plating. This technique was designed to buttress the dorsally displaced fracture but had problems with soft tissue complications. Volar locking plates were then introduced to stabilize dorsally displaced fractures. As fixed angle devices, theoretically volar locked plates provide sufficient stability to the dorsally displaced distal fragments. 
Volar Locked Plating
Indications.
The main indication for volar locked plating in extra-articular or minimal articular displaced fractures is similar to that for nonbridging external fixation, namely for actual or predicted instability of a distal radius fracture, and there must be sufficient space for pins in the distal fragment. This technique is therefore contraindicated in cases with a very small distal fragment. Volar locked plating can be used for corrective osteotomy for malunion of the distal radius. It may also be used for volar displaced fractures, although in younger patients with good bone quality it is not necessary to use locking screws. It is advisable to use locking plates for volar displaced fractures in the older patient who is likely to be osteoporotic. 
Technique
Positioning.
Positioning of the patient is similar to that for other techniques with the patient supine and the arm abducted to 90 degrees, supinated, and placed on an arm table. A tourniquet is applied to the upper arm. The surgeon sits in the axilla and the C-arm is positioned diagonally from the opposite side of the arm table. 
Approach.
The approach used for the majority of distal radius fractures is the modified Henry’s approach or trans-flexor carpi radialis (FCR) approach between the radial artery and FCR tendon. A longitudinal skin incision is used in line with the FCR tendon. The length of the incision depends on the plate size. The fascia is released to expose the FCR tendon, which is mobilized by incising the sheath. The tendon is then retracted in an ulnar direction and an incision made in the floor of the tendon sheath. This exposes the flexor pollicis longus (FPL) muscle belly, which is swept to the ulnar side by blunt dissection. The transverse muscle fibers of pronator quadratus are then evident and should be released from the radial side of the radius and elevated subperiosteally from the radius in a volar direction. A cuff of pronator quadratus should be left attached to the radius if repair is planned but there is no evidence that repair confers any advantage in range of rotation, pain levels, DASH scores, or prevention of FPL rupture.155 The exposure should be as far radial as the first dorsal compartment subperiosteally. The brachialis tendon may be released if necessary. This allows visualization of the dorsal surface of the radius, which is useful when fixation is late and early callus has formed dorsally. Further subperiosteal release dorsally allows the radius to be pronated away from the distal fragment. Articular displacement can then be seen and reduced and subarticular graft used. 
The main limitation of this approach is visualization of the volar ulnar corner of the distal radius. The ideal position of a volar plate incorporates the volar ulnar corner with the ulnar side of the plate. Where there is an intra-articular fracture at the volar ulnar corner, it is mandatory to capture that fragment with the plate. In these circumstances, an approach between the flexor tendons and ulnar neurovascular bundle should be used. The incision for this approach is more ulnar over the ulnar border of palmaris longus. The flexor tendons are mobilized in a radial direction and the ulnar neurovascular bundle in an ulnar direction. The pronator quadratus is incised at its attachment to the ulna and elevated radially. This approach gives easy access to the carpal tunnel should the median nerve require release. 
Plate Application.
The technique of volar plating for extra-articular or minimal articular fractures depends on whether the surgeon wishes to reduce the fracture manually or with the plate. Reduction with the plate allows easier restoration of the volar tilt. Screws are placed distally in the plate parallel to the joint surface in the lateral view, taking care not to penetrate the dorsal cortex (Fig. 32-21A). Pronated and supinated oblique views and a tilted lateral view are useful at this stage to ensure that the distal screws have not penetrated the radiocarpal or distal radioulnar joints (Fig. 32-5). The plate is then lying off the shaft of the radius. The proximal limb of the plate is then gently pushed on to the shaft, the so called lift technique336 and fixed in place (Fig. 32-21B). This usually reduces the distal fragment in a similar manner to the joystick effect of nonbridging external fixation. 
Figure 32-21
 
A: A volar plate has been fixed to the distal end of the radius in the unreduced position. The screws are parallel to the joint. B: The shaft of the plate has been reduced to the radial thereby reducing the fracture. C: AP and lateral views of the reduced fracture after healing.
A: A volar plate has been fixed to the distal end of the radius in the unreduced position. The screws are parallel to the joint. B: The shaft of the plate has been reduced to the radial thereby reducing the fracture. C: AP and lateral views of the reduced fracture after healing.
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A: A volar plate has been fixed to the distal end of the radius in the unreduced position. The screws are parallel to the joint. B: The shaft of the plate has been reduced to the radial thereby reducing the fracture. C: AP and lateral views of the reduced fracture after healing.
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Figure 32-21
A: A volar plate has been fixed to the distal end of the radius in the unreduced position. The screws are parallel to the joint. B: The shaft of the plate has been reduced to the radial thereby reducing the fracture. C: AP and lateral views of the reduced fracture after healing.
A: A volar plate has been fixed to the distal end of the radius in the unreduced position. The screws are parallel to the joint. B: The shaft of the plate has been reduced to the radial thereby reducing the fracture. C: AP and lateral views of the reduced fracture after healing.
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A: A volar plate has been fixed to the distal end of the radius in the unreduced position. The screws are parallel to the joint. B: The shaft of the plate has been reduced to the radial thereby reducing the fracture. C: AP and lateral views of the reduced fracture after healing.
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In volar displaced fractures the fracture must be reduced prior to application of the plate. The plate is then secured to the radial shaft using one screw, usually in an oval hole, which allows adjustment of the plate’s position. The positioning of the plate is then confirmed on an image intensifier and adjusted distally or proximally as necessary to ensure correct placement of the distal screws. The plate should not be placed distal to the watershed line as this risks FPL rupture.18 The distal screws are then inserted using oblique views or rotational fluoroscopy344 to ensure that the radiocarpal or distal radioulnar joints are not penetrated. The length of the central two screws should be around 2 mm less than the measured length to avoid penetration of the dorsal cortex and to reduce the risk of tendon rupture. There is some evidence that inserting screws in all available holes in the distal fragment confers additional stability.256 
In cases with a large metaphyseal defect there is a risk of subsidence of the fracture and migration of the screws into the radiocarpal joint. This may be prevented by augmentation by either bone substitute or grafting.157,195 
Postoperative Care.
Theoretically, after volar plating whether locked or not, there is no need for immobilization of the wrist as the fixation is very stable. However, in practice a plaster or splint is frequently used in the first few weeks.62,98 Early finger motion is encouraged and wrist motion when comfort allows but certainly by 3 to 4 weeks after fracture. 
Complications of Volar Locked Plating
Reported rates of complications after volar locked plating are high, ranging from 5.9% to 48%16,90,128,195,366,393 with the majority of complications being hardware related. The main hardware-related complications are tendon rupture or irritation and screw penetration into the radiocarpal joint or DRUJ and frequently result in high reoperation rates.16,90,128,195,317,393 
Screw Penetration.
Screw penetration into the radiocarpal joint or DRUJ is reported in a number of studies and ranges from 3% to 57%.16,85,195,311,317 Although screws may inadvertently be placed into a joint at the time of surgery this should largely be avoidable with the use of suitable imaging such as oblique and tilted lateral views. However, in patients with significant metaphyseal comminution, collapse around the plate is a concern with rates of collapse of up to 57% being reported.17,145,195,311 As the plate is a fixed angle device the screws penetrate the radiocarpal joint as the fracture collapses (Fig. 32-22) which is more likely in a fracture with a small distal fragment as screws are of necessity close to the subchondral bone.195 In intra-articular fractures there is also a danger of screws being placed in sagittal fracture lines allowing their migration into the joint.317 Such penetration of the radiocarpal joint usually requires removal of the metalwork. It has been suggested that augmentation of the defect with bone substitutes may prevent collapse.195,317 This has been supported by cadaver experiments showing that subsidence of the distal fragment can be significantly decreased by augmentation.157 However, in a recent RCT, no significant differences in radiologic or clinical measurements were found in elderly patients treated with volar locking plate with or without calcium phosphate bone cement augmentation.191 
Figure 32-22
An unstable fracture of the distal radius fixed with a volar locked plate.
 
The fracture has collapsed into dorsal angulation allowing the fixed angle screws to penetrate the radiocarpal joint. The leading edge of the plate is prominent risking flexor tendon rupture.
The fracture has collapsed into dorsal angulation allowing the fixed angle screws to penetrate the radiocarpal joint. The leading edge of the plate is prominent risking flexor tendon rupture.
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Figure 32-22
An unstable fracture of the distal radius fixed with a volar locked plate.
The fracture has collapsed into dorsal angulation allowing the fixed angle screws to penetrate the radiocarpal joint. The leading edge of the plate is prominent risking flexor tendon rupture.
The fracture has collapsed into dorsal angulation allowing the fixed angle screws to penetrate the radiocarpal joint. The leading edge of the plate is prominent risking flexor tendon rupture.
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Table 32-6
Pitfalls and Prevention Volar Plating
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Table 32-6
Pitfalls and Prevention Volar Plating
Pitfalls of Volar Plating Prevention
Fracture collapse/malunion Beware of overreduction of volar displaced fracture if dorsal comminution present
Ensure volar ulnar corner fragment captured by plate
Avoid screws in sagittal intra-articular fractures
Augment with bone substitute/graft if large metaphyseal defect
Tendon injury Reduce measured size of distal screws by 2 mm
Ensure proximal screws not prominent dorsally
Ensure distal end of plate is proximal to watershed line
Look for signs of tendon irritation post-op and if present remove plate early
Joint penetration by screws Use oblique and tilted lateral views peroperatively
Examine flexion/extension and rotation at end of procedure
Prevent fracture collapse
X
Tendon Complications.
Hardware-related tendon problems are either tendon irritation or rupture and may involve flexor or extensor tendons with EPL and FPL being most commonly affected. A wide range of prevalences are reported from 0.8% to 19.6%.16,85,195,311,359,366,391 
Extensor tendon pathology is likely to be related to screw prominence dorsally (Fig. 32-23) which can be difficult to visualize using radiographs because of the irregularity of the dorsal surface of the radius (Fig. 32-2) and the prominence of Lister’s tubercle. Using ultrasound on 46 distal radius fractures treated with volar locking plates one study demonstrated that of 230 distal screws 59 were proud of the cortex distally and resulted in seven cases of tenosynovitis and two EPL ruptures.359 Another study used CT and MR scanning to demonstrate that in a substantial number of cases the depth of the valley between Lister tubercle and the sigmoid notch was more than 2 mm.284 Both sets of authors recommended that the measured length of the distal screws should be reduced by 2 mm and that symptoms of tenosynovitis should prompt hardware removal. 
Figure 32-23
 
