Plating of the distal radius

Plating of the Distal Radius

Arvind D. Nana, MD, Atul Joshi, MD, and David M. Lichtman, MD

Abstract

Distal radius fractures constitute upto 15% of all extremity fractures.1

Patients include both active elderlyindividuals and younger persons in-volved in high-energy trauma. Con-sequently, restoration of wrist func-tion to close to preinjury levels is ofconcern to patients in both groups.

Anatomic restoration of the distalradius and ulna is of major impor-tance in achieving normal wrist func-tion; open reduction has become in-creasingly useful in reaching this goal.The advantages of plating include ac-curate restoration of bony anatomy,stable internal fixation, a decreasedperiod of immobilization, and earlyreturn of wrist function. Recent ad-vances in plate design can help re-duce or eliminate additional steps toaugment stability, such as bone voidfiller, supplemental pins, and exter-nal fixation. A thorough understand-

ing of plating alternatives is necessaryto tailor treatment methods appropri-ately.

Anatomy

Distal RadiusThe distal radius consists of three

independent articular surfaces—thescaphoid facet, lunate facet, and sig-moid notch (Fig. 1). The scaphoid fac-et is part of the lateral distal radius,which includes the radial styloid. Themedial aspect of the distal radius con-sists of the lunate facet and sigmoidnotch. The sigmoid notch is nearly per-pendicular to the lunate facet and ar-ticulates with the distal ulna to formthe distal radioulnar joint (DRUJ). Theclose proximity of the sigmoid notchto the lunate facet implies that any in-jury to the medial aspect of the distal

radius, whether intra-articular or extra-articular, involves the DRUJ.

The lunate facet and its strong lig-amentous attachments to the proxi-mal carpal row and the ulnar styloidform the medial complex of the dis-tal radius. The carpus is nearly alwaysdisplaced with the volar and/or dor-sal medial fragment of the distal ra-dius because of the exceptionally strongligaments of the medial complex.2

Distal Ulna and DistalRadioulnar Joint

The head of the ulna articulateswith the sigmoid notch of the distalradius and abuts the triangular fibro-cartilage complex (TFCC) and the ul-nar carpus. Because the base of theulna styloid (fovea) is the insertionpoint for much of the TFCC and im-portant ulnocarpal ligaments, its in-tegrity is critical to the stability of theDRUJ.3

Dr. Nana is Staff Physician, Department of Or-thopaedic Surgery, JPS Health Network, FortWorth, TX. Dr. Joshi is Resident, Department ofOrthopaedic Surgery, JPS Health Network. Dr.Lichtman is Chairman/Director, Department ofOrthopaedic Surgery, JPS Health Network.

None of the following authors or the departmentswith which they are affiliated has received anythingof value from or owns stock in a commercial com-pany or institution related directly or indirectlyto the subject of this article: Dr. Nana, Dr. Joshi,and Dr. Lichtman.

Reprint requests: Dr. Nana, JPS Health Network,1500 South Main Street, Fort Worth, TX 76104.

Copyright 2005 by the American Academy ofOrthopaedic Surgeons.

Distal radius fractures are common injuries that can be treated by a variety of meth-ods. Restoration of the distal radius anatomy within established guidelines yieldsthe best short- and long-term results. Guidelines for acceptable reduction are (1)radial shortening <5 mm, (2) radial inclination >15°, (3) sagittal tilt on lateral pro-jection between 15° dorsal tilt and 20° volar tilt, (4) intra-articular step-off <2 mmof the radiocarpal joint, and (5) articular incongruity <2 mm of the sigmoid notchof the distal radius. Treatment options range from closed reduction and immobili-zation to open reduction with plates and screws; options are differentiated based ontheir ability to reinforce and stabilize the three columns of the distal radius and ulna.Plating allows direct restoration of the anatomy, stable internal fixation, a decreasedperiod of immobilization, and early return of wrist function. Buttress plates reduceand stabilize vertical shear intra-articular fractures through an antiglide effect, where-as conventional and locking plates address metaphyseal comminution and/or pre-serve articular congruity/reduction. With conventional and locking plates, intra-articular fractures are directly reduced; with buttress plates, the plate itself helpsreduce the intra-articular fracture. Complications associated with plating includetendon irritation or rupture and the need for plate removal.

J Am Acad Orthop Surg 2005;13:159-171

Vol 13, No 3, May/June 2005 159

Columnar Classification of theDistal Radius and Ulna

Conceptually, the distal radius andulna may be divided into three col-umns based on the anatomy (Fig. 1,inset); this columnar classification thencan be used to guide treatment plans.The distal radius is divided into thelateral and medial columns, which an-atomically correlate with the scaphoidfacet and lunate facet, respectively. Themedial column of the distal radius isfurther subdivided into dorsal medi-al and volar medial columns. The lat-eral, dorsal medial, and volar medi-al columns correspond with Melone’s2

system for classifying intra-articulardistal radius fractures. The ulnar col-umn represents the ulnar styloid andthe TFCC.

Pathophysiology

In most activities of daily living, thedorsum of the distal radius is subjectto tensile forces, whereas the volarsurface is subject to compression. Thisis reflected in the bony architectureof the distal radius, with its strongvolar buttressing cortex and thinnercancellous dorsal surface. When thewrist is subjected to a nonphysiolog-ic load, as in a dorsally directed com-pression force (eg, a fall on the out-

stretched hand), predictable fracturepatterns result.

Melone2 aptly described the fourmajor components of intra-articulardistal radius fractures as radial sty-loid, dorsal medial, volar medial, andshaft fragments (Fig. 1). The transversecoronal split between the dorsal andvolar medial distal radius fragmentscan be difficult to assess on plain ra-diographs.4 In many ways, the com-binations of displaced Melone com-ponentsreflectvariantsof fracture typesand classification described in the past.For example, isolated radial styloiddisplacement represents a chauffeur’sfracture. Volar medial displacementdescribes Barton’s fracture; displace-ment of the dorsal medial fragmentrepresents the common reversed Bar-ton’s or dorsal compression fracture.Displacement of all articular fragmentsas a unit is comparable to the classicextra-articular Colles fracture (dorsal)or to Smith’s fracture (volar).

