Treatment

36

Treatment has long been defined by the lack of correlation between
anatomic reduction and function. This idea is only true in extremely elderly,
dependent patients, with low functional needs. Thus, today anatomic
reduction is the goal because it makes it possible to limit loss of function.
The problem is not the type of fixation or the immobilization technique, but
the quality and stability of reduction. A fracture with malunion is going to
affect the radiocarpal joint (problems with underlying carpal alignment, loss
of flexion-extension, loss of wrist strength) and the radioulnar joint (loss of
pronosupination, ulnocarpal impingement syndrome).
[61]
When the dorsal angle is greater than 20, radial inclination is below
10, and radial shortening is more than 6 mm, there are definite functional
consequences. Thus the more a fracture is displaced and/or associated with
an ulnar head fracture, the older the patient is (after the age of 60) and the
more fragile the bone is (osteoporosis), the less immobilization (normally
associated with reduction) will result in permanent reduction. A displaced
fracture should therefore be reduced and stabilized.
[61]
Although fragile bone can make fixation insufficient to maintain the
patients level of activity and autonomy, this aspect of treatment should
never be neglected. Over time, the limits of reduction and immobilization by
cast including the elbow became evident (too much secondary
displacement). Intra- and extrafocal pinning techniques, which were made
popular by Kapandji in France, made it possible to improve functional
outcome. However little by little as the life expectancy and the frequency of
osteoporosis has increased in the population, the development of plate
fixation is solving the problem of secondary displacement (which occurs in
30% of the cases of pin fixation) while making it unnecessary to wear a cast
Treatment

37

(allowing patients to use their new wrist at their own speed). External
fixation is still indicated for high-energy fractures with metaphyseal-
epiphyseal injury.
[61]
Despite the frequency of this type of fracture and because of the wide
variety of lesions, the level of evidence to define the best fixation is low.
Finally for the same fracture, the type of complications they cause
differentiates different types of internal fixation techniques. An effort must
be made in methodology to better identify the costs of each technique and
the functional advantages for the patient.
[61]


CAST IMMOBILIZATION
Cast immobilization is an appropriate treatment for all nondisplaced
fractures and stable displaced fractures that have been reduced. It may also
be appropriate for low demand patients who would not be able to tolerate
surgery for medical reasons. Closed reduction of displaced fractures consists
of longitudinal traction, palmar translation of the hand, pronation of the hand
relative to the forearm, and finally ulnar tilt. This reduction maneuver does
not require wrist flexion.
[42]
Determining which fractures will heal uneventfully with cast
immobilization may be difficult. An unstable distal radius fracture can be
defined by several criteria, which include: comminution greater than 50%
from dorsal to volar, angulation greater than 20 degrees of dorsal tilt,
shortening greater than 10 mm, a shearing fracture pattern, and significant
displacement with 100% loss of opposition.
[62]
All unstable fracture patterns
require surgical intervention.
[42]
Treatment

38

Cast treatment typically consists of immobilization in a sugar-tong
splint for three weeks immediately following closed reduction, which is then
converted to a short arm cast for an additional three weeks. Patients are
usually given a removable splint for a final three weeks and instructed to
perform active range of motion exercises to regain flexibility. Early in the
treatment course, radiographs should be obtained weekly to ensure fracture
stability. The palmar crease should be free to allow full motion about the
metacarpophalangeal joints (Fig. 21).
[42]


(Fig. 21) A well molded short arm cast applied for a stable distal radius fracture.
[42]