A, B: A patient with an extensor pollicis longus tendon rupture following palmar plate application. Note that on the initial lateral view from the OR (A), the screws appear to be well contained by the dorsal cortex. However, the Lister tubercle is the outline dorsally on the lateral view (C, D) and does not protect against dorsal cortical penetration either radially or ulnarly.
A, B: A patient with an extensor pollicis longus tendon rupture following palmar plate application. Note that on the initial lateral view from the OR (A), the screws appear to be well contained by the dorsal cortex. However, the Lister tubercle is the outline dorsally on the lateral view (C, D) and does not protect against dorsal cortical penetration either radially or ulnarly.
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A, B: A patient with an extensor pollicis longus tendon rupture following palmar plate application. Note that on the initial lateral view from the OR (A), the screws appear to be well contained by the dorsal cortex. However, the Lister tubercle is the outline dorsally on the lateral view (C, D) and does not protect against dorsal cortical penetration either radially or ulnarly.
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Figure 32-23
A, B: A patient with an extensor pollicis longus tendon rupture following palmar plate application. Note that on the initial lateral view from the OR (A), the screws appear to be well contained by the dorsal cortex. However, the Lister tubercle is the outline dorsally on the lateral view (C, D) and does not protect against dorsal cortical penetration either radially or ulnarly.
A, B: A patient with an extensor pollicis longus tendon rupture following palmar plate application. Note that on the initial lateral view from the OR (A), the screws appear to be well contained by the dorsal cortex. However, the Lister tubercle is the outline dorsally on the lateral view (C, D) and does not protect against dorsal cortical penetration either radially or ulnarly.
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A, B: A patient with an extensor pollicis longus tendon rupture following palmar plate application. Note that on the initial lateral view from the OR (A), the screws appear to be well contained by the dorsal cortex. However, the Lister tubercle is the outline dorsally on the lateral view (C, D) and does not protect against dorsal cortical penetration either radially or ulnarly.
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X
Flexor tendon irritation or rupture usually affects the FPL tendon although it has been reported in other flexor tendons.183,391 It has been attributed to plate prominence, especially with placement distal to the watershed and was rarely reported as a complication of distal radius fractures before the advent of locked plating. A recent study analyzed the risk of flexor tendon rupture related to plate positioning and found that volar prominence of the distal end of the plate of more than 2 mm and plate positioning within 3 mm of the distal rim of the radius had high sensitivity and specificity for tendon rupture. Elective hardware removal after union was recommended in such cases.193 
Outcome of Volar Plating
Cohort Studies.
Despite initial enthusiasm, the radiologic and functional outcomes of volar locked plating for extra-articular and minimal articular distal radius fractures are similar to other techniques. Reported radiologic results indicate that volar locked plating is successful in restoring volar tilt and radial length17,62,195,311 even in older patients.61,98 
Functional outcome with volar locked plating is generally good with DASH scores ranging from 13 to 28.17,98,195,311 Some of the differences are probably explained by the age of the patient with the oldest cohorts having the highest DASH scores.98 Variations in the length of follow-up may also explain some of the differences. When other outcome measures are used, the percentages of good and excellent scores are usually high. 
Randomized Controlled Trials.
There are now a number of RCTs comparing volar locked plates with other treatment methods, although they suffer from heterogeneity of inclusion criteria, especially in the definition of instability and the inclusion of both extra-articular and severe articular fractures. 
Volar Locked Plating Versus Nonoperative Management.
There is only one RCT comparing volar locked plating and nonoperative management. Arora et al. reported on 90 patients over 65 years with unstable distal radius fractures treated with a volar locked plate or manipulation under anesthetic and plaster management. Radiologic results were superior in the plated group, which was reflected by better grip strength in this group. The DASH and PRWE scores showed early advantages in the plated group but this was not sustained at later follow-up. The operative group had a higher complication rate (36% vs. 11%) with a 22% tendon complication rate and a 31% secondary surgery rate.16 
Volar Locked Plating Versus External Fixation.
The largest number of RCTs compare volar locked plating and external fixation.90,128,137,174,388,390,393 Six of the seven studies used bridging external fixation, five of which used augmentation with percutaneous pins. 
Maintenance of reduction was achieved in both methods of treatment. Most studies found no differences in longer-term functional or patient-related outcomes, although some showed advantages to plating at the early stage of rehabilitation,137,388,393 but this may reflect earlier immobilization in the plated group. 
No studies found differences in the complication rates but when the types of complications are examined, some differences emerged. Westphal et al. reported that of 12 complications, 10 were minor in their external fixation group compared to 4 out of 4 major complications in their plated group. They recommended that all plates should be removed.390 Grewal et al. reported that hardware-related tendon complications were significantly more frequent with their group treated with ORIF with a 23% rate of tendon complication. The external fixation group had a significantly increased infection rate but these were all minor pin track infections not requiring reoperation.137 
There is only one study comparing nonbridging external fixation with volar locked plating.128 The authors examined 102 patients randomized to either nonbridging external fixation or volar locked plating. They found that surgery time was significantly shorter in the external fixation group. Volar tilt was restored in all cases treated with external fixation but in none treated with ORIF. There were no significant differences in patient-related outcome scores. The complication rates were similar but the reoperation rate in the volar locked plate group was 36.5% compared to 6% in the external fixation group, reflecting the more major nature of complications encountered with volar locked plating. 
Volar Locked Plating Versus Percutaneous Pinning.
Two RCTs have compared the use of volar locked plates versus closed reduction and percutaneous pinning.245,311 Rozental et al. reported on 45 relatively young patients and found better early DASH and PRWE scores in the plated group but had mobilized this group earlier. There were no other significant differences barring an increased rate of minor complications in the form of minor pin track infection in the group treated with percutaneous pinning.311 
In a later RCT the authors reported improved radiologic results, patient-related outcome scores, and fewer complications and reoperations in the plated group but this study suffers from a shorter review period of 6 months.245 
Dorsal Plating.
Prior to the introduction of volar locked plates, dorsal plating was used for dorsally displaced extra-articular or minimally articular distal radius fractures. Theoretically, this technique should give improved stability as the plate is placed on the compression side of the fracture and acts as a buttress for dorsally displaced fractures. However, concerns about fracture collapse and tendon irritation or rupture have limited the use of this technique in extra-articular or minimal articular fractures although it is used in some displaced articular fractures. 
Intramedullary Nailing.
In recent years there have been reports of the use of intramedullary nailing techniques for extra-articular or minimal articular fractures of the distal radius.166,266,363,378 This technique requires closed reduction of the fracture and provisional fixation with percutaneous wires. The entry point for the nail is at the radial styloid between the first and second dorsal compartment. Reaming over a guidewire is necessary before introduction of the nail. Distal locking screws are placed subchondrally with a jig. Proximal locking is also used. 
Two cohort studies have shown that the technique has good radiologic results although in common with most techniques allows slight shortening in terms of ulnar variance.266 Good functional results have also been reported.266,378 Reported complications are as yet few with some volar malunions and superficial radial nerve irritation. There is presumably also a risk of distal locking screw penetration into the radiocarpal joint and care must be taken to prevent this at surgery. 
There are two comparative studies available, one an RCT comparing nonbridging external fixation and intramedullary nailing326 and one retrospective comparison of cast management and intramedullary nailing.363 The RCT showed better reduction of volar tilt in the external fixator group but better grip strength in the intramedullary nailing group, but only reviewed patients for 3 months after surgery. Patient-related outcome measures showed no significant differences between the two techniques.326 In the retrospective comparison of intramedullary nailing and casting, it is not surprising that radiologic results were heavily in favor of the intramedullary nailing group. Restoration of function was better in the intramedullary nailing group.363 
Clearly, the reported results of this technique are as yet limited and superficial radial nerve problems may be a concern, but intramedullary nailing may be an addition to the surgeon armamentarium. 

Author’s Preferred Method of Treatment for Unstable Extra or Minimal Articular Fractures of the Distal Radius and Ulna (Fig. 32-24)

Figure 32-24
Management of the unstable extra-articular or minimal articular distal radius fracture.
Rockwood-ch032-image024.png
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In low-demand patients with unstable extra- or minimal articular distal radius fractures, I do not recommend manipulative or operative treatment. The main effect of malunion of the distal radius is to reduce the individual’s ability to undertake the activities of daily living which require strength in the hand and wrist. The frailer the patient, the less likely it is they will need such activities on a daily basis, which I believe explains the results of studies which show limited or no evidence of an advantage to frailer patients in restoration of normal anatomy by any means.16,92,250

 

I therefore do not undertake any intervention in this patient group including manipulation. The deformity should be accepted with appropriate patient counseling and a plaster cast applied until the patient is comfortable mobilizing the wrist.

 

In the fitter, less dependent patients, my treatment of choice is nonbridging external fixation where there is space for pins in the distal fragment and when it can be predicted that the fracture is reducible by closed means. Augmentation with this technique is not required. I believe that the radiologic and functional outcomes of nonbridging external fixation and volar locked plating are similar in most cases but when complications are encountered, those associated with nonbridging external fixation are minor (usually minor pin track infection), do not result in reoperation, and do not affect the final outcome. In contrast, the complications associated with volar locked plating are usually major, result in a higher reoperation rate, and may affect the final outcome.

 

The external fixator is retained for 5 to 6 weeks and the patient is encouraged to mobilize the wrist and hand during this period. Removal is achieved in the outpatient setting and does not require a further anesthetic. Physiotherapy is rarely required.

 

Where the fracture is likely to be irreducible closed, usually because of marked bayoneting of the volar cortex or because there has been a delay in diagnosis and there is a nascent malunion, then I recommend open reduction and locked volar plating, provided there is room for screws in the distal fragment. It is important to counsel the patient about the risk of complications such as tendon rupture, fracture collapse, and the need for plate removal. If possible I use the lift technique (Fig. 32-21) to ensure restoration of the volar tilt. It is essential to ensure correct placement of the plate proximal to the watershed and to ensure that screws do not penetrate the dorsal cortex. If there is a large metaphyseal defect with a risk of fracture collapse, I augment the fixation with a bone substitute. Postoperatively, the wrist is placed in a removable splint for 10 days to 2 weeks after which the patient is advised to mobilize within limits of their comfort.

 

Where there is no space for pins or screws in the distal fragment, I use bridging external fixation augmented with percutaneous pins, one running diagonally from the radial styloid and extending through the cortex of the proximal radius and one from dorsal to volar in the midline. The fixator and pins are retained for 5 to 6 weeks when both are removed. I usually bury the percutaneous pins below the skin to reduce the possibility of pin track infection, so local anesthetic is required for their removal.

Displaced Intra-Articular Fractures

Although severe articular fractures account for less than 5% of distal radius fractures, they are the most challenging to treat. There remains debate about the effect of articular incongruity on the eventual outcome of these fractures but it is still recommended that intra-articular fractures with articular displacement of more than 2 mm in fit, active patients require surgical treatment (Table 32-4) (www.aaos.org/research/guidelines/drfguidline.pdf). However, as for extra-articular or minimal articular fractures, nonoperative treatment with a cast for comfort is sufficient for the frail elderly patient. Articular fractures without articular displacement should be treated as extra- or minimal articular fractures. 
Surgical treatment must address both the intra-articular displacement and any accompanying metaphyseal displacement and instability, so a combination of techniques may be required. Each fracture must be assessed to ascertain the fracture pattern and displacement of the fragments and a treatment strategy defined on this basis. A knowledge of the typical fracture patterns as described by Melone257 is useful. He described four parts—radial styloid, dorsal and ulnar volar fragments, and the radial shaft (Fig 32-7). As the lunate impacts on to the articular surface, the lunate facet may be depressed as one or split into a volar and dorsal component with added central impaction. The impact of the scaphoid on the radial styloid typically causes a shearing fracture. An understanding of this mechanism is helpful to the surgeon in planning procedures. 
Two techniques are used for the surgical treatment of displaced articular fractures: closed or percutaneous reduction of the articular surface with bridging external fixation to stabilize the metaphyseal comminution or ORIF. An RCT of the two techniques204 demonstrated that if indirect reduction and percutaneous fixation was possible then better functional outcome was achieved compared to ORIF, provided the joint was reduced. If the closed method did not reduce the joint, the authors proceeded to ORIF. The authors recommended that open reduction be preceded by an attempt at a minimally invasive percutaneous reduction and if a good reduction is achieved then ORIF is unnecessary. 
In practice, closed reduction and percutaneous fixation is generally possible in the less severe fractures, particularly when there is no volar ulnar fragment displacement. Traction radiographs are helpful to confirm the ability to reduce the metaphysis and the radial column. In general, residual compression is easier to correct percutaneously than residual rotatory displacement. 