Associated Injuries

Associated injuries must be consid-ered in any comprehensive treatmentplan for patients with distal radius andulna fractures. Up to 68% of distal ra-dius fractures are associated with soft-tissue injuries, such as partial or com-

plete tears of the TFCC, scapholunateligament, and/or lunotriquetral lig-ament.5,6 Fractures involving the lu-nate facet (the medial aspect of the dis-tal radius) and fractures of the radialstyloid cause the most intracarpal in-juries because of the strong ligamen-tous interconnections between the dis-tal radius and carpus.5 Intracarpalligament disruption does not have tobe repaired unless gross instability isnoted on postreduction radiographs(eg, scapholunate diastasis). The 4- to6-week immobilization necessary fordistal radius healing is usually suf-ficient for ligament healing in nondis-placed injuries.

Radiographic and clinical exami-nations of the injured wrist after sur-gical reduction are helpful in evalu-ating the integrity of the DRUJ andTFCC, both components of the ulnarcolumn. TFCC tears are also common,particularly when the medial columnof the distal radius and/or the ulnarstyloid is intact. A fracture of the ul-nar styloid base and significant dis-placement (>2 mm) of an ulnar sty-loid fracture increase the risk of DRUJinstability.7 Treatment of the ulnar col-umn is focused on restoring DRUJstability by closed, percutaneous, oropen treatment of the ulnar styloidand the TFCC.

Imaging Studies

Posteroanterior (PA) and lateral ra-diographs are necessary for every pa-tient with a distal radius injury. Thelateral view of the wrist places the an-terior surface of pisiform between thevolar surface of the scaphoid (thescaphoid tuberosity) and the anteri-or surface of the capitate.8

Treatment options for distal radi-us fractures are based on the initialinjury as well as on radiographs madeafter closed reduction. If the initialinjury position is within acceptableguidelines9 (Table 1) for the patient’sfunctional requirements, any loss ofreduction is usually insignificant as

Figure 1 Distal radius anatomy. The fracture line between the volar medial and dorsal me-dial columns extends into the sigmoid notch and thus must also be evaluated on postreduc-tion radiographs. (Reproduced with permission from Trumble TE, Culp RW, Hanel DP, GeisslerWB, Berger RA: Intra-articular fractures of the distal aspect of the radius. Instr Course Lect1999;48:465-480.) Inset, Columnar classification of distal radius and ulna.


160 Journal of the American Academy of Orthopaedic Surgeons

long as the fracture is adequately im-mobilized and protected. Converse-ly, unacceptable initial displacementoften means that loss of reduction af-ter nonsurgical treatment may requiresurgical intervention.

The initial postinjury lateral viewof the distal radius will demonstrateeither the more common dorsal dis-placement or the less frequent volardisplacement of the distal radius col-umns. The direction of initial displace-ment on the lateral radiograph gen-erally correlates with the side of bothgreatest cortical comminution and re-quired initial treatment. For example,if the lateral view shows dorsal dis-placement of the lunate facet, then thedorsal surface will have the greatestcortical fragmentation, and reductionwill initially be focused dorsally.

Postreduction or traction radio-graphs also are useful in assessingwhether the distal radius fracture isintra-articular or extra-articular. Theextent of cortical comminution ismore easily visualized on postre-duction radiographs than on initialpostinjury radiographs.11 All plain ra-diographs of distal radius fracturesshould include evaluation of radialinclination, radial length, ulnar vari-ance, radial tilt,9 articular step-off orgap, sigmoid notch step-off or gap,DRUJ subluxation/dislocation, andthe presence and extent of displace-ment of ulnar styloid fractures (Fig.2). Because of individual variability,

appropriate radiographs of the unin-jured contralateral wrist are recom-mended to evaluate the patient’s nor-

mal anatomy and correspondingradiologic measurements.

Plain radiographs may be insuffi-cient to assess the extent of intra-articular and extra-articular fragmen-tation and injury to the DRUJ. Axialcomputed tomography (CT) scanswith sagittal and coronal plane recon-structions can aid in visualizing die-punch fractures, volar rim fractures,and scaphoid facet fractures.

Treatment of Distal RadiusFractures

All patients with distal radius frac-tures warrant a trial of closed reduc-tion and plaster immobilization; ex-

Table 1Guidelines for Acceptable Reduction of Distal Radius Fractures*

1. Radial shortening <5 mm at the DRUJ compared with the contralateralside

2. Radial inclination on posteroanterior radiographs >15°3. Sagittal tilt on the lateral projection between 15° dorsal tilt and 20° volar

tilt4. Intra-articular step-off or gap <2 mm of the radiocarpal joint10

5. Articular incongruity <2 mm of the sigmoid notch of the distal radius

*These guidelines must be individualized to accommodate each patient’s functionalactivity levels and general medical status.Adapted with permission from Graham TJ: Surgical correction of malunited fracturesof the distal radius. J Am Acad Orthop Surg 1997;5:270-281.

Figure 2 The various angles to assess in distal radius fractures. A, Radial inclination (RI;normal, 22°). B, Radial length (RL; normal, 12 mm). C, Ulnar variance (UV; normal, 0 to −2mm). D, Radial tilt (RT; normal, 11° volar). (Reproduced with permission from Graham TJ:Surgical correction of malunited fractures of the distal radius. J Am Acad Orthop Surg 1997;5:270-281.)

Arvind D. Nana, MD, et al

Vol 13, No 3, May/June 2005 161

ceptions include those with openinjuries, those who cannot tolerate im-mobilization, and those with volar ordorsal vertical shear fractures (Barton’sfracture). Multiple trauma is also anindication for early surgical interven-tion. If the fracture can be reduced towithin acceptable guidelines (Table 1)and maintained in satisfactory align-ment by plaster sugar-tong splint im-mobilization, it is considered to be sta-ble.Anunstablefracture ischaracterizedby inadequate reduction of a displacedfracture fragment or by the inabilityto maintain reduction after closed frac-ture manipulation. Depending on func-tional expectations, surgical treatmentmay be considered for unstable frac-tures involving the medial column ofthe distal radius (Fig. 3).