Treatment

39

PERCUTANEOUS PIN FIXATION
Because unstable distal radius fractures have a tendency to redisplace
in plaster, percutaneous pinning is a relatively simple and effective method
of fixation that is recommended for reducible extra-articular fractures,
simple intra-articular fractures that are nondisplaced, and in patients with
good bone quality.
[42]
Multiple different techniques have been described for pinning distal
radius fractures. These include pins placed through the radial styloid, two or
three crossed pins across the fracture site, or intrafocal pinning within the
fracture site. Some techniques also incorporate transfixation wires across the
distal radioulnar joint for added stability. The actual technique used is
probably not significant as long as the wires confer sufficient fixation to the
fractured radius.
[42]
Kapandji
[63]
popularized the technique of double intrafocal pinning to
both reduce and maintain distal radius fractures. This procedure is probably
best reserved for noncomminuted extraarticular injuries. Kapandjis
technique first requires a Kirschner wire introduced into the fracture site in a
radialtoulnar direction. When the wire reaches the ulnar cortex, the wire is
used to elevate the radial fragment and recreate the radial inclination. This
wire is then driven through the ulnar cortex for stability. A second wire is
introduced 90 degrees to the first in a similar manner to restore volar tilt.
Generous skin incisions must be made about the pin sites to prevent skin
tethering. Care must also be taken to avoid injury to the cutaneous nerves
(Fig. 22).
[63]
Treatment

40


(a) (b)

(c) (d)

(Fig. 22) Percutaneous pin fixation of an unstable distal radius fracture: a. The xrays of the initial fracture.
b. Two percutaneous pins through the radial styloid. c. Fracture healing in an anatomic position.
d. Functional result.
[42]


Treatment

41

EXTERNAL FIXATION
External fixators are typically used as an adjunct to other forms of
fixation, particularly for the treatment of highly unstable or comminuted
injuries. External fixators provide ligamentotaxis that can help to maintain
fracture reduction, thereby preventing collapse. In addition, they function by
neutralizing compressive, torsional, and bending forces across the fracture
site. Occasionally, external fixators will be used for definitive reduction of
fractures, but more often it will be used in conjunction with other forms of
fixation.
[42]
Several biomechanical studies support the use of augmented external
fixation with supplemental Kirschner wires. Wolfe, et al.
[64]
performed a
cadaveric study comparing osteotomized distal radii stabilized with an
external fixator alone or with various supplemental Kirschner wire
configurations. Fracture transfixation wires placed into the distal fragment
and secured to the external fixator were superior to exfixation alone in
reducing fracture motion. A single wire was enough to gain appreciable
stability, and additional wires did not improve stability further.
[64]
Despite its usefulness, the rate of complications with external fixation
is high. Complications include stiffness, pin tract infections, pin loosening,
radial sensory nerve injury, and reflex sympathetic dystrophy. These
complications may be avoided to some degree by avoiding carpal
overdistraction, excessive wrist flexion, and prolonged fixator treatment.
[42]

(Fig. 23)
Treatment

42



(Fig. 23) External fixator with K-wires in management of DRF
[42]
Treatment

43

ARTHROSCOPICALLY ASSISTED FIXATION
Wrist arthroscopy is a technique that provides a minimally invasive
way of monitoring closed reduction of distal radius fractures with
percutaneous pin fixation. Obviously, it allows assessment of the articular
joint surface as well as the diagnosis of interosseous carpal ligament injury
or TFCC injury. Finally, it facilitates the excision of osteochondral flaps and
loose bodies as needed.
[42]
To perform wrist arthroscopy, a small joint (2.7 mm) arthroscope may
be introduced through the 34 portal. Instrumentation can be introduced
through the 45 or 6R portals. Wrist arthroscopy with fixation is generally
best achieved about four to seven days from the time of injury. Surgery
performed too soon after injury may face difficulties with fracture hematoma
impeding articular visualization. Likewise, fractures treated after one week
from the time of injury may be difficult to manipulate with percutaneous
wires. Fracture fragments are typically elevated using Kirschner wires as
joysticks. Fractures can then be pinned transversely beneath subchondral
bone.
[42]

FRAGMENT SPECIFIC FIXATION
The concept of fragment specific fixation has been touted as a surgical
alternative to volar plating alone. Some basic tenets of fracture fixation for
fragment specific systems include: (1) application of small contoured plates
on the specific components of the fracture; (2) fixation of distal fragments is
based on the strong bone proximally; (3) hardware should allow for gliding
motion of tendons; (4) the exposure should cause minimal soft tissue
Treatment