External Fixation with Percutaneous Reduction and Pinning

Technique.
The positioning of the patient is identical to that for the application of a bridging external fixator. The first step is to reduce any metaphyseal malalignment and apply a bridging external fixator. 
The articular surface is then assessed with a fluoroscope. If there is a radial styloid fragment, this is addressed first to reconstitute the radial column. The radial styloid may reduce with the longitudinal traction and slight ulnar deviation used to reduce the metaphysis, in which case two wires are driven from the tip of the styloid diagonally to engage in the ulnar cortex of the radius proximal to the fracture. If the styloid remains displaced then percutaneous manipulation may be performed either by partially inserting a pin and using it as a lever or by inserting a small awl percutaneously and elevating the styloid. 
Once the radial column is reduced, attention is turned to the lunate facet. If the lunate facet is reduced then pins are placed transversely from the styloid in the subchondral area as far as but not penetrating the DRUJ. Residual lunate facet displacement is either a depression or a sagittal gap when the facet itself is intact. The facet may be elevated with a small awl. Using a small 1-cm longitudinal incision on the dorsum of the wrist, an awl can be inserted into the radius through the dorsal comminution. Using image intensifier control, the tip of the awl is placed just proximal to the depressed fragment and the fragment is elevated (Fig. 32-25B). If a sagittal split remains, a large bone clamp can be placed percutaneously between the radial column and the dorsal ulnar corner. Transverse pins are then inserted. 
Figure 32-25
 
A: A complex intra-articular fracture of the distal radius with central impaction, a die punch lesion. B: A bridging external fixator has been applied. The central depression is reduced closed with a bone awl. C: The fragment is reduced and held with a transverse K-wire. There is a significant metaphyseal defect. D: The metaphyseal defect has been filled with bone substitute.
A: A complex intra-articular fracture of the distal radius with central impaction, a die punch lesion. B: A bridging external fixator has been applied. The central depression is reduced closed with a bone awl. C: The fragment is reduced and held with a transverse K-wire. There is a significant metaphyseal defect. D: The metaphyseal defect has been filled with bone substitute.
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A: A complex intra-articular fracture of the distal radius with central impaction, a die punch lesion. B: A bridging external fixator has been applied. The central depression is reduced closed with a bone awl. C: The fragment is reduced and held with a transverse K-wire. There is a significant metaphyseal defect. D: The metaphyseal defect has been filled with bone substitute.
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Figure 32-25
A: A complex intra-articular fracture of the distal radius with central impaction, a die punch lesion. B: A bridging external fixator has been applied. The central depression is reduced closed with a bone awl. C: The fragment is reduced and held with a transverse K-wire. There is a significant metaphyseal defect. D: The metaphyseal defect has been filled with bone substitute.
A: A complex intra-articular fracture of the distal radius with central impaction, a die punch lesion. B: A bridging external fixator has been applied. The central depression is reduced closed with a bone awl. C: The fragment is reduced and held with a transverse K-wire. There is a significant metaphyseal defect. D: The metaphyseal defect has been filled with bone substitute.
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A: A complex intra-articular fracture of the distal radius with central impaction, a die punch lesion. B: A bridging external fixator has been applied. The central depression is reduced closed with a bone awl. C: The fragment is reduced and held with a transverse K-wire. There is a significant metaphyseal defect. D: The metaphyseal defect has been filled with bone substitute.
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If there is a four-part fracture with displacement of the volar and dorsal fragments of the volar facet then percutaneous fixation is not usually possible. If the surgeon plans to retain the external fixator, the volar and dorsal fragments may be reduced and fixed through limited open approaches, using either K-wires or a buttress fixation with plate and screws on the dorsal or volar side or both as appropriate to the fracture and its reduction. It is usually best to reduce and fix the volar ulnar fragment first. This allows the use of the volar ulnar fragment as a fulcrum to reduce the dorsal ulnar fragment using palmar flexion and radial deviation followed by K-wire fixation from posterior to anterior. 
If there are large metaphyseal defects after elevation of the fragment, then support from either cancellous bone grafting or bone substitute is recommended (Fig. 32-25C, D).120,204,218,306 
Postoperative Care.
Postoperatively, the external fixator and K-wires are removed at 6 weeks, provided radiographic control reveals fracture healing. Physiotherapy is started at this stage or earlier if there is any compromise of hand movement. 

Open Reduction and Internal Fixation.

ORIF of displaced articular fractures of the distal radius can be achieved using a single plate, usually a volar locked plate, or with a column- or fragment-specific approach with multiple plates. The choice of technique should be determined by the fracture configuration; if all the fragments can be captured by a single plate then this is used but if not, multiple plates are required. 
Technique.
The positioning for this technique is the same as plating for the extra-articular fracture. The approach to severe articular fractures is determined by the location and displacement of the intra-articular fragments and by the degree of metaphyseal comminution. If it is anticipated that a volar plate will capture all necessary fragments, then an open reduction using the modified Henry’s approach as described above for extra- and minimal articular fractures is used. It is essential that the surgeon visualizes the volar ulnar corner of the radius clearly to capture any volar ulnar corner fragments. Failure to do this may result in escape of the fragment from the plate and volar subluxation of the carpus (Fig. 32-26). 
Figure 32-26
An intra-articular fracture of the distal radius with a volar ulnar corner fracture and subluxation of the carpus.
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Where it is not possible to capture all fragments with a volar plate, for example, when there is a displaced dorsal ulnar fragment, then column-specific or fragment-specific fixation may be used. This was pioneered by Rikli and Regazzoni299 who recognized intermediate and lateral columns in the distal radius corresponding to the lunate facet and radial styloid and used radial and dorsal ulnar plates (Fig. 32-27). However, the limitation of this technique was when a displaced volar ulnar column was present when a palmar plate was required. This technique therefore evolved into fragment-specific fixation where small implants are used depending on the configuration of the fracture. 
Figure 32-27
 
Lateral and PA fluoroscopy views (A, B) after reduction in traction of a highly comminuted intra-articular fracture. Note that the dorsal cortex comes out to length whereas the palmar cortex remains displaced. Following application of a palmar plate, there still remains some residual comminution of the radial styloid (C, D). The radial styloid (particularly distally) may require adjunctive fixation with either a second plate or K-wires. For this case a separate radial column plate was used to create the final construct (E, F).
Lateral and PA fluoroscopy views (A, B) after reduction in traction of a highly comminuted intra-articular fracture. Note that the dorsal cortex comes out to length whereas the palmar cortex remains displaced. Following application of a palmar plate, there still remains some residual comminution of the radial styloid (C, D). The radial styloid (particularly distally) may require adjunctive fixation with either a second plate or K-wires. For this case a separate radial column plate was used to create the final construct (E, F).
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Lateral and PA fluoroscopy views (A, B) after reduction in traction of a highly comminuted intra-articular fracture. Note that the dorsal cortex comes out to length whereas the palmar cortex remains displaced. Following application of a palmar plate, there still remains some residual comminution of the radial styloid (C, D). The radial styloid (particularly distally) may require adjunctive fixation with either a second plate or K-wires. For this case a separate radial column plate was used to create the final construct (E, F).
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Figure 32-27
Lateral and PA fluoroscopy views (A, B) after reduction in traction of a highly comminuted intra-articular fracture. Note that the dorsal cortex comes out to length whereas the palmar cortex remains displaced. Following application of a palmar plate, there still remains some residual comminution of the radial styloid (C, D). The radial styloid (particularly distally) may require adjunctive fixation with either a second plate or K-wires. For this case a separate radial column plate was used to create the final construct (E, F).
Lateral and PA fluoroscopy views (A, B) after reduction in traction of a highly comminuted intra-articular fracture. Note that the dorsal cortex comes out to length whereas the palmar cortex remains displaced. Following application of a palmar plate, there still remains some residual comminution of the radial styloid (C, D). The radial styloid (particularly distally) may require adjunctive fixation with either a second plate or K-wires. For this case a separate radial column plate was used to create the final construct (E, F).
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Lateral and PA fluoroscopy views (A, B) after reduction in traction of a highly comminuted intra-articular fracture. Note that the dorsal cortex comes out to length whereas the palmar cortex remains displaced. Following application of a palmar plate, there still remains some residual comminution of the radial styloid (C, D). The radial styloid (particularly distally) may require adjunctive fixation with either a second plate or K-wires. For this case a separate radial column plate was used to create the final construct (E, F).
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Limited dorsal, radial, and volar approaches are used. For the radial approach, a longitudinal incision is made radial to the radial artery protecting the superficial branches of the radial nerve in the skin flaps. The first dorsal compartment is released proximally only and the tendons retracted. Brachioradialis is then released from the radius and the radial styloid exposed. If volar exposure of the radial styloid is required, pronator quadratus can be released from the distal radius and elevated to expose the volar aspect. The radial styloid is then reduced and held with a K-wire. In some cases, addition of a further K-wire is sufficient, but frequently a small (usually 2 mm) plate is required, which is contoured to fit the radial styloid on its lateral aspect. 
Once the radial column is stabilized, attention is turned to the ulnar side of the radius. If dorsal fixation is required, a longitudinal incision is made between the third and fourth extensor compartments. If necessary the EPL tendon is released and the fourth compartment elevated subperiosteally which gives good exposure of the dorsal ulnar radius. The fracture is reduced using bone graft, if necessary, to augment the elevated position. A T plate is usually necessary to maintain the reduction (Fig. 32-28). 
Figure 32-28
 
Residual displacement of the dorsal intermediate column (A, B) can be addressed through a dorsal approach. The intermediate column is stabilized and then the radial column is assessed for palmar displacement and rotation (C, D). If necessary, a second radial plate is applied (E).
Residual displacement of the dorsal intermediate column (A, B) can be addressed through a dorsal approach. The intermediate column is stabilized and then the radial column is assessed for palmar displacement and rotation (C, D). If necessary, a second radial plate is applied (E).
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Figure 32-28
Residual displacement of the dorsal intermediate column (A, B) can be addressed through a dorsal approach. The intermediate column is stabilized and then the radial column is assessed for palmar displacement and rotation (C, D). If necessary, a second radial plate is applied (E).
Residual displacement of the dorsal intermediate column (A, B) can be addressed through a dorsal approach. The intermediate column is stabilized and then the radial column is assessed for palmar displacement and rotation (C, D). If necessary, a second radial plate is applied (E).
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On the volar side of the radius, a volar ulnar fracture is approached between the flexor tendons and the ulnar neurovascular bundle. The fracture is reduced, bone graft used as necessary, and a small T plate is applied (Fig. 32-29). 
Figure 32-29
 
A: Typical three-part intra-articular fracture of the distal radius. B: Depression of the lunate facet palmarly is difficult to reduce by closed methods. C: A plate applied palmarly to the lunate facet reduces and mortars both the DRUJ and the radiocarpal joint.
A: Typical three-part intra-articular fracture of the distal radius. B: Depression of the lunate facet palmarly is difficult to reduce by closed methods. C: A plate applied palmarly to the lunate facet reduces and mortars both the DRUJ and the radiocarpal joint.
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Figure 32-29
A: Typical three-part intra-articular fracture of the distal radius. B: Depression of the lunate facet palmarly is difficult to reduce by closed methods. C: A plate applied palmarly to the lunate facet reduces and mortars both the DRUJ and the radiocarpal joint.
A: Typical three-part intra-articular fracture of the distal radius. B: Depression of the lunate facet palmarly is difficult to reduce by closed methods. C: A plate applied palmarly to the lunate facet reduces and mortars both the DRUJ and the radiocarpal joint.
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Postoperative Care.
Postoperatively, if fixation is deemed satisfactory, a plaster is not required although a resting splint may be used for comfort. Active range of movement is started as soon as pain allows although patients should be cautioned to avoid weight bearing on the hand. 