Determining short-term stabilityafter closed reduction is difficult andis based largely on personal experi-ence in the treatment of distal radiusfractures. If the surgeon thinks thata fracture is unstable and may presentan unacceptable risk to the patient,

then early open treatment with fix-ation should be considered. Success-ful closed treatment requires attentionto detail by the physician as well ascomplete patient compliance withpostreduction protocols.

Normal wrist and forearm motionsubjects the dorsal metaphysis of thedistal radius to both tensile and com-pressive forces, but the volar surfacetransmits greater compressive forc-es.8 Restoration of these biomechan-ical relationships is necessary to es-tablish a stable reduction of the distalradius fracture. The first step towarda stable reduction is to create a sta-ble volar buttress. In distal radiusfractures with dorsal comminution,volar integrity is reestablished by ac-curate cortical apposition of the largevolar metaphyseal fragments. Withcomminuted volar metaphyseal frag-ments or inherently unstable volarvertical shear fractures (volar Bartonfractures), stable fracture reductioncan be achieved by placement of avolar buttress plate. Once volar sta-

bilityisrestored,thedorsalmetaphys-eal fragments can be reduced againstthe stable volar buttress using exter-nal fixation, percutaneous pins, and/or bone void filler (bone graft).8

Autograft, allograft, or other bonegraft substitutes may be used to fillthe metaphyseal defect created afterreduction of distal radius fractures.Comminuted metaphyseal fragmentsare characterized by more compressedcancellous bone and a greater void af-ter reduction. Conversely, large meta-physeal fragments are associated withless compressed cancellous bone andthus a lower requirement for bonegrafting. A bone void filler has sev-eral advantages, including mechan-ical support,12 providing osteoconduc-tive material for the bone defect, fasterbone healing, and decreased incidenceof loss of reduction.12-15 Hydroxyapa-tite cement without additional fixa-tion is inadequate for the treatmentof distal radius fractures;16 it shouldbe combined with external fixation tosupplement any bone void filler.

Volar buttress plate

Medial column fractureof the distal radius

Large dorsalmetaphyseal

fragments

Unstable dorsalmetaphyseal

fragments

Stable dorsal metaphysealfragments or no dorsal

fracture

Small dorsalmetaphyseal

fragments

Percutaneous pins and splintimmobilization

Splint immobi-lization

Stable volar metaphysealfragments after closed

reduction* or no volar fracture

Unstable volar metaphysealfragments after closed

reduction

Conventional volarplate with dorsal

percutaneous pins

Volar plate withdistal lockingscrews/pegs

Small dorsalmetaphyseal

fragments

Large dorsalmetaphyseal

fragments

Unstable dorsalmetaphyseal

fragments

Stable dorsalmetaphyseal

fragments

Volar platewith distal

lockingscrews/pegs

Dorsal platewith distal

lockingscrews/pegs

Conventional volarplate with bone void filler and

external fixation

Dorsalbuttress

plate

Dorsal bone void filler andneutralization

external fixation

Figure 3 Plating recommendations for fractures of the medial column of the distal radius. Treatment choice depends on surgeon pref-erence and experience. * = accurate cortical apposition of the volar metaphyseal fragments.



Restoration of volar stability hasimportant radiocarpal implicationsbecause the stronger and more impor-tant radiocarpal ligaments are at-tached to the volar surface. Volar in-tegrity therefore is critical because itfacilitates adequate reduction of dor-sal metaphyseal fragments against astable volar buttress and because itprevents possible volar radiocarpalinstability.8

Plate FixationPlate fixation is primarily indicat-

ed for unstable fractures of the volarmedial column of the distal radius;it is also helpful for combined volarand dorsal medial column injuries.Although some authors recommenddorsal plates for isolated dorsal me-dial column injuries of the distal ra-dius, other methods of treatment areavailable for these injuries. Volarplates with locking screws or pegsmay be effective for extensive dorsalcomminution.

Distal radius plates are categorizedby location of use and type of plate.Plates categorized by location may beused on the dorsal medial, volar me-dial, and radial styloid aspects of thedistal radius. Certain plate designsaddress two areas simultaneously (ie,dorsal medial distal radius and radi-al styloid, or volar medial distal ra-dius and radial styloid). Smaller im-plants are also available to stabilizeeach area separately.

The two principal types of distalradius plates are buttress plates andplates that can span metaphysealcomminution and/or maintain artic-ular congruity and reduction. Onlythe buttress plate, with its antiglideeffect, reduces intra-articular fractures(eg, volar Smith or Barton fractures[Fig. 4] or dorsal Barton fracture). Allother distal radius plates require di-rect reduction of intra-articular frac-tures; the plating serves to maintainthe alignment.

Plates that maintain alignment canbe further subdivided into two types:conventional and locking. In conven-

tional plate design, stability of theconstruct is ultimately achievedthrough apposition of the bone andplate by screw purchase in the bone.Conventional plates can be used dor-sally or volarly. The use of dual smallconventional plates on the dorsal dis-tal radius also has been described.17

When cortical or cancellous screwsare used in the distal holes of the but-tress plate, they are most effective ifthe opposite cortex is not comminut-ed. If the opposite cortex is commi-nuted, the surface could collapse be-cause of both axial forces across thewrist joint and toggle of the screwsin the plate, which may result in loos-ening of the distal screws.18

Plates with locking distal screwsor pegs support the subchondral boneand resist forces across the articula-tion that may displace the articularfragments (Figs. 5, 6, and 7). Lockingscrews or pegs offer numerous advan-tages over regular screws because theirstability is achieved through plate de-sign. The screws or pegs become fixed-angle devices via threaded heads thatengage the threaded distal screw holesof the plate for stability. New plate de-signs allow locking screw insertion inthe most distal screw holes as well asin the proximal screw holes. Of his-torical note, the dorsal plate used byGesensway et al19 employed a bladeplate construct with multiple tines toachieve fixed-angle fixation.

Locking screws or pegs supportthe subchondral bone without rely-ing on the purchase of the screws orpegs in bone, and they are indepen-dent of opposite cortex comminution.Accordingly, no bone void filler is re-quired to prevent collapse at the siteof comminution. The distal screws orpegs—whether cortical, cancellous, orfixed-angle—serve to maintain reduc-tion of articular fragments, but theydo not directly reduce the articularfracture.