44

disruption; and (5) the fracture should be stable to allow early range of
motion. The type of implant used should match the specific fracture
fragment being reduced via the use of limited volar and dorsal incisions.
[42]
Rikli and Regazzoni
[15]
reviewed a series of 20 patients with distal
radius fractures fixed with two 2.0 mm titanium plates placed at 50 - 70
degrees to one another. No cases of extensor tendon problems were noted,
most likely because they were able to place a flap of retinaculum over the
small dorsal plates. Clearly, fragment specific fixation may provide some
advantages over the traditional methods of dorsal or volar plating for
fractures at the distal end of the radius.
[15]
( Fig. 24)




(a)
Treatment

45


(b)
(Fig. 24) A complex articular fracture treated with fragment specific fixation with small Synthes
plates: a. The preoperative CT scan; b. Two plate dorsal fixation.
[42]

OPEN REDUCTION AND INTERNAL FIXATION
Open reduction internal fixation has obvious advantages over the
other methods discussed so far. It allows direct restoration of anatomy,
stable internal fixation, a decreased period of immobilization, and an earlier
return of wrist function. There are a number of different indications for open
reduction internal fixation, and these include: unstable articular fractures
(such as a volar Bartons injury), impacted articular fractures, radiocarpal
fracturedislocations, complex fractures requiring direct visualization of the
fracture fragments, and failed closed reductions.
[42]
Historically, distal radius fractures were treated nonoperatively until
1929, when techniques utilizing pins and plaster were introduced. External
skeletal fixation evolved in 1944 and remained popular even after the AO
group designed plates specifically for the treatment of distal radius fractures
in the 1970s. In 1994, Agee introduced the Wrist Jack (Hand Biomechanics
Treatment

46

Lab Inc, Sacramento, CA), which utilized adjustable gears for multiplanar
ligamentotaxis, but by this time open reduction internal fixation was
becoming more popular, particularly when it was noted that precise
reductions of the articular surface led to better outcomes.
[65]

LOCKED PLATE DISTAL RADIUS
Locking plates have revolutionised treatment for distal radius
fractures. However, proper reduction and technique remain as important as
ever.
[66]
The advent of fixed-angle locking plates has improved fracture
healing and addressed the inadequacies of nonlocked plates. Formerly, a
rigid fixation construct with a nonlocked plate was achieved only if there
was minimal motion at the joint or if the bone density was sufficient to
withstand applied physiologic load. In other words, the stability of the
screws in the bone and at the screwplate interface was possible if the load
was kept to a minimum. These are limiting factors that require prolonged
cast immobilization even after surgical fixation. In osteoporotic bone,
minimal axial stress may permit toggling of the screws and become loose.
The locking plate introduced threads at the screw plate interface creating a
single beam construct, which has been reported to be four times stronger
than constructs that allow motion between the screws and plate.
[39]

Locked plates are ideal for osteoporotic fractures because they
decrease the potential for toggling of the screws in the cortex. Furthermore,
a fixed-angle device transfers the load from the intact subchondral bone
across the compromised metaphysis to the intact diaphysis, which would
Treatment

47

theoretically permit early range of motion postoperatively, as the construct
can withstand physiologic loading.
[67]
Since its introduction in 2000, volar fixed-angle fixation technique has
provided an effective alternative for the management of dorsal and volar
fractures. This approach is used because fixed-angle plates eliminate the
need to place the implant on the unstable side of the fracture; therefore, the
more physiologic volar approach can be used to treat the majority of
fractures.
[68]
This approach is less disruptive to the tendons because there is
more space available on the volar aspect of the radius. Flexor tendons are
located away from the volar surface of the radius, while extensor tendons
run directly on the dorsal surface. The volar approach allows the use of a
thicker, stronger implant to better resist the loads applied during functional
rehabilitation. Refinements of volar fixed-angle fixation were based on
insights into the anatomy of the radius, biomechanics, and blood supply.
[69]