Outcomes

Combined External and Internal Fixation.
There are a limited number of reports of the outcome of external fixation and limited open reduction. Limited open reduction without external fixation has been reported but should be reserved for the treatment of fractures with articular displacement without metaphyseal comminution. In one study the authors reported on 40 patients with intra-articular fractures of the distal radius, of which 12 had AO type C3 fractures and 5 of the 12 had percutaneous reduction and fixation without external fixation. The authors found that there was loss of the metaphyseal reduction in patients with metaphyseal comminution. Articular reduction was achieved in half of the 40 patients but limited open reduction was required for displaced volar fractures or small impacted joint fragments. They cited the minimal soft tissue disruption as an advantage of the technique.120 
A combination of external fixation and plating of the lunate facet was used in the treatment of 21 patients younger than 65 years of age by Ruch et al.314 with good or excellent results in 18 patients. The most comprehensive cohort study of combined closed reduction and external fixation retrospectively examined 22 patients with 23 AO type C3 fractures at an average review time of 40 months. Excellent or good results using the Gartland and Werley scale were obtained in 17 cases with the average grip strength being 67.5% of the opposite sides. Five of twenty-three fractures healed with a step greater than 2 mm and two with a gap greater than 2 mm. There was statistical correlation between better results and patients aged less than 40 years and in those fractures which healed with a gap or step of less than 2 mm. The authors concluded that the technique led to a satisfactory outcome in most cases.32 This study illustrates that closed reduction techniques are satisfactory, provided reduction of the joint is achieved. 
Open Reduction and Internal Fixation.
There are considerably more papers published on this subject than on limited reduction and external fixation. There are reports of the use of both single (usually volar locked) plates and of fragment-specific fixation. Caution should be used in comparing the results of these studies as a single plate will generally be used in less complex intra-articular fractures.320 Even studies concentrating on one type of plating are difficult to interpret as the cohort usually contains a heterogeneous group of patients and fractures ranging from extra-articular to severely displaced intra-articular fractures.62,85,90,95,388,393 Even if the studies are restricted to AO/OTA type C fractures, no attention is paid to whether the articular fragments are displaced requiring open reduction or not, which is likely to have a significant influence on their outcome. 
The outcome of 54 patients with intra-articular fractures of the distal radius treated with volar locked plates was reported by Gruber et al. Forty-nine fractures were AO type C2 or C3 with the remaining five being type C1. The average age was 63 years with older women and younger men. The authors considered that a volar locked plate alone was not sufficient in “more difficult” fractures when K-wires were added. They reported good restoration of metaphyseal alignment and 89% of cases with articular incongruity of less than 1 mm. Radiologic arthritis was evident in 24% of cases at 2 years and 37% of cases at 6 years with the average severity increasing significantly over the time period.140 
In the same year, Konstantinidis et al. reported the results of volar plating of 40 AO type C fractures, 60% of which were type C3. Metaphyseal alignment was well maintained but joint alignment was not reported. The mean DASH score was 18 at a minimum follow-up of 1 year. Ten percent required revision surgery which resulted in worse functional outcomes. As in other reports of the treatment of articular fractures, the complication rate was high. Ten cases required augmentation with external fixation or K-wires and the authors acknowledged that it may be difficult to treat both radial and ulnar column fractures with a single plate.199 
Column- or fragment-specific internal fixation was reported by Jakob et al. in 2000. They included 77 patients, 40 of which were described as complex articular. One year after surgery 75% had no pain. Ninety-seven percent returned to work at a mean of 6 months after injury. There was no residual intra-articular incongruity and 7% had radiographic evidence of osteoarthritis. There was a 21.6% complication rate with nine patients experiencing tendon problems. Four fractures redisplaced and the reoperation rate was 23%. The authors concluded that the technique reliably restored joint congruency and extra-articular alignment but was technically demanding.169 
The column-specific technique was extended to include fixation of any fragment with small implants, the fragment-specific technique. The largest series of intra-articular distal radius fractures reported using this technique contains 105 patients, all with AO type C fractures of which only 33 were type C3.118 The remainder consisted of 41 C1 fractures and 31 C2 fractures. Six patients had additional bridging external fixators applied, demonstrating the need for a combination of techniques in the more complex cases. Thirty-one patients had nonanatomical joint reduction with the odds of achieving a good reduction being 0.25 for C2 fractures and 0.17 for C3 fractures compared to C1 fractures. Eleven patients had radiologic evidence of arthritis at 1 year, eight of whom had initial malreduction of the joint. The DASH and PRWE scores had not returned to baseline at 1 year but this was not affected by fracture subtype or quality of reduction. Five patients lost reduction because of unaddressed dorsal comminution or volar ulnar corner fractures and eight patients had tendon problems. The authors concluded that most articular fractures can be managed using a volar approach. Indications for an added dorsal approach were defined as a dorsal ulnar fragment, dorsal comminution, or joint impaction. 
Other authors have reported similar outcomes with the fragment-specific type of technique. All studies report some residual articular incongruity.52,178,323 In the more complex fractures, augmentation of the plates with external fixation, K-wires, bone graft, or bone substitute may be required.52,178,323 Functional outcome scores rarely revert to baseline and complication rates are high, reflecting the complexity of the fractures treated. 
Randomized Controlled Trials.
Kreder et al.204 performed a randomized controlled study on 179 patients with intra-articular distal radius fractures with 118 patients attending for review at 2 years. Eighty-eight patients were treated with indirect reduction, percutaneous fixation, and bridging external fixation, whereas 91 were treated with ORIF. The majority of fractures were AO type C. Bone graft was used in 13% of the closed group and 50% of the open group. Residual articular incongruity occurred in 12 in the closed group and 13 in the open group with radiologic osteoarthritis in 7 and 6 patients respectively. The closed reduction and external fixation group had superior upper limb Musculoskeletal Functional Assessment (MFA) scores, less pain and better grip strength, and specialized grip strength. Eight patients in this group had crossed over to the ORIF group because it proved impossible to reduce the fracture by closed means. The authors reported a more than 10-fold increase in the likelihood of osteoarthritis if there was a residual step of more than 2 mm. They concluded that there was a more rapid return to function and superior overall function within 2 years in the closed reduction and external fixation group provided articular incongruity was minimized. They believe that neither the fixation nor the implant dictates outcome but rather the ability of the surgeon to obtain a satisfactory reduction with the least invasive procedure possible and recommended that ORIF of articular fractures of the distal radius be preceded by an attempted indirect reduction and percutaneous fixation supplemented by bridging external fixation. 
Leung et al.217 performed a similar RCT on 137 patients with 134 AO type C fractures with 113 patients followed for 2 years. The Gartland and Werley scores and radiologic osteoarthritis was less for C2 fractures treated with plating but no such difference could be demonstrated for the more complex C3 nor the simpler C1 fractures. The authors attributed the differences between theirs and Kreder’s study to the use of fewer dorsal approaches in their study and the use of external fixation at the surgeon’s discretion in the latter study. 
An earlier comparison between dorsal plating and limited open reduction and external fixation was abandoned before completion of enrolment because of higher complication rates, more pain and worse grip strength in the dorsal plating group.139 
Volar locked plating was compared retrospectively with external fixation for AO type C2 and C3 fractures in 115 patients.297 Better grip strength, range of movement, and DASH scores, but higher complication rates were reported in the volar locked plating group but a trend toward the use of external fixation in open fractures and a higher proportion of C3 fractures in the external fixation group suggests that as this study was retrospective, the more complex fractures may have been treated with external fixation. 

The Role of Arthroscopy.

Arthroscopy has now been used for a number of years to assist in the reduction of intra-articular distal radius fractures but despite this there is no consensus on its utility. Advantages of arthroscopy include direct visualization of the articular surface with minimal soft tissue violation, which allows confirmation of joint reduction and exclusion of inadvertently placed intra-articular implants. However, technically and logistically there are disadvantages: a longer, more difficult procedure, greater expense, a long learning curve, and the risk of fluid extravasation, which may result in acute compartment syndrome. 
Any benefit of arthroscopy to patient outcome has not been firmly established. Doi et al.83 performed a randomized study comparing 34 patients with arthroscopy-assisted reduction, external fixation, and K-wires with 58 patients treated with ORIF and followed them for a minimum of 2 years. Radiologically, there was no difference in the residual step-off but a 0.5 mm difference in residual gap. This was statistically significant but its clinical significance must be in doubt. There was better metaphyseal alignment in the arthroscopic group. Better outcomes as measured by the Gartland and Werley and Green and O’Brien scores were reported in this group but this may be because of the improved metaphyseal alignment, which is difficult to attribute to the use of an arthroscope. In a later RCT, 20 fractures were treated with fluoroscopy alone and 20 with fluoroscopy and arthroscopy.379 All fractures had a residual gap or step of 2 mm or more after closed reduction and were treated with external fixation and percutaneous pinning. The tourniquet time (and presumably, therefore, surgery time) was significantly prolonged in the arthroscopy group. The authors reported a mean of 0.45 mm less step or gap in the arthroscopy group and improved early outcome measures at 3 months. They concluded that the addition of arthroscopy improved the outcome of intra-articular distal radius fractures. 

Salvage Procedures.

In a small number of cases it may not be possible to restore articular congruity or metaphyseal alignment because of severe articular or metaphyseal comminution, poor bone quality, or any combination of the three. In these circumstances a salvage procedure may be required. 
Distraction Plating.
This technique involves bridging of the joint and metaphysis using a standard plate from the third metacarpal distally to the radial diaphysis proximal to the fracture. It has been described as an “internal fixator,” using ligamentotaxis to obtain reduction and has been recommended for polytrauma patients who need to bear weight on the limb, for fractures caused by high-energy injury with extensive articular comminution and diaphyseal extension126 and for osteoporotic patients with severely comminuted fractures.296 
Technique.
The plate is usually applied using minimally invasive techniques although an open approach may be used if necessary. Under tourniquet control, a 4-cm incision is made over the third metacarpal and the extensor tendons retracted. A similar-sized or slightly larger incision is made over the dorsum of the radius proximal to any diaphyseal comminution and the radius is exposed, taking care to protect the superficial radial nerve. A third small incision is made at the level of Lister tubercle and the EPL tendon is released from its groove. An elevator is then used to develop a plane deep to the extensor tendon. This incision can also be used to reduce the fracture or insert bone graft if necessary. A plate, usually containing 12 to 14 holes, is then passed from distal to proximal, and its position verified with fluoroscopy. Care should be taken to avoid entrapment of extensor tendons under the plate. One screw is inserted into the metacarpal and distraction applied to the fracture. The plate is then clamped to the proximal radius and the fracture reduction confirmed by fluoroscopy. Overdistraction should be avoided. The surgeon should then confirm that full forearm rotation and finger flexion are possible to exclude rotational deformity at the fracture or tendon entrapment. At least three screws proximally and distally are then inserted. The articular surface is then reduced if necessary through the middle incision and the fragments held with K-wires or screws. Bone graft is usually required as these fractures usually have a large metaphyseal void. Splintage is only required for a short period for pain relief following which the patient is encouraged to mobilize. The plate is removed after fracture union. 
Outcome.
Two reports of the outcome of this technique included 22313 and 33 patients296 with the latter study recruiting patients over 60 years of age. Both studies reported good restoration of both metaphyseal and articular alignment. The DASH scores at 1 year were a mean of 15313 and 32296 respectively, but in the latter report had reduced to 11.5 at 2 years after injury. The severity of the fractures treated should be remembered when considering these results. 
Double or Sandwich Plating.
This technique is indicated in cases with both volar and dorsal comminution, which may cause severe instability. The use of a single plate may lead to loss of alignment in the opposite direction, for example, application of a volar plate may cause dorsal displacement (Fig. 32-30).185 Articular displacement can be addressed prior to the insertion of the distal screws in the plate. Reports of this technique indicate that satisfactory radiographic reduction is usually achieved.77,303 Functional results are variable with one study reporting 10 good or excellent, 14 fair, and 1 poor result according to the modified Green and O’Brien score at an average of 26 months after injury.303 Day et al. reported a mean DASH score of 16 points in 10 patients at an average of 17 months after injury. Concerns about avascularity of fragments or delayed union are unfounded but the technique’s disadvantages are the need for plate removal and the risk of tendon rupture. 
Figure 32-30
A poorly applied volar plate in the presence of both volar and dorsal comminution has resulted in a dorsal malunion.
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Arthrodesis.
Rarely, severe articular bone loss or incongruity cannot be corrected and in this situation, early radiocarpal or complete wrist arthrodesis should be considered. Such injuries are the result of high energy transfer and are most frequently caused by gunshot wounds, crush, or blast injuries.112 When a decision is made that the fracture is irreparable, arthrodesis should be performed primarily if the soft tissues allow or as a delayed primary procedure after satisfactory soft tissue coverage or healing is obtained. Early surgery will reduce the chance of posttraumatic stiffness in the hand and forearm. 
Radiocarpal fusion has the advantage of retaining some wrist motion which occurs at the midcarpal and carpometacarpal joints. However in one study, 3 of 15 patients required conversion to total wrist fusion because of symptomatic midcarpal osteoarthritis occurring between 1 and 2 years after injury. Two patients required conversion to total wrist fusion because of nonunion of the radiocarpal fusion. At follow-up on 10 patients 8 years after surgery, there was sufficient residual pain in two cases to interfere with the normal activities of daily living. Grip strength was an average of 43% of the opposite side. There was an average of 50 degrees of a flexion extension arc but radial deviation was severely limited.261 
For a complete wrist fusion, the midcarpal and carpometacarpal joints are included with the radiocarpal joints. Fusion is best performed in 10 to 20 degrees of wrist extension with slight ulnar deviation and this is most easily achieved with commercially available plates. Fusion rates are generally high and occur 3 to 4 months after surgery112 with recovery of grip strength between 60% and 80%. 