Distal Radius PlatingPlating offers direct restoration of

the distal radius through stable fix-

ation. The stability of the construct en-sures more predictable healing of thefracture and thus shortens the peri-od of immobilization of the wrist. Theprincipal advantage of distal radiusplating is the early return of wrist func-tion, an important criterion for patientswho expect wrist function after inju-rytoreturntopreinjurylevels.Conven-tional plates can be used for buttressand/or neutralization support of adistal radius fracture. Plates with lock-ing screws or pegs do not rely on an-atomic contour of the plate to obtainstability. Stabilization of the oppositecortex through locking screws or pegssignificantly decreases or eliminatesthe need for further stabilization ofthe opposite cortex fragmentation.

Figure 4 The antiglide effect of a buttressplate helps reduce a volar vertical shear frac-ture (volar Barton fracture) of the distal ra-dius. The most proximal screw is placed first;the penultimate distal screw (A) reduces thefracture (arrows) (B) before placement of thefinal distal screw (C). (Reproduced with per-mission from Jupiter JB: Complex articularfractures of the distal radius: Classificationand management. J Am Acad Orthop Surg 1997;5:119-129.)


Vol 13, No 3, May/June 2005 163

Surgical Treatment

Extra-articular Distal RadiusFractures

These injuries are transverse orshort oblique fractures proximal to theDRUJ and are usually amenable toclosed treatment methods with sup-plementary percutaneous pin stabi-

lization. For an unstable distal shaftfracture with minimal or no commi-nution that is either dorsally or vo-larly displaced, a volar plate is suf-ficient to achieve stable fixation. Alocking volar plate does not offer anyspecific advantage over convention-al volar plating systems for this typeof fracture. However, for an extra-

articular fracture with dorsal or volarcomminution, a locking volar platemay offer stability; it also restoreslength without the mobilization ofextensor tendons that is required fordorsal plating. A dorsal plate for anextra-articular fracture with dorsalcomminution is considered excessivetreatment without sufficient benefit be-cause these fractures can be routine-ly pinned and stabilized in a closedfashion. Bone void filler and externalfixation may be used for severely com-minuted extra-articular fractures.

Intra-articular Distal RadiusFractures

The concept of four-part displace-ment is useful in conceptualizing atreatment algorithm, especially withregard to the indications for distal ra-dius plating. When evaluating a pa-tient with a distal radius fracture,three distinct areas (columns) are as-sessed (Fig. 1, inset). The medial col-umn of the distal radius representsMelone’s dorsal and volar die-punchradius fragments; plates and/or bonevoid filler are particularly applicablefor restoration of this column. The ra-dial styloid component—the lateraldistal radius column—is then re-viewed to determine whether local-ized treatment is sufficient (eg, per-cutaneous pins or screws for thedisplaced radial styloid) or whethertreatment should be combined withfixation of the medial column of thedistal radius (eg, a volar or dorsalplate that also fixes the styloid). Fi-nally, the ulnar column, representingthe TFCC and the ulnar styloid com-ponents, is addressed.

Intra-articular Fractures of theLateral Column

The radial styloid fracture and itscorresponding scaphoid facet areusually displaced proximally by ax-ial compression forces. Often the frag-ment is rotated in pronation, but thisis not easily appreciated on routineradiographs. CT scan and dynamicfluoroscopy can help delineate this

Figure 5 A, With conventional screws, stability is achieved through friction between theplate undersurface and the underlying bone (arrows) resulting from screw compression atthe interface. This stability is augmented by bicortical screw purchase, which also decreasestoggle between the screw and plate hole (represented by the rectangles). Friction at the in-terface must be higher than the axial forces to ensure absolute stability. Thus, anatomic con-touring of the conventional screw/plate system is needed to obtain a stable construct. B, Ina locking screw system, the threaded screw head locks in the threaded screw hole of the plateto attain stability. Consequently, axial forces in the bone are transmitted to the plate ratherthan the screw, and no screw toggle can occur (arrows). Because stability with a locking screwdoes not require compression between the bone and the plate (rectangles), the periosteal bloodsupply under the plate is preserved. (Adapted with permission from Appenzeller A, Chris-tensen R, Frenk A, Gilbert S, Schavan R: The development of the distal femur LISS. Injury2001;32[suppl 3]:5-25.)

Figure 6 In the distal radius, the principal advantage of a plate with locking screws is sta-bility of the construct, even in the presence of segmental bone defect or comminution of cor-tex opposite the plate. Because the screws lock into the plate, the axial forces are transmittedto the plate. This diagram shows locking screws along the entire plate. F = axial force in thedirection of the arrow. (Adapted courtesy of Synthes [USA], Paoli, PA.)



rotational deformity. Isolated radialstyloid fractures should raise con-cerns about concomitant intracarpalinjury. A displaced radial styloid usu-ally can be reduced by closed means(ligamentotaxis by wrist flexion and

ulnar deviation) and stabilized withtwo percutaneous pins. Reductionand pin placement are assessed intra-operatively with fluoroscopy or, ifopen reduction is used, under directvisualization (Figs. 8 and 9). Occa-

sionally the radial styloid fragmentmust be manipulated into position,using the pins as joysticks, before se-curing the position by advancing thepins into the opposite cortex. The di-rection of the styloid pins is from ra-

Figure 7 Anteroposterior (A) and lateral (B) radiographs of a distal radius injury. The fracture, which demonstrates volar and dorsal in-stability, is fixed with a volar locking plate (C and D). The dorsal instability is best seen in the postoperative lateral view (D), which showsa dorsal gap just proximal to the locking pegs. The locking pegs stabilize both the dorsal and volar articular fragments. In this patient, bonevoid filler was not used in the dorsal gap, and the distal ulna was not surgically stabilized. (Courtesy of Arvind D. Nana, MD, Fort Worth,TX.)

Figure 8 Anteroposterior (A) and lateral (B) radiographs of a wrist at initial presentation. Anteroposterior (C) and lateral (D) radiographsof the wrist in longitudinal traction. The patient is immobilized in a plaster sugar-tong splint. (Courtesy of David M. Lichtman, MD, FortWorth, TX.)