(Fig. 25) Bridging produces a load-free area to give added stability to the fracture zone.
[70]
Treatment

48

The most attractive anatomic feature of the volar aspect of the distal
radius is the absence of flexor tendon-bone intimacy. Implant fixation on the
volar aspect of the distal radius is also advantageous because its surface,
except at the very distal margin, is relatively flat in the transverse plane. This
feature facilitates the accurate restoration of rotational alignment. The volar
radius also presents a concave profile in the sagittal plane (the pronator
fossa). This feature is limited distally by a ridge called the watershed line
[71]

and allows the application of implants of substantial profile. The gliding
surface of the flexor tendons should not come in contact with the plate as
long as the implant is nested in the pronator fossa, does not cross its distal
boundary, or project above it.
[71]
A properly applied plate should be just proximal to the watershed line
and not project above or beyond it in order to avoid contact with the flexor
tendons. In addition, the plate should be in line with bone and the pegs of
adequate length.
[66]
The watershed line is used as a surgical landmark because it is easily
palpable as a bony prominence through the fibrous tissue that covers it,
especially over the most ulnar aspect (volar rim of lunate fossa) where it is
very close (2 mm) to the joint line. The radial aspect of the watershed line is
proximal (1015 mm) to the joint line as it courses along the base of the
styloid process. The volar wrist capsule and ligaments insert distal to the
watershed line, and the most distal edge of the pronator quadratus muscle is
located several millimeters proximal. The intermediate fibrous zone is
located here between capsule and muscle.
[72]

Fracture fixation frequently requires a thorough exposure of the volar
surface of the radius, including the volar rim of the lunate fossa where rare
Treatment

49

volar marginal fragments originate. This exposure is best obtained by
elevating all soft tissue proximal to the watershed line including the
intermediate fibrous zone and pronator quadratus muscle. Dorsally displaced
fractures frequently present with a rupture of the pronator quadratus muscle
located through its most distal fibers proximal to the intermediate fibrous
zone.
[72]
The need for fixed-angle plates arose from the failure of conventional
buttress plates to achieve stable fixation. Conventional screws toggle as
purchase on the weak bone of the distal fragment is usually poor. Fixed-
angle implants do not depend on screw purchase, they depend on direct bone
support through an interference effect.
[72]
Volar and dorsal fracture fixation constructs require different implant
architecture. Dorsal fracture fixation is usually performed with at least two
orthogonal implants. Volar plating, by virtue of precise peg distribution,
allows a single fixed-angle plate to provide the same dorsal stability as with
multiple dorsal implants.
[72]

Most distal radius fractures are dorsally displaced. Support of the
dorsal aspect of the articular surface is of primary importance, hence the
distal tilt of the pegs. Fixed-angle volar fixation of dorsally unstable distal
radius fractures results from the capture of distal fragment(s) between
distally inclined pegs and the surface of the plate. The distal inclination of
the pegs in the lateral plane will neutralize dorsal displacing forces while
inducing a volar force, which must be opposed by a properly configured
volar buttressing surface. Also, divergence of the pegs in space to closely
follow the complex three-dimensional shape of the articular surface
Treatment

50

improves fixation. Pegs support load in a cantilever manner, therefore the
greatest resist physiologic loads.
[72]