Partial Articular Fractures

Partial articular fractures of the distal radius are either volar shearing or volar lip (volar Barton’s), dorsal shearing or dorsal lip (Barton’s), or radial styloid (Chauffeur’s) fractures and usually result from impaction of the scaphoid and lunate complex onto the distal radius. They are characterized as partial articular fractures because a part of the metaphysis remains intact and in continuity with the diaphysis of the radius and the intact part of the joint. The fracture line is oblique rendering it unstable but it can be anchored to the intact column of the radius using internal fixation. 
Volar Shearing Fractures.
These are the AO type B3 fractures and are categorized by the size and comminution of the volar fragment and whether the sigmoid notch is involved. They have long been recognized as being inherently unstable24,93 and nonoperative treatment is therefore reserved for the elderly, frail patient, or the rare undisplaced fracture. 
Operative treatment is with a palmar buttress plate with an emphasis on reduction of the articular surface, including the sigmoid notch. The plate should be slightly undercontoured to apply compression across the fracture against the intact dorsal cortex (Fig. 32-31). Care should be taken to place the plate sufficiently ulnar to support an ulnar-sided volar lip fracture which may be occult. The surgeon should examine the preoperative imaging carefully to exclude subtle fracture lines extending into the dorsal cortex which may otherwise be unrecognized risking dorsal malunion if an undercontoured plate is used.185 
Figure 32-31
 
A: A volar shearing fracture of the distal radius. B: A palmar plate is being applied slightly undercontoured. Screws are inserted and tightened sequentially to compress the fracture against the intact dorsal cortex.
A: A volar shearing fracture of the distal radius. B: A palmar plate is being applied slightly undercontoured. Screws are inserted and tightened sequentially to compress the fracture against the intact dorsal cortex.
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Figure 32-31
A: A volar shearing fracture of the distal radius. B: A palmar plate is being applied slightly undercontoured. Screws are inserted and tightened sequentially to compress the fracture against the intact dorsal cortex.
A: A volar shearing fracture of the distal radius. B: A palmar plate is being applied slightly undercontoured. Screws are inserted and tightened sequentially to compress the fracture against the intact dorsal cortex.
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Most reports of the outcome of volar shearing fractures of the distal radius include a majority of cases with high-energy injury which may not reflect the true epidemiology of these injuries. Reported radiologic results are good provided the risk of dorsal malunion is avoided.5,177,185,255,347 Functional results are reported with a high proportion of excellent and good results in the older studies.5,177 A more recent study reported a mean DASH score of 3.9 2 years after injury.347 Bolmers et al.35 reported much longer-term outcomes with a mean DASH score of 14 in 17 patients examined between 15 and 25 years after injury. The latter two studies found no significant differences in outcome between volar shearing fractures with or without a dorsal fracture line. 
Dorsal Lip Fractures.
Dorsal lip or dorsal marginal articular fractures are rare injuries and usually occur in association with a variety of other injuries and radiocarpal subluxation or dislocation (Fig. 32-32). Lozano-Calderon et al. identified four patterns of associated injury226
  1.  
    Impaction of the majority of the articular surface with a simple volar metaphyseal fracture line.
  2.  
    Radiocarpal fracture dislocation with radiolunate ligament rupture.
  3.  
    Radiocarpal fracture dislocation with fracture of the volar margin of the lunate facet, the origin of the radiolunate ligament.
  4.  
    Central articular impaction with relative sparing of the volar half of the joint and the radial styloid.
Figure 32-32
 
A: A dorsal lip fracture of the distal radius with carpal subluxation B: The fracture has been reduced and held with a small dorsal plate and the carpus is relocated.
A: A dorsal lip fracture of the distal radius with carpal subluxation B: The fracture has been reduced and held with a small dorsal plate and the carpus is relocated.
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Figure 32-32
A: A dorsal lip fracture of the distal radius with carpal subluxation B: The fracture has been reduced and held with a small dorsal plate and the carpus is relocated.
A: A dorsal lip fracture of the distal radius with carpal subluxation B: The fracture has been reduced and held with a small dorsal plate and the carpus is relocated.
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They are frequently the result of high-energy injury and tend to occur in younger patients. Careful examination of the carpus is mandatory to exclude scaphoid fracture or carpal ligamentous injury. 
Treatment of these injuries is usually surgical with a dorsal, volar, or combined approach depending on the characteristics of the injury. A study of 20 patients reported an average DASH score of 15 at 30 months, but more than half of the patients had unsatisfactory results with the modified Mayo risk score. The authors concluded that this is a severe injury in which permanent impairment should be anticipated.226 
Radial Styloid Fractures.
Radial styloid fractures are the commonest type of partial articular fracture. They may occur in isolation, in association with scaphoid fracture, scapholunate injury, radiocarpal dislocation, or with a more complex distal radius fracture. The latter is described in the section in this chapter on displaced articular fractures. 
Isolated Radial Styloid Fractures.
These are usually undisplaced and generally benign injuries but careful examination of the carpus is mandatory to exclude scaphoid fracture or carpal ligamentous injury. If undisplaced they may be treated in a cast or splint for pain relief and the wrist mobilized when symptoms allow. Intervention is indicated where there is a significant articular step or gap when surgery is usually required. If possible treatment should be percutaneous with manipulative reduction and fixation using pins, screws, or headless screws. If reduction cannot be achieved percutaneously then open reduction is necessary. Radial buttress plating may be necessary in this situation. 
Helm and Tonkin reported the results of surgical treatment in 14 radial styloid fractures of which most were caused by high-energy injury. Four had associated carpal injury with three scaphoid fractures and one transscaphoid, transstyloid perilunate fracture dislocation. Fixation of the radial styloid was with headless screws and K-wires and in one case a T plate. The authors reported good or excellent functional results.153 
Radial Styloid and Scaphoid Fractures.
Simultaneous fracture of the distal radius and carpal bones is uncommon. Hove162 reported on 2,330 distal radius fractures and 390 scaphoid fractures with only 12 cases of combined fractures. Scaphoid fractures can occur with any type of distal radius fracture but are significantly more common in partial articular fractures.197 The same authors report that the commonest associated carpal bone fracture is the scaphoid. Combined fractures were commoner in younger men with high-energy injuries and the authors stress the importance of CT imaging where combined fractures are suspected. 
Treatment of combined fractures generally depends on the severity of the distal radius fracture and any displacement of the scaphoid fracture. Older reports suggest that nonoperative management yields reasonable results,162,275 but more recent reports recognize a shift in strategy with increasing severity of the distal radius fracture. Of 10 patients Rutgers et al. treated 8 with surgery to both the distal radius and scaphoid. Of the two treated nonoperatively initially one required ORIF of the scaphoid 6 weeks later. Low pain levels, good ranges of movement, and consistent return to previous employment were reported at a mean review time of 40 months and a minimum review time of 1 year. The authors recommend that if surgery is required for the distal radius fracture then the scaphoid fracture should also be fixed. They concluded that early aggressive internal fixation of both fractures combined with early rehabilitation led to satisfactory outcomes for low level of complications.316 

Fractures of the Distal Ulna

Fractures of the distal ulna are a common association with distal radius fractures. They may involve the ulnar shaft, neck, head, or ulnar styloid, or a combination of several of these. Although common there is not much guidance in the current literature as to their management. 

Extra-Articular Distal Ulnar Fractures

Extra-articular fractures of the distal ulna associated with distal radius fractures are either diaphyseal or in the neck or distal part of the ulna. The latter are defined as being within 5 cm of the dome of the ulna.224 They have been reported as occurring in 5.6% of displaced distal radius fractures.34 
Many of these fractures will be realigned once the distal radius is reduced in which case cast immobilization is sufficient (Fig. 32-33). However, if the ulna remains malaligned or unstable after distal radius stabilization, then ORIF is required. Malalignment has been defined as more than 10 degrees of angulation and instability as more than 50% translation with forearm rotation.51 
Figure 32-33
 
A: An unstable extra-articuar fracture of the distal radius with a comminuted fracture of the ulnar neck. B: After fixation of the distal radius the ulnar fracture is out to length with acceptable alignment and does not require fixation. Both fractures went on to heal in this position.
A: An unstable extra-articuar fracture of the distal radius with a comminuted fracture of the ulnar neck. B: After fixation of the distal radius the ulnar fracture is out to length with acceptable alignment and does not require fixation. Both fractures went on to heal in this position.
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A: An unstable extra-articuar fracture of the distal radius with a comminuted fracture of the ulnar neck. B: After fixation of the distal radius the ulnar fracture is out to length with acceptable alignment and does not require fixation. Both fractures went on to heal in this position.
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Figure 32-33
A: An unstable extra-articuar fracture of the distal radius with a comminuted fracture of the ulnar neck. B: After fixation of the distal radius the ulnar fracture is out to length with acceptable alignment and does not require fixation. Both fractures went on to heal in this position.
A: An unstable extra-articuar fracture of the distal radius with a comminuted fracture of the ulnar neck. B: After fixation of the distal radius the ulnar fracture is out to length with acceptable alignment and does not require fixation. Both fractures went on to heal in this position.
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A: An unstable extra-articuar fracture of the distal radius with a comminuted fracture of the ulnar neck. B: After fixation of the distal radius the ulnar fracture is out to length with acceptable alignment and does not require fixation. Both fractures went on to heal in this position.
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ORIF can be achieved by a number of different methods.51,110,213,263,301 Although most of these studies include extra-articular fractures only one concentrates exclusively on neck or distal ulnar fractures without articular involvement.51 This was a prospective nonrandomized study of 61 unstable or malaligned fractures of the distal ulna with associated distal radius fractures, all of which were internally fixed. The patients were all over 64 years of age. Twenty-nine patients were treated with ORIF and 32 with closed reduction and cast management. At an average review period of 34 months there were no significant differences in the radiologic or functional outcome.51 For the older patient it seems that nonoperative management is satisfactory but there is no available comparison of treatment methods in younger patients. 
The results of ORIF of extra-articular fractures are generally good. Ring et al. reported on 24 patients, 21 of whom had extra-articular fractures. They used condylar blade plate fixation and reported good restoration of alignment and function, with 21 of their patients achieving good or excellent results according to the modified Gartland and Werley score. One fracture failed to unite and seven plates required removal.301 Dennison reported on five distal ulnar fractures treated with locking plates which achieved excellent and good results with the modified Gartland and Werley score. Two patients had transient dorsal ulnar nerve symptoms.79 
For the older patient it seems that nonoperative management of extra-articular distal ulnar fracture associated with distal radius fracture is satisfactory. If ORIF is deemed necessary it will achieve union with few complications and good functional result. 