Vol 13, No 3, May/June 2005 165

dial volar to ulnar dorsal. Other op-tions for styloid fixation includepercutaneous lag screw fixation or asmall buttress plate and pins.20

Plate fixation of the radial styloidis usually done in combination withstabilization of medial column inju-ries of the distal radius. Volar or dor-sal distal radius plates include radialstyloid stabilization in their constructand therefore do not need separate ra-dial styloid plating or pinning. Cer-tain smaller implant designs are avail-able for separate plating of radialstyloid fractures, but this is almost al-ways in combination with medial col-umn stabilization (whether dorsal orvolar). Separate lateral and medialcolumn plating of the distal radius ismost mechanically stable when theplates are angled 50° to 90° to eachother.11,17,20,21 Separate radial styloidplates are placed on the dorsal radialor most radial aspect of the distal ra-dius; this placement requires a low-profile design to avoid irritation of thebrachioradialis tendon or dorsal ex-tensor tendons.

Intra-articular Fractures of theMedial Column

Unstable volar fractures are ame-nable to volar plate stabilization. If thefracture is isolated (ie, there is no dor-sal fragment instability), then a sim-ple buttress plate may be used to re-constitute the volar cortex. If the volarmetaphysis is comminuted, bonevoid filler may be used to fill in thegap and also to support the distal ar-ticular surface. The integrity of thejoint should not be violated by dis-secting the volar radiocarpal liga-ments. When necessary, the volar cor-tex can be hinged open like a bookto inspect and realign volar intra-articular injuries.

When dorsal fragment instabilityalso is present, several options areavailable. If a volar buttress plate hasbeen applied, then the dorsal frag-ment must be stabilized from a dor-sal approach. If the dorsal fragmentis large, it can be fixed by one or (pref-erably) two percutaneous cross pinsentering the dorsal medial fragmentdistally and aimed proximally and ra-

dially (Figs. 8 and 9). As with the ra-dial styloid fragment, percutaneouspins can be used as joysticks to ma-nipulate the dorsal fragment into po-sition. The pins also may be placedinto the fracture line (intrafocal Ka-pandji pinning [Fig. 10]), startingmore perpendicular to the dorsal cor-tex, and then used to reduce the dor-sal fragment by moving the pins morenearly parallel to the dorsal cortex,with subsequent fixation into thevolar cortex.

If the dorsal medial fragment iscomminuted, reducing and holdingthe area with pin fixation may be dif-ficult. The fracture can be opened dor-sally, usually through a longitudinalapproach between the third andfourth dorsal extensor compartments.An approach ulnar to the fourth com-partment also may be used if the com-minution is limited to the dorsal ul-nar corner and semilunar notch. Thefloor of the third extensor compart-ment is incised longitudinally; thenthe fourth extensor compartment(sheath and tendons) is sharply ele-

Figure 9 Same patient as in Figure 8. Anteroposterior (A) and lateral (B) radiographs made 1 week after injury. The laterally displacedradial styloid fragment and volarly displaced volar medial fragment (arrows) are evident. Instability of these fragments is easily demon-strated by their inability to maintain initial closed reduction. Anteroposterior (C) and lateral (D) postoperative radiographs show that thevolar medial fragment is stabilized with a volar plate. The radial styloid is fixed with two percutaneous pins; the dorsal cortex with its largedorsal fragments is stabilized with a dorsal percutaneous pin. The ulnar styloid also was stabilized because of the fracture through its base,marked displacement (>2 mm), and clinical instability of the DRUJ after stabilization of the distal radius. (Courtesy of David M. Lichtman,MD, Fort Worth, TX.)



vated off the dorsal distal radius.Bone grafting of the dorsal metaphy-sis is now possible. If the joint needsto be viewed, the dorsal capsule canbe incised transversely. Reduction un-der direct visualization usually can bedone, and bone void filler is oftenused to stabilize and buttress the dor-sal cortex. If necessary, a transversecapsular incision may be used to ex-plore the radiocarpal joint and reduceintra-articular or intracarpal injuries.Some surgeons use low-profile dor-sal plates at this point to maintain ar-ticular reduction and stability; othersapply an external fixator for 3 to 4weeks to avoid use of a dorsal plate.

An alternative for treating bothdorsal and volar instability is to usea plate with locking screws or pegsto transfix both volar and dorsal cor-tices of the medial column of the dis-tal radius (Fig. 7). Satisfactory resultshave also been achieved using lock-ing screw–plate combinations fromthe dorsal side.22-24

Although dorsal plates do permitadequate healing of the fracture, theirsecondary effects—particularly onsurrounding soft-tissue structures—render them a less appealing option.

Disadvantages of dorsal plates in-clude the need for mobilization of ex-tensor tendons to achieve properplate placement, possible tendon ir-ritation or rupture because of a prom-inent plate or screws, and the possi-bility of additional surgery to removethe symptomatic dorsal plate.

In isolated unstable fractures of thedorsal medial column, the decision totreat with pin fixation or with openbone grafting plus neutralization ex-ternal fixation depends on the size ofthe fragments. Treatment is the sameas when combined with volar insta-bility: percutaneous pins for largefragments or open reduction, bonevoid filler, and external fixation forcomminuted fractures (small frag-ments). Once again, low-profile dor-sal plates can be applied instead ofan external fixator, but locking screwsor pegs are not necessary in this in-stance.

A lateral column injury of the dis-tal radius is usually treated concom-itantly or after stabilization of the me-dial column. As noted, if the fracturepattern permits, the styloid can befixed with either a volar or dorsalplate. In most instances, the radial sty-

loid can be fixed separately using twopercutaneous pins, as described forisolated radial styloid fractures.Aper-cutaneous lag screw or a small dorsalradial buttress plate are also options.

Surgical Approach

Volar Radial ApproachThe volar radial (Henry) approach

is utilitarian; it can expose the entirevolar radial surface up to the DRUJ(Fig. 11, A). This exposure uses the in-terval between the flexor carpi radi-alis (FCR) and the radial artery orgoes through the floor of the FCR ten-don sheath. The pronator quadratusmuscle is elevated in a subperiostealfashion to visualize the volar distalradius.25 Orbay26 and Orbay andFernandez27 also describe the releaseof the first extensor compartment andthe insertion of the brachioradialis offthe lateral distal radius to permit ac-cess to the dorsal surface and to fa-cilitate the reduction of the lateral col-umn of the distal radius (radialstyloid). Release of the volar capsuleor the ligamentous attachments onthe volar rim may lead to volar ra-diocarpal instability and should beavoided.