Pegs can be smooth or threaded. Smooth pegs are easier to insert and
provide the necessary subchondral support. Threaded pegs are useful for
stabilizing a coronal fracture plane and preventing diastases of the articular
fragment. Fixed-angle volar plates transfer loads directly from the articular
surface to the proximal radial shaft, circumventing any metaphyseal
comminution.
[72]
The implant acts as an internal fixator in which stability across the
fracture becomes a function of the properties of the plate. A volar fixed-
angle plate supporting a fracture unstable in dorsal and volar directions can
bear loads better than a dorsal fixed-angle plate. It is able to do this because
of shape of the distal radius. Its articular surface is offset with respect to the
diaphysis by a few millimeters in a volar direction, placing the joint reaction
force closer to the volar plate and decreasing its bending moment.
[72]
Providing stable fixation in the presence of substantial osteopenia has
been challenging because the holding power of a conventional screw is
directly proportional to the density of the bone. About 100,000 distal radius
fractures in osteoporotic bone have been reported annually in the United
States, most from low energy falls.
[73]
Fixed-angle support has successfully
overcome the limitations of the more traditional forms of internal fixation.
[74]

The subchondral plate is usually the strongest bone on the distal fragment,
and fixed-angle pegs provide reliable fixation if applied immediately
underneath it.
[72]
Distal radius fractures in the elderly or infirmed populations are
common and continue to occur more frequently. These patients have specific
Treatment

51

needs: stable fixation for poor quality bone, simple anesthesia because of
poor general health, and the need for quick rehabilitation. Volar fixed-angle
fixation offers an adequate treatment method for this patient population, as
the technique relies on the only substantial bone remaining in advanced
osteoporosis - the subchondral plate. The volar approach is well tolerated
and can be performed under regional anesthesia.
[33]
The question of whether using pegs or screws results in important
biomechanical differences has been addressed in a cadaveric study.
Although there were no statistically significant differences in torsional or
axial stiffness at the beginning of loading, after 1,000 cycles, pegs failed by
loosening, most often at the pegplate interface. Screw fixation provided a
more stable construct.
[75]
A number of studies were carried out to evaluate the effectiveness of
this method of treatment which contained series of unstable dorsally
displaced distal radius fractures and which treated them with volar plates
with locking screws. Constantine et al.
[76]
used a volar plate (-plate
[Synthes, Paoli, PA]) in 20 fractures with 12 months follow-up. Eighty
percent of these dorsally displaced fractures were intra-articular, and this
same percentage of patients initiated early preoperative joint motion. The
authors reported a mean range of flexion-extension of 123, a mean range of
pronosupination of 156, without any significant loss of reduction, and a low
incidence of complications.
Orbay
[68]
who employed the DVR plate, conducted a prospective
study of 29 patients with 31 unstable dorsally displaced distal radius
fractures and a mean follow-up of 13 months. With a mean final range of
flexion-extension of 112 and mean pronosupination of 158, he obtained
Treatment

52

100% of excellent or good results. Only 2 patients lost part of the radial
length obtained in the immediate post-op period. The only complication in
the series was a case of dorsal tendinous irritation caused by a screw of
incorrect length.
Drobetz and Kutscha-Lissberg
[77]
reviewed 50 dorsally displaced
distal radius fractures (two-thirds of these fractures were intra-articular),
with 26 months follow-up, treated with a fixed-angle volar plate (Mathys
Plate, Synthes, Solothurn, Switzerland). Loss of initial reduction achieved
occurred in 21 patients and implant failure in 2 cases. Final range of motion
was not reported. They had 12 complications, 6 of which were tears of the
flexor pollicis longus attributable to the design of the plate.
Chung et al
[78]
treated 87 distal radius fractures with a DVR plate and
their patients were able to start mobilizing the operated wrist at the first
week post-op, without any apparent losses of the initial reduction achieved.
Similarly, Osada et al
[9]
in a series of 49 patients with this type of fracture,
used the DRV Locking Plate (Mizuho Ikakogyo Co, Ltd, Tokyo, Japan) and,
without recourse to splinting in the first few weeks post-op, observed that,
physiologically, wrist joint motion during everyday activities transmitted an
axial load of 100 N through the joint, while the load rose to 250 N on active
finger flexion. This seems to confirm that an antebrachiopalmar splint does
not neutralize the axial load generated by finger movements in the operated
wrist.
[9]

In view of these results, authors do not recommend routine use of the
splint, except in patients where there is doubt as to the stability afforded by
the fixation system used.
[79]