Intra-Articular Distal Ulnar Fractures

Intra-articular distal ulnar fractures may occur in isolation338 or in association with distal radius fractures when they may occur with ulnar neck or styloid fractures. Treatment should follow the general principles of the treatment of intra-articular fractures as residual displacement is likely to cause a block to forearm rotation (Fig. 32-34).338 Where there is significant displacement ORIF with headless screws or K-wires may be necessary, supplemented with plating where appropriate. 
Figure 32-34
Without ORIF this would result in a block to forearm rotation.
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Figure 32-34
A severe intra-articular fracture of the ulnar head in association with a distal radius fracture.
Without ORIF this would result in a block to forearm rotation.
Without ORIF this would result in a block to forearm rotation.
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There are no reports of series of displaced intra-articular ulnar head fractures associated with distal radius fracture, but Namba et al. documented 14 patients with intra-articular ulnar fractures in association with distal radius fractures. The patients were all older than 55 years with an average age of 74 years and the ulnar fractures were treated nonoperatively after fixation of the distal radius fractures with plates. All had stable DRUJs perioperatively. At a mean of 18 months’ review all had healed. Five had some residual ulnar angulation and five had mild radiographic arthrosis in the distal radioulnar joint but all had good or excellent results using the modified Gartland and Werley score. The authors concluded that bone union with satisfactory results can be achieved by nonoperative management, especially in older patients who may have osteoporotic bone.263 Rarely, there may be severe comminution both within the joint and in the metaphysis when fixation is not feasible. This may be treated initially with restoration of alignment and cast management with the option of a salvage procedure at a later date. Acute salvage procedures have been described using ulnar head replacement,133 resection of the ulnar head, and soft tissue interposition328 or an acute Sauvé–Kapandji procedure,159 but no author has demonstrated superiority of these techniques over later reconstruction. 

Ulnar Styloid Fractures

Ulnar styloid fractures are the most common ulnar-sided injury associated with distal radius fractures being reported to occur in 40% to 60% of distal radius fractures.114,190,243,277,370 Despite their frequency there remains controversy about their role in functional outcome after distal radius fracture. 
There is conflicting evidence about the effect of an ulnar styloid fracture on the outcome. Older publications examine ulnar styloid fractures in association with a nonoperatively managed distal radius fracture. Frykman considered that ulnar styloid fracture had sufficient prognostic importance to include it in his classification.114 Oskarsson et al. examined 158 patients with nonoperatively treated distal radius fractures, 70 of whom had an ulnar styloid fracture. The authors concluded that an ulnar styloid fracture was a more important predictor of outcome than articular involvement.277 This was supported by Stoffelen et al.356 who found a poorer prognosis in the presence of an ulnar styloid fracture. 
However, other studies using nonoperative management of the distal radius fracture showed no prognostic value of an ulnar styloid fracture.309,353 More recent studies evaluated a series of distal radius fractures treated with volar plating and ulnar styloid fractures without intraoperative distal radioulnar joint instability. None showed any correlation between functional outcomes and the presence, level, or displacement of an ulnar styloid fracture.45,190,192,321,401,402 Kim et al.190 concluded that an unrepaired ulnar styloid fracture does not affect wrist function or stability. 
Ulnar Styloid Fracture with Distal Radioulnar Joint Instability.
The stabilizing ligaments of the distal radioulnar joint (radioulnar, TFCC) insert on to the base of the ulnar styloid which may lead to concern in basal fractures that DRUJ instability is present. This is reported as occurring in 5% to 23% of distal radius fractures115,150,184,190,210 but is likely to be less as these are selected series of unstable distal radius fractures. There is a recognized possibility of DRUJ instability with basal styloid nonunion and the importance of assessing DRUJ instability in all distal radius fractures has been emphasized.150 Open fractures, more than 6 mm of ulnar variance, basal fracture with significant displacement, radial translation on initial radiographs, and initial fracture displacement have all been implicated as predictors of DRUJ instability.115,210,243,298 Although suspicion of DRUJ instability should be heightened by the presence of these predictors it is generally recommended that DRUJ stability should be tested after stabilization of a distal radius fracture. This is achieved by the examiner grasping both the radius and ulna between their thumb and index finger and applying dorsal and volar pressure. The test is positive if there is more movement than on the opposite side with no firm endpoint. 
If DRUJ instability is detected it can be expected to lead to a worse outcome, especially in younger patients.224 There is no consensus on how this should be treated except when a basal ulnar styloid fracture coexists when most authorities agree that ORIF should be used to stabilize the DRUJ. 
The styloid fragment is approached through a longitudinal incision over extensor carpi ulnaris with care being taken to protect the sensory branches of the ulnar nerve. Supination of the wrist may be required to reduce the fragment and fixation may then be achieved with a small cannulated screw if the fragment is large, or alternatively, K-wires and tension banding. Stability of the DRUJ should then be confirmed. 

Management of Expected Adverse Outcomes and Unexpected Complications

Complications of distal radius fractures are relatively common and are reported to occur in a wide range from 5% to 31% of mixed series of fractures.69,81,246 Some of these complications are associated with treatment of the fracture and are reported elsewhere in this chapter. This section will concentrate on fracture-specific complications. 

Nerve Injury

Median Nerve

The commonest nerve injury associated with distal radius fracture is median nerve injury presenting as CTS. It has been reported as occurring in between 3% and 17% of fractures.15,69,114,246,354 Suggested contributory causes of early CTS after distal radius fracture are swelling and hematoma extending into the carpal canal or deep to the fascia at the level of the fracture,219,230,280 direct nerve contusion,202,257 hematoma block,69,202 and the Cotton-Loder position.230 Later CTS has been attributed to callus formation and malunion.15,69,219,280,354 
Itsubo et al. recognized that the onset of CTS after distal radius fracture can vary from 1 day to 25 years.167,354 They grouped the onset intervals into three: 
  1.  
    Acute—within 1 week of fracture (27.4%).
  2.  
    Subacute—1 to 12 weeks after fracture (44.3%).
  3.  
    Delayed—more than 12 weeks after fracture (28.3%).
The acute onset group was younger and contained significantly more males, high-energy injuries, and AO type C injuries. In contrast the other two groups had more older women with lower-energy injuries and extra-articular fractures. Residual deformity after reduction was evenly distributed between the three groups. A further group could be added—the transient CTS where symptoms resolve after reduction.15 
It is important to recognize the development of acute CTS after distal radius fracture as failure to treat the condition can lead to permanent median nerve dysfunction. It is defined by its development within hours of fracture injury and reduction and its progressive worsening. It is thought to be caused by increased pressure in the carpal tunnel. Dyer et al. examined 50 patients who had carpal tunnel decompression for acute CTS and ORIF of their fracture, and using multivariant analysis identified women less than 48 years of age with more than 35% fracture translation as being at significant increased risk of developing acute CTS. The authors suggested that further study was required before considering prophylactic carpal tunnel decompression in this group and emphasized the need for vigilance in diagnosing acute CTS after distal radius fracture.87 
Subacute or delayed onset CTS occurs in older patients with lower-energy injury, with malunion being a possible contributory factor.15,167,354 Late CTS also has a negative influence on functional outcome after distal radius fracture.31 Decompression is successful in the majority of patients,230,354 but it should be noted that compression may occur proximal to the wrist crease at the level of the fracture and release should be extended to this area.219 

Ulnar Nerve

Ulnar nerve injury is less common than median injury with prevalence reported as being 0.5% to 4.2%.15,21 It is thought that the mobility of the ulnar nerve at the wrist and in the forearm protects it from injury.63 Reported risk fractures are instability of the DRUJ,63,345 open fractures, high-energy injury, and severe fracture displacement. Most of these injuries are neurapraxias which recover spontaneously. Exploration is recommended where there is complete ulnar palsy with an open wound or concurrent acute CTS.345 

Tendon Injury

Tendon injury occurs with distal radius fractures treated both operatively and nonoperatively. The commonest tendon involved is EPL which is usually reported as occurring in less than 1% of fractures161,246,354 but has been reported in up to 5% of fractures.69,307,334 
A number of mechanisms for EPL injury after distal radius fracture have been proposed and may be either fracture- or hardware-related. Hardware-related ruptures most commonly occur with volar or dorsal plating and are discussed in the relevant sections of this chapter. 
Both mechanical and biologic causes have been suggested for fracture-related EPL rupture. Attritional causes cited theorize that an intact extensor retinaculum holds the tendon on to a spike of sharp bone, a roughened area of the distal radius, or a nonunion of Lister tubercle.152,350 Some authors have postulated a vascular cause with ischemia of a segment of the tendon because of narrowing of the third extensor compartment with an already poorly vascularized area becoming avascular and mechanical obstruction preventing the normal volume of synovial fluid.156 This theory is supported by the ultrasonic finding of thickening of the EPL sheath after distal radius fracture.279 
EPL ruptures have been reported as occurring more commonly in undisplaced or minimally displaced distal radius fractures307 and at various times after injury. It is likely that fracture-related ruptures occur earlier after injury at an average of around 6 weeks whilst later ruptures may be more likely to be related to attritional problems on hardware. White et al.391 reported that EPL rupture occurred at an average of 9 weeks after initial injury in nonoperatively managed patients and at an average of 20 months after plating. 
If the patient has symptoms causing a functional problem after EPL rupture then tendon transfer, usually with extensor indicis proprius, should be considered. This is reported as achieving satisfactory outcomes with low DASH scores,391 a high proportion of excellent and good results,161 minimal loss of thumb extension, and restoration of around 70% of grip and tip pinch strength by 8 weeks after surgery.125 
Fracture-related flexor tendon injuries are much rarer possibly because the muscle belly of pronator quadratus acts as a cushioning layer between the flexor tendons and bone. Before the early 1990s only 12 cases of flexor tendon rupture had been reported in the world literature. However, a literature search for flexor tendon rupture in distal radius fracture in the last 25 years records 19 studies specifically relating to flexor tendon rupture, mainly FPL, after volar plating indicating that this is a hardware-related problem. 