Carpal tunnel release through thedistal extension of this approach is notrecommended because of potentialinjury to the volar cutaneous branchof the median nerve. If carpal tunnelrelease is indicated, a separate stan-dard or a mini carpal tunnel incisionis recommended. Prophylactic carpaltunnel release is not routinely per-formed21,28,29 unless acute carpal tun-nel symptoms are present or unlessthe distal fragment is significantlydorsally displaced for a prolongedperiod of time.

Volar Ulnar ApproachThe volar ulnar approach offers

limited exposure to the radial columnand is indicated for injuries to the vo-lar aspect of the medial column andthe DRUJ (Fig. 11, B). The interval be-tween the flexor carpi ulnaris and the

Figure 10 With intrafocal Kapandji pinning, the pin is placed through the fracture site andmaneuvered to elevate the fragment. Once adequate reduction is achieved, the pin is thendriven through the opposite cortex to achieve stability. This technique can be used to restoreradial inclination (A) or volar tilt (B). (Adapted with permission from Palmer AK: Fracturesof the distal radius, in Green DP [ed]: Operative Hand Surgery. New York, NY: Churchill Liv-ingstone, 1993, pp 929-971.)


Vol 13, No 3, May/June 2005 167

finger flexor tendons is used for thisapproach. While retracting the flexortendons radially and protecting theulnar nerve and artery, the pronatorquadratus muscle is mobilized off thedistal ulna. This exposure has the ad-vantage of permitting distal extensionto complete a carpal tunnel release.

Postoperative Management

After surgery, immobilization is de-sirable to facilitate soft-tissue heal-ing and resolution of swelling. Plas-ter splinting is preferable to the useof circumferential or bivalved castsbecause use of casts may lead to po-tential complications such as fingeredema and compartment syndrome.

Postsurgical follow-up includessuture removal at 10 to 14 days and

serial radiographs for the first 2weeks if deemed necessary. Arm el-evation and finger range of motionare important components of earlyrehabilitation. Conversion to a cir-cumferential cast may be consideredat 2 weeks; however, complete wristimmobilization beyond the fourthpostoperative week usually is notdesirable because it negates the ad-vantage of early restoration of wriststability with plating. During the pe-riod of immobilization, therapy isfocused on finger motion; once im-mobilization is discontinued, ther-apy expands to include wrist motion(flexion, extension, ulnar deviation,and radial deviation) and forearmrotation (pronation, supination). Aremovable Velcro wrist splint thencan be provided for support andcomfort while the patient engages in

gentle activities of daily living andactive range-of-motion exercises.

With plating of extra-articular frac-tures, or for fractures with well-fixedintra-articular fragments, immobili-zation can be discontinued as earlyas 2 weeks after surgery as long as theincision is sufficiently healed and ede-ma has decreased to allow wrist mo-tion. For more complex intra-articularfractures treated with plating, immo-bilization for at least 4 weeks is nec-essary to permit healing of the intra-articular fragments and to allow wristmotion without risk of displacementof the intra-articular fragments. For6 to 8 weeks, splints can be worn atnight, and only light physical thera-py is recommended. Strenuous push-ing, pulling, twisting, or lifting shouldbe avoided for the first 3 months tofacilitate optimal bone healing.

Figure 11 A, The volar radial approach uses the interval between the flexor carpi radialis tendon and the radial artery. The pronator quadra-tus is elevated sharply, starting at its insertion on the distal radius. B, Top detail, the volar ulnar approach can be extended distally to releasethe median nerve from the carpal tunnel. Bottom detail, at the level of the distal radius, the flexor tendons and the median nerve are re-tracted radially to expose the volar medial distal radius. (Adapted with permission from Fernandez DL, Jupiter JB: Fractures of the DistalRadius. New York, NY: Springer, 1996, pp 67-102.)



Complications

The most common complication ofplate fixation in the distal radius istendon injury; 25% of patients eval-uated reported everything from ten-don irritation to frank rupture.17,24,30

With the volar plate, tendon injurieshave included rupture of the flexorpollicis longus,22,31,32 FCR tenosyno-vitis,28 and dorsal extensor tendon in-volvement as a result of protrudingscrews.28,33 Dao et al34 reported radi-al artery pseudoaneurysm secondaryto volar distal radius plate design.Median nerve dysfunction (ie, pares-thesia, carpal tunnel syndrome, or re-flex sympathetic dystrophy) is asso-ciated with volar plating, but routineprophylactic carpal tunnel release inthis scenario is not considered stan-dard treatment.21,28,29 Adverse effectsare more common with dorsal plat-ing than with volar plating.

As with dorsal plates, tendon-related complications requiring plateremoval also occur after volar plat-ing; in one study, 13 of 73 patients(18%) required plate removal aftervolar plating.32 Tendon irritation isthought to be caused by prominentor sharp plate edges,17,23,30 prominentor loose screws,35 and cellular reac-tion to the titanium metal of theplates.34,36 Extensor tendon rupturecan be caused by screws that are looseor backing out,30,33,37 by sharp edgescreated by cutting of the plate,17 andby prominent design of the distal as-pect of the dorsal plate.36,38,39 Manyauthors have reported a high inci-dence (up to 30%) of dorsal plate re-moval secondary to tendon inflam-mation or rupture.17,23,30,34-36 Toprevent tendon injury, some recom-mend that a portion of the extensorretinaculum be interposed betweenthe plate and the tendon or tendonsheath,21,30,40 or that the dorsal platesbe routinely removed.23,37,40 Tendonrupture has been reported as early as8 weeks and as late as 7 months af-ter surgery.30,38 Plate breakage is an-other reason for plate removal.37

Loss of reduction also can be aproblem and is seen more frequentlywith the use of conventional plateswhen the opposite cortex is not fur-ther augmented with pins, bone voidfiller, or external fixation.24,34,41,42

Outcomes

Functional outcomes of distal radiusfractures depend on multiple factors,including radial shortening, radial in-clination, sagittal tilt, intra-articularstep-off or gap, and articular congru-ity of the sigmoid notch (Table 1). Al-though intra-articular step-off >2 mmhas been shown to lead to radio-graphic osteoarthritis, this does notnecessarily correlate with poor func-tional outcome.10 Radial shortening>5 mm, however, may have a markedimpact on outcome because it can af-fect both the DRUJ and the radiocar-pal joint.9,10,43

Outcome studies for each type ofdorsal plate design (conventional,dual, and locking) have been per-formed, but the average follow-up isonly 12 to 19 months for populationgroups ranging from 21 to 73 patients.Two studies of conventional plate de-sign demonstrated 72% to 95% good-to-excellent functional results, with areported complication rate of 20% to23%. The largest study evaluated dualdorsal plating in the treatment of dis-tal radius fractures; however, evenwith 97% good-to-excellent results,the incidence of complications was21%.17,24,30

Of the dorsal plates with lockingscrews or pegs, the Synthes pi plate(Paoli, PA) demonstrated a 57% good-to-excellent outcome and a 23% com-plication rate.39 Subsequent reportson the pi plate show good-to-excellent functional results of 56% to68%.21,44 All of the studies on dorsalplating, regardless of design, includethe complication of plate removal asa secondary procedure.21,39,44 The rea-son for plate removal is usually ex-tensor tenosynovitis or rupture.

Keating et al42 examined the resultsof the volar buttress plate in 79 pa-tients and found that functional re-covery associated with malunion wassignificantly less than in those withgood anatomic restoration. Malunionwas the most frequent complication(28%) of all complications reported(40.5%).42

Orbay26 and Orbay and Fernan-dez27 examined the use of the volarplate with locking pegs for the treat-ment of dorsally displaced fracturesof the distal radius; they reported100% good-to-excellent results. Theauthors attributed the success of thetreatment plan to stable internal fix-ation and preservation of dorsal softtissues, which facilitate early fracturehealing; decreased need for bonegrafting; and low incidence of tendoninjury. In their study, 9 of 29 patients(31%) had preoperative median nervesymptoms and also underwent car-pal tunnel release. One patient hadextensor tendon irritation secondaryto a long peg that necessitated hard-ware removal, but all other plateswere left in place.26,27 No study has afollow-up >19 months; thus, conclu-sive long-term recommendations fordistal radius plating cannot be madebased on these reports.

Summary

Improved restoration of the anatom-ic relationship in unstable distal ra-dius fractures can lead to improved,early functional outcome; the trendis to achieve this goal through openreduction and internal fixation. Ben-efits of plate fixation include direct vi-sualization of the fracture, stable in-ternal fixation, a shortened period ofimmobilization, and early return ofextremity function. Recent plate de-signs include locking screws or pegsthat maintain articular reduction aswell as span and stabilize the com-minution of the opposite cortex.

The outcome of plating distal ra-dius fractures cannot be compared to


Vol 13, No 3, May/June 2005 169

other surgical options because of alack of long-term follow-up and thewide variation of indications for plat-ing in published studies. The three-column system for distal radius andulna fractures is a simple and prac-tical approach to understanding and

treating these common, yet some-times complex, injuries. The risks andbenefits of plating must be balancedfor each patient and weighed withcomplete understanding of the patho-logic anatomy and physiology of eachspecific fracture pattern.

The OKO video ″Intra-articular Distal Radius Fractures,″ byChristopher H. Allan, MD, is avail-able at http://www5.aaos.org/oko/jaaos/main.cfm.

References1. Sanders WE: Distal radius fractures, in

Manske PR (ed): Hand Surgery Update.Rosemont, IL: American Academy of Or-thopaedic Surgeons, 1996, pp 117-123.

2. Melone CP Jr: Articular fractures of thedistal radius. Orthop Clin North Am1984;15:217-236.

3. Palmer AK: The distal radioulnar joint.Orthop Clin North Am 1984;15:321-335.

4. Andersen DJ, Blair WF, Steyers CM,Adams BD, El-Khouri GY, BrandserEA: Classification of distal radius frac-tures: An analysis of interobserver reli-ability and intraobserver reproducibil-ity. J Hand Surg [Am] 1996;21:574-582.

5. Geissler WB, Freeland AE, Savoie FH,McIntyre LW, Whipple TL: Intracarpalsoft-tissue lesions associated with anintra-articular fracture of the distal endof the radius. J Bone Joint Surg Am 1996;78:357-365.

6. Richards RS, Bennett JD, Roth JH,Milne K Jr: Arthroscopic diagnosis ofintra-articular soft tissue injuries asso-ciated with distal radius fractures.J Hand Surg [Am] 1997;22:772-776.

7. May NM, Lawton JN, Blazar PE: Ulnarstyloid fractures associated with distalradius fractures: Incidence and implica-tions for distal radioulnar joint instabil-ity. J Hand Surg [Am] 2002;27:965-971.

8. Nana AD, Lichtman DM: Distal-thirdforearm fractures. Available at http://www.emedicine.com/orthoped/topic79.htm. Accessed April 27, 2005.

9. Graham TJ: Surgical correction ofmalunited fractures of the distal radius.J Am Acad Orthop Surg 1997;5:270-281.

10. Knirk JL, Jupiter JB: Intra-articular frac-tures of the distal end of the radius inyoung adults. J Bone Joint Surg Am 1986;68:647-659.

11. Rikli DA, Regazzoni P: Fractures of thedistal end of the radius treated by inter-nal fixation and early function. J BoneJoint Surg Br 1996;78:588-592.

12. Fernandez DL, Geissler WB: Treatmentof displaced articular fractures of the ra-dius. J Hand Surg [Am] 1999;24:102-107.

13. Leung KS, Shen WY, Leung PC, Kinnin-month AWG, Chang JCW, Chan GPY:

Ligamentotaxis and bone grafting forcomminuted fractures of the distal ra-dius. J Bone Joint Surg Br 1989;71:838-842.

14. Putnam MD, Fischer MD: Treatment ofunstable distal radius fractures: Meth-ods and comparison of external distrac-tion and ORIF versus external distrac-tion-ORIF neutralization. J Hand Surg[Am] 1997;22:238-251.