Malunion

Malunion of fractures of the distal radius (Fig. 32-35) remains common although it is frequently not reported as a complication of distal radius fracture. When reported the prevalence is difficult to assess as there is considerable controversy around the definition of malunion. The reported rates of malunion are also affected by the selective nature of some studies in their recruitment of stable and unstable fractures and their methods of treatment, both of which influence the prevalence of malunion. The effect of malunion on functional outcome is also debatable but treatment of malunion should not be considered because of radiologic deformity alone but only in the symptomatic patient. A possible exception to this is in severe articular malunion where symptoms may not arise until there is irreversible degeneration within the joint. In these circumstances some authorities recommend osteotomy in cases with severe articular displacement in the absence of symptoms.242,294,302 
Figure 32-35
Malunion of a distal radius fracture with dorsal tilt, radial shortening, and carpal malalignment.
Rockwood-ch032-image035.png
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Typical symptoms of malunion are as follows. 
  1.  
    Pain—ulnar sided
    •  
      carpal
    •  
      radiocarpal
  2.  
    Weakness of grip
  3.  
    Reduced range of movement, especially rotation
  4.  
    Deformity
Pain is a common symptom of distal radius malunion and can be located in the DRUJ, the carpal area or the radiocarpal joint. DRUJ pain is common253 and probably caused by incongruency of the sigmoid notch because of the tilt of the radius, intra-articular malunion, or damage to the cartilage of the ulnar head. Carpal pain is caused by the altered mechanics of the malaligned carpus,30,143,285,361 is typically felt over the dorsum of the hand, and may develop gradually after fracture healing.362 Radiocarpal pain is usually attributable to intra-articular malalignment or developing osteoarthritis in the radiocarpal joint. It is important to differentiate between the three areas of pain to direct treatment appropriately. 
A reduced range of movement is also a common complaint after distal radius malunion, most frequently reduced forearm rotation caused by malalignment or incongruity of the DRUJ from dorsal or volar tilt, radial shortening, or intra-articular pathology. Wrist flexion may be reduced with dorsal malunion and extension with volar malunion. Weak grip strength may be because of pain or the mechanical disadvantage of the adaptive carpal collapse or malalignment. Later CTS may also develop as malunion of the distal radius.15,280 

Treatment of Malunion

In the fit independent patient the treatment of symptomatic malunion is surgical. 
Timing.
The timing of surgical treatment has recently been questioned and highlights a dilemma for the surgeon. It is usual practice that correction of malunion be delayed as this allows a clear definition of residual problems and may prevent unnecessary surgery.103 However, delay leads to an increased period of disability and more difficulty in defining the plane of deformity at surgery. Delay may also lead to soft tissue contracture and more challenging correction of the deformity with the potential for more added ulnar procedure. Jupiter and Ring examined 20 patients who had undergone distal radial osteotomy for a variety of deformities. Half had surgery within 14 weeks of fracture with an average of 8 weeks delay and 10 had later correction at a minimum of 30 weeks and an average of 40 weeks. At review at an average of 4 years for the early or “nascent” malunions and 34 months for the late malunions the authors demonstrated easier correction, less graft donor site morbidity, more rapid healing, and better outcomes in the early group.179 A similar more recent study found fewer benefits although the early group required less bone grafting.286 The former group concluded that early osteotomy should be considered in patients with high functional demand; the latter recommended early osteotomy if the patient presented early with symptoms but a period of review before coming to a decision on later presenting patients. 
Contraindications to distal radial osteotomy include significant osteoarthritis of the radiocarpal joint when fusion may be necessary, intra-articular osteotomy in the presence of less than 2 mm of displacement, and the presence of complex regional pain syndrome.44 Technique positioning is similar to that for ORIF with the patient supine and the affected arm abducted on the side table. A tourniquet is used. The approach and technique then depend on the anatomy of the deformity. 
Dorsal Extra-Articular Malunion.
Dorsal malunion usually requires a dorsal approach. The size of the incision is determined by the technique of stabilization used. For plating a dorsal longitudinal approach is required. The EPL tendon is released from its groove and the radius exposed subperiosteally. Alternatively, a minimally invasive technique using nonbridging external fixation may be used.253 This requires a 3-cm transverse or skin crease incision at the level of the deformity with a longitudinal incision in the extensor retinaculum. The technique requires less dissection as access is only required for the saw blade. Some surgeons may utilize a volar approach if a volar locking plate is to be used. 
Either a closing or an opening wedge may be used. A closing wedge osteotomy has the advantage of bone-to-bone contact and more stability although with modern implants the latter is less important. However there is no residual bone defect so bone grafting is not required. The disadvantage of a closing wedge is its failure to correct any radial shortening leading to the frequent need for ulnar-sided procedures.382 An opening wedge osteotomy is more frequently used as it generates additional radial length. It can be tailored to correct both frontal and sagittal deformity (Fig. 32-36). The disadvantages of this technique are less stability and the need for bone graft. 
Figure 32-36
Technique of osteotomy for a dorsal malunion.
 
Pins are placed parallel to the joint and perpendicular to the shaft (A). An oscillating saw is used to cut the dorsal cortex (B), whereas the palmar cortex is left intact. The fragment is levered into position (C), and the bone graft is placed (D) and a dorsal plate is applied (E, F).
Pins are placed parallel to the joint and perpendicular to the shaft (A). An oscillating saw is used to cut the dorsal cortex (B), whereas the palmar cortex is left intact. The fragment is levered into position (C), and the bone graft is placed (D) and a dorsal plate is applied (E, F).
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Pins are placed parallel to the joint and perpendicular to the shaft (A). An oscillating saw is used to cut the dorsal cortex (B), whereas the palmar cortex is left intact. The fragment is levered into position (C), and the bone graft is placed (D) and a dorsal plate is applied (E, F).
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Figure 32-36
Technique of osteotomy for a dorsal malunion.
Pins are placed parallel to the joint and perpendicular to the shaft (A). An oscillating saw is used to cut the dorsal cortex (B), whereas the palmar cortex is left intact. The fragment is levered into position (C), and the bone graft is placed (D) and a dorsal plate is applied (E, F).
Pins are placed parallel to the joint and perpendicular to the shaft (A). An oscillating saw is used to cut the dorsal cortex (B), whereas the palmar cortex is left intact. The fragment is levered into position (C), and the bone graft is placed (D) and a dorsal plate is applied (E, F).
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Pins are placed parallel to the joint and perpendicular to the shaft (A). An oscillating saw is used to cut the dorsal cortex (B), whereas the palmar cortex is left intact. The fragment is levered into position (C), and the bone graft is placed (D) and a dorsal plate is applied (E, F).
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Many types of fixation have been described to stabilize distal radial osteotomy. Dorsal plating has been the most popular42,44,103,225,294 (Fig. 32-36) although some more recent reports have described the use of volar locked plates for dorsal deformity.154,236,273 Cited advantages over dorsal plating are fewer tendon problems than dorsal plates and the use of morselized bone grafting as the volar locked plate does not need structural support154 and in some cases no bone graft,236 but these advantages have not yet been proven. 
The use of nonbridging external fixation to stabilize the osteotomy (Fig. 32-37) has a number of potential advantages. These include a minimally invasive technique, easy control and correction of the distal fragment, the use of nonstructural cancellous bone graft, and the ease of removal of the implant which does not require hospital admission.22,253 
Figure 32-37
 
A: For distal radial osteotomy using nonbridging external fixation a small transverse skin incision is sufficient. A longitudinal incision is then made through the extensor retinaculum. B: After insertion of the fixator pins the osteotomy is made at the site of deformity. C: Correction is performed using an osteotome as a lever. The pins are only used for fine adjustments to avoid excessive force on them. D: The postoperative radiographs show cancellous bone graft in the defect and a good correction of the deformity shown in Figure 38. E: The external fixator is removed in the outpatient department at about 6 weeks when healing has taken place.
A: For distal radial osteotomy using nonbridging external fixation a small transverse skin incision is sufficient. A longitudinal incision is then made through the extensor retinaculum. B: After insertion of the fixator pins the osteotomy is made at the site of deformity. C: Correction is performed using an osteotome as a lever. The pins are only used for fine adjustments to avoid excessive force on them. D: The postoperative radiographs show cancellous bone graft in the defect and a good correction of the deformity shown in Figure 38. E: The external fixator is removed in the outpatient department at about 6 weeks when healing has taken place.
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A: For distal radial osteotomy using nonbridging external fixation a small transverse skin incision is sufficient. A longitudinal incision is then made through the extensor retinaculum. B: After insertion of the fixator pins the osteotomy is made at the site of deformity. C: Correction is performed using an osteotome as a lever. The pins are only used for fine adjustments to avoid excessive force on them. D: The postoperative radiographs show cancellous bone graft in the defect and a good correction of the deformity shown in Figure 38. E: The external fixator is removed in the outpatient department at about 6 weeks when healing has taken place.
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Figure 32-37
A: For distal radial osteotomy using nonbridging external fixation a small transverse skin incision is sufficient. A longitudinal incision is then made through the extensor retinaculum. B: After insertion of the fixator pins the osteotomy is made at the site of deformity. C: Correction is performed using an osteotome as a lever. The pins are only used for fine adjustments to avoid excessive force on them. D: The postoperative radiographs show cancellous bone graft in the defect and a good correction of the deformity shown in Figure 38. E: The external fixator is removed in the outpatient department at about 6 weeks when healing has taken place.
A: For distal radial osteotomy using nonbridging external fixation a small transverse skin incision is sufficient. A longitudinal incision is then made through the extensor retinaculum. B: After insertion of the fixator pins the osteotomy is made at the site of deformity. C: Correction is performed using an osteotome as a lever. The pins are only used for fine adjustments to avoid excessive force on them. D: The postoperative radiographs show cancellous bone graft in the defect and a good correction of the deformity shown in Figure 38. E: The external fixator is removed in the outpatient department at about 6 weeks when healing has taken place.
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A: For distal radial osteotomy using nonbridging external fixation a small transverse skin incision is sufficient. A longitudinal incision is then made through the extensor retinaculum. B: After insertion of the fixator pins the osteotomy is made at the site of deformity. C: Correction is performed using an osteotome as a lever. The pins are only used for fine adjustments to avoid excessive force on them. D: The postoperative radiographs show cancellous bone graft in the defect and a good correction of the deformity shown in Figure 38. E: The external fixator is removed in the outpatient department at about 6 weeks when healing has taken place.
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Percutaneous pin stabilization of distal radial osteotomies has been used previously but does not give sufficient stability for a reliable result. The evolving technique of intramedullary nailing has also been reported to be successful.47 
The consensus view on the outcome of osteotomy for a dorsal extra-articular malunion is that the procedure improves both radiologic and functional outcomes but rarely to normal.44,103,207,225 All authors agree that prevention of malunion is preferable. 
The technique is reliable in improving the radiologic outcome although volar tilt is not consistently restored with plating techniques.42,44,103,225 Volar tilt is reported as being reliably restored and maintained using nonbridging external fixation, perhaps because of the control obtained by the distal pins.253 Functional outcomes show consistent improvement in both objective and patient-related outcome measures,154,179,207,253 but a number of authors caution that results can deteriorate in the longer term as distal radial osteotomy does not prevent progression of osteoarthritis.103,225 Complication rates are generally high with substantial reoperation rates in some series.44,103,179,225 
Volar Extra-Articular Malunion.
Volar malunion of the distal radius is less common than dorsal malunion, probably because the prevalence of volar displacement is less and because there is a general recognition that volar displaced fractures are unstable and undergo primary fixation. 
The approach is volar and plating is the treatment of choice. Volar malunion is frequently a translational deformity with little angular deformity or bone loss. Where this is the case an oblique sliding osteotomy can be performed and bone grafting is not required (Fig. 32-38).367 If an angular deformity is present an opening wedge osteotomy and bone graft is required.329 Good radiographic and functional results have been reported with both techniques although residual DRUJ symptoms limit its success.329,367 
Figure 32-38
 