15. Trumble TE, Schmitt SR, Vedder NB: Fac-tors affecting functional outcome of dis-placed intra-articular distal radius frac-tures. J Hand Surg [Am] 1994;19:325-340.

16. Jeyam M, Andrew JG, Muir LT, McGov-ern A: Controlled trial of distal radialfractures treated with a resorbable bonemineral substitute. J Hand Surg [Br]2002;27:146-149.

17. Jakob M, Rikli DA, Regazzoni P: Frac-tures of the distal radius treated by in-ternal fixation and early function. J BoneJoint Surg Br 2000;82:340-344.

18. Small Fragment Locking CompressionPlate (LCP): Technique Guide. Paoli, PA:Synthes (USA), 2002, pp 1-20.

19. Gesensway D, Putnam MD, Mente PL,Lewis JL: Design and biomechanics ofa plate for the distal radius. J Hand Surg[Am] 1995;20:1021-1027.

20. Swigart CR, Wolfe SW: Limited incisionopen techniques for distal radius frac-ture management. Orthop Clin NorthAm 2001;32:317-327.

21. Hahnloser D, Platz A, Amgwerd M,Trentz O: Internal fixation of distal ra-dius fractures with dorsal dislocation:π-plate or two ¼ tube plates? A prospec-tive randomized study. J Trauma 1999;47:760-765.

22. Fuller DJ: The Ellis plate operation forSmith’s fracture. J Bone Joint Surg Br1973;55:173-178.

23. Fitoussi F, Ip WY, Chow SP: Treatmentof displaced intra-articular fractures ofthe distal end of the radius with plates.J Bone Joint Surg Am 1997;79:1303-1312.

24. Finsen V, Aasheim T: Initial experiencewith the Forte plate for dorsally dis-placed distal radius fractures. Injury2000;31:445-448.

25. Trumble TE, Culp RW, Hanel DP, Gei-

ssler WB, Berger RA: Intra-articularfractures of the distal aspect of the ra-dius. Instr Course Lect 1999;48:465-480.

26. Orbay JL: The treatment of unstabledistal radius fractures with volar fixa-tion. Hand Surg 2000;5:103-112.

27. Orbay JL, Fernandez DL: Volar fixationfor dorsally displaced fractures of thedistal radius: A preliminary report.J Hand Surg [Am] 2002;27:205-215.

28. Jupiter JB, Fernandez DL, Toh C-L, Fell-man T, Ring D: Operative treatment ofvolar intra-articular fractures of the dis-tal end of the radius. J Bone Joint SurgAm 1996;78:1817-1828.

29. Schneeberger AG, Ip WY, Poon TL,Chow SP: Open reduction and plate fix-ation of displaced AO type C3 fracturesof the distal radius: Restoration of artic-ular congruity in eighteen cases.J Orthop Trauma 2001;15:350-357.

30. Carter PR, Frederick HA, Laseter GF: Openreduction and internal fixation of unsta-bledistal radiusfractureswithalow-profileplate: Amulticenter study of 73 fractures.J Hand Surg [Am] 1998;23:300-307.

31. Bell JSP, Wollstein R, Citron ND: Rup-ture of flexor pollicis longus tendon.J Bone Joint Surg Br 1998;80:225-226.

32. Nunley JA, Rowan PR: Delayed ruptureof the flexor pollicis longus tendon af-ter inappropriate placement of the π plateon the volar surface of the distal radius.J Hand Surg [Am] 1999;24:1279-1280.

33. Wong-Chung J, Quinlan W: Rupture ofextensor pollicis longus following fixa-tion of a distal radius fracture. Injury1989;20:375-376.

34. Dao KD, Venn-Watson E, Shin AY: Ra-dial artery pseudoaneurysm complica-tion from use of AO/ASIF volar distalradius plate: A case report. J Hand Surg[Am] 2001;26:448-453.

35. Schnur DP, Chang B: Extensor tendonrupture after internal fixation of a dis-tal radius fracture using a dorsallyplaced AO/ASIF titanium Pi plate. AnnPlast Surg 2000;44:564-566.

36. Lowry KJ, Gainor BJ, Hoskins JS: Exten-sor tendon rupture secondary to theAO/ASIF titanium distal radius plate



without associated plate failure: A casereport. Am J Orthop 2000;29:789-791.

37. Kambouroglou GK, Axelrod TS: Com-plications of the AO/ASIF titanium dis-tal radius plate system (π plate) in in-ternal fixation of the distal radius: Abriefreport. J Hand Surg [Am] 1998;23:737-741.

38. Lucas GL, Fejfar ST: Complication ininternal fixation of the distal radius.J Hand Surg [Am] 1998;23:1117.

39. Ring D, Jupiter JB, Brennwald J,Buchler U, Hastings H: Prospectivemulticenter trial of a plate for dorsal fix-

ation of distal radius fractures. J HandSurg [Am] 1997;22:777-784.

40. Peine R, Rikli DA, Hoffmann R, DudaG, Regazzoni P: Comparison of three dif-ferent plating techniques for the dorsumof the distal radius: A biomechanicalstudy. J Hand Surg [Am] 2000;25:29-33.

41. Hove LM, Nilsen PT, Furnes O, OulieHE, Solheim E, Molster AO: Open reduc-tion and internal fixation of displaced in-traarticular fractures of the distal radi-us. Acta Orthop Scand 1997;68:59-63.

42. Keating JF, Court-Brown CM, Mc-

Queen MM: Internal fixation of volar-displaced distal radial fractures. J BoneJoint Surg Br 1994;76:401-405.

43. Catalono LW III, Cole RJ, GelbermanRH, Evanoff BA, Gilula LA, Borelli J Jr:Displaced intra-articular fractures ofthe distal aspect of the radius. J BoneJoint Surg Am 1997;79:1290-1302.

44. Campbell DA: Open reduction and in-ternal fixation of intra-articular and un-stable fractures of the distal radius us-ing the AO distal radius plate. J HandSurg [Br] 2000;25:528-534.


Vol 13, No 3, May/June 2005 171

Plating of the distal radius

Health & Medicine

distal ulna

anatomy distal radius

distal radius arvind

lateral distal radius

lunate facet

distal radioulnar joint

jps health network

medial complex