Palmar displacement of the distal fragment (A, B). This deformity is common with collapse following dorsal plating. There is a profound effect on supination as the ulna becomes in essence “dislocated” dorsally because of the palmar displacement of the radius. The osteotomy is performed through a palmar approach and stabilized with a palmar plate (C, D).
Palmar displacement of the distal fragment (A, B). This deformity is common with collapse following dorsal plating. There is a profound effect on supination as the ulna becomes in essence “dislocated” dorsally because of the palmar displacement of the radius. The osteotomy is performed through a palmar approach and stabilized with a palmar plate (C, D).
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Figure 32-38
Palmar displacement of the distal fragment (A, B). This deformity is common with collapse following dorsal plating. There is a profound effect on supination as the ulna becomes in essence “dislocated” dorsally because of the palmar displacement of the radius. The osteotomy is performed through a palmar approach and stabilized with a palmar plate (C, D).
Palmar displacement of the distal fragment (A, B). This deformity is common with collapse following dorsal plating. There is a profound effect on supination as the ulna becomes in essence “dislocated” dorsally because of the palmar displacement of the radius. The osteotomy is performed through a palmar approach and stabilized with a palmar plate (C, D).
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Intra-Articular Malunion.
Intra-articular malunion of the distal radius may have serious consequences with early onset of degenerative changes, particularly if associated with joint subluxation. Despite this there were few reports of intra-articular osteotomy until recently possibly because of concerns about the difficulty of the technique and potential complications. The advent of improved imaging may have promoted interest in the technique. 
Indications for surgery are a residual step-off or gap of more than 2 mm especially if associated with extra-articular malunion or joint subluxation (Fig. 32-39). Surgery should not be considered in lower-demand patients or those with advanced osteoarthritis. Most authorities do not feel that it is necessary for the patient to be symptomatic as awaiting symptoms inevitably means progression of arthritis which may preclude a reconstructive procedure.294,302 
Figure 32-39
 
A: A displaced intra-articular fracture of the distal radius with volar subluxation of the joint 8 weeks after injury. B: A CT scan demonstrates the deformity. C: An intra-articular osteotomy was performed through a volar approach. The displacement and subluxation have been corrected.
A: A displaced intra-articular fracture of the distal radius with volar subluxation of the joint 8 weeks after injury. B: A CT scan demonstrates the deformity. C: An intra-articular osteotomy was performed through a volar approach. The displacement and subluxation have been corrected.
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A: A displaced intra-articular fracture of the distal radius with volar subluxation of the joint 8 weeks after injury. B: A CT scan demonstrates the deformity. C: An intra-articular osteotomy was performed through a volar approach. The displacement and subluxation have been corrected.
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Figure 32-39
A: A displaced intra-articular fracture of the distal radius with volar subluxation of the joint 8 weeks after injury. B: A CT scan demonstrates the deformity. C: An intra-articular osteotomy was performed through a volar approach. The displacement and subluxation have been corrected.
A: A displaced intra-articular fracture of the distal radius with volar subluxation of the joint 8 weeks after injury. B: A CT scan demonstrates the deformity. C: An intra-articular osteotomy was performed through a volar approach. The displacement and subluxation have been corrected.
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A: A displaced intra-articular fracture of the distal radius with volar subluxation of the joint 8 weeks after injury. B: A CT scan demonstrates the deformity. C: An intra-articular osteotomy was performed through a volar approach. The displacement and subluxation have been corrected.
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The approach is dictated by the location of the malunion and both dorsal and volar approaches may be necessary. On the dorsal side the joint may be visualized by a transverse capsulotomy; on the volar side the joint should be seen through the osteotomy as a volar capsulotomy is contraindicated. The original fracture line is re-created using an osteotome and fixation is usually by small plates or wires (Fig. 32-39C). Bone grafting is required for any residual metaphyseal defect. 
Marx and Axelrod reported an early series of four patients treated with intra-articular osteotomy and demonstrated excellent and good results, an average grip strength of 86%, and no advancing arthrosis at an average of 23 months postoperatively. The authors concluded that intra-articular osteotomy was the treatment of choice for intra-articular malunion.242 More recently larger series have been reported. Both studies reported significant improvements in ranges of movement and grip strength with an average DASH score of 11 in one44 and 19 of 23 good or excellent results in another.302 The authors of the latter study concluded that the procedure rarely restored normal function but useful function could be obtained. 
Ulnar-Sided Procedures.
There are a number of ulnar-sided procedures available ranging from excisional hemiarthroplasty of the DRUJ to an excision of the distal ulna with or without replacement.116 Ulnar-sided procedures are indicated for persistent pain, rotational contracture, or instability of the DRUJ and may be performed in conjunction with distal radial osteotomy, at a later stage, or in isolation if there is no malunion of the distal radius. After distal radial osteotomy the range of forearm rotation should always be assessed. If rotation remains significantly compromised then an ulnar-sided procedure should be considered. 
Bower’s Procedure.
This is a hemiresection interposition arthroplasty of the DRUJ and is indicated for a symptomatic DRUJ without an ulnar positive variance. This technique involves excision of a substantial portion of the ulnar head leaving the ulnar styloid, TFCC, and an ulnar column of cortex intact. It has the advantage of retaining the connection between the ulnar column and the radius leaving support on the ulnar side of the carpus from the ulnar styloid and TFCC. To gain full benefit the TFCC must be intact and sufficient bone must be excised. It will not succeed where there is radial shortening as resection of the ulnar head allows some radioulnar convergence which may cause ulnocarpal impingement. In this situation the procedure should be combined with ulnar shortening.37 
The outcome of the Bower’s procedure is usually reported for mixed conditions and not specifically for distal radius fracture. Improvement in pain, function, and patient satisfaction is usually reported.37,287 
Sauvé–Kapandji Procedure.
The Sauvé–Kapandji procedure also maintains support on the ulnar side of the radiocarpal joint by retaining the ulnar head and fusing it with screws to the sigmoid notch (Fig. 32-40). To regain rotation a segment of ulna is excised at the level of the ulnar neck. If there is radial shortening the ulnar head must be aligned with the sigmoid notch prior to fusion. Sufficient bone must be excised to prevent the osteotomy healing but this must be balanced against the risk of instability of the stump if too much is excised. The recommended length of excision is 10 to 15 mm plus any ulnar positive variance present.49,75,123,361 
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Figure 32-40
A Sauvé–Kapandji procedure.
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The outcome of this procedure is generally agreed to improve pain and function but not predictably. George et al.123 reported mean DASH scores of 23 ranging from 0 to 60 at an average of 4 years postoperatively. Rotation is reliably restored or improved but in some cases remains painful with symptoms of clicking or instability at the osteotomy site.49,123,361 Disappointing numbers of patients return to their preinjury employment, especially if manual laborers.49,361 It should be recognized that this is a salvage technique and may not restore a painfree wrist. 
Darrach’s Procedure.
Darrach’s procedure is excision of the distal end of the ulnar and was first described for malunion of the distal radius by William Darrach in 1912. The recommended level of excision is at the proximal end of the sigmoid notch.123,247 Mixed results are reported with the main problem being radioulnar convergence which occurs with loss of the buttress at the DRUJ and causes scalloping in the radius at the level of the stump.27 George et al.123 reported a mean DASH score of 23 after Darrach’s procedure with a range from 4 to 61. Grawe et al.132 examined 27 patients in the longer term and found a mean score of 17 using the QuickDASH score. The range of rotation is reliably restored.123,132,258 
Two studies have compared the Darrach’s procedure with the Sauvé–Kapandji procedure with one of these also including Bower’s procedure. Minami et al.258 found significantly less pain relief, deterioration in grip strength, and fewer patients returning to work after Darrach’s compared to Sauvé–Kapandji and Bower’s with increased wrist instability, although they recognized that the Darrach’s group was older. George et al.123 found no significant differences between the Darrach’s procedure and the Sauvé–Kapandji procedure in younger patients. It is generally recommended that Darrach’s procedure should be reserved for older, frailer patients. 
Ulnar Shortening.
Ulnar shortening is indicated where there is symptomatic ulnocarpal impingement after a distal radius fracture, the commonest reason for ulnar positive variance.116 If there is an accompanying angular malunion of the radius then up to 7 mm of radial length can be restored by distal radial osteotomy, but if larger length discrepancy needs to be corrected ulnar shortening is required. If the radius has shortened without angular deformity an isolated ulnar shortening is the procedure of choice. Where there is degenerative change evident in the DRUJ an added Bower’s procedure may be necessary. 
Ulnar shortening osteotomy is performed using parallel transverse cuts, a step cut, or an oblique osteotomy. A transverse osteotomy is simplest but requires the use of a compression device to stabilize the osteotomy during plating.116 Compression plating is then used (Fig. 32-41). Immobilization is not required if the plating is secure. 
Figure 32-41
 
A distal radius fracture has healed without angular deformity but with radial shortening (A). In this situation an isolated ulnar shortening procedure was performed using a transverse cut and a 4 hole plate (B). The normal radio-ulnar relationship has been restored.
A distal radius fracture has healed without angular deformity but with radial shortening (A). In this situation an isolated ulnar shortening procedure was performed using a transverse cut and a 4 hole plate (B). The normal radio-ulnar relationship has been restored.
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Figure 32-41
A distal radius fracture has healed without angular deformity but with radial shortening (A). In this situation an isolated ulnar shortening procedure was performed using a transverse cut and a 4 hole plate (B). The normal radio-ulnar relationship has been restored.
A distal radius fracture has healed without angular deformity but with radial shortening (A). In this situation an isolated ulnar shortening procedure was performed using a transverse cut and a 4 hole plate (B). The normal radio-ulnar relationship has been restored.
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Ulnar shortening has been reported to result in patient satisfaction in most cases113 with improvement in QuickDASH scores reported in one study from 43 preoperatively to 11 postoperatively at an average of almost 3 years after surgery.349 The technique has a low complication rate with the commonest complication being nonunion. Step cut and oblique osteotomies are more complex and were proposed initially to reduce the nonunion rate but this benefit has not yet been demonstrated.113 
Ulnar Head Replacement.
Ulnar head replacement after distal radius fracture is a salvage procedure usually reserved for painful radioulnar impingement following failed Darrach or Sauvé–Kapandji procedures. Restoration of stability with the prosthesis depends on adequate soft tissues being available to stabilize the head of the implant in the sigmoid notch. Distal radial malunion should be corrected prior to replacement. Both short- and long-term results of this procedure are encouraging with restoration of lasting stability and few complications.376,397 

Nonunion

Nonunion of the distal radius is rare occurring in well under 1% of fractures21 and may occur in the presence of extensive metaphyseal comminution.292 The diagnosis is made in the presence of continuing pain and increasing deformity. It is usually treated with plating and bone grafting to which most nonunions are amenable even with small distal fragments.89,292,293 Wrist fusion should be reserved for cases where plating and bone grafting fail. 

Complex Regional Pain Syndrome (CRPS)

CRPS is a serious and often debilitating complication of a number of injuries but is most commonly seen after distal radius fracture. Its etiology is unknown and it is characterized by a number of symptoms and signs including pain, swelling, color and temperature change, and joint contracture. The subject is considered in detail in Chapter 25

Controversies and Future Directions

Fracture of the distal radius remains the commonest fracture treated by orthopedic trauma surgeons, but despite this there is no consensus about the treatment of more complex cases with metaphyseal instability or intra-articular displacement. More work is required to define more accurately those cases that require surgical management. It is essential to eliminate bias toward surgery from our studies and concentrate on patient benefit. 
Over the next decade the most challenging aspect of distal radius fractures will be the increasing numbers of older patients presenting with the injury. To meet this challenge future research should focus on defining those older patients who will benefit from more invasive treatment. 

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