Volar Fixation for DorsallyDisplaced Fractures of the Distal

Radius: A Preliminary Report

Jorge L. Orbay, MD, Miami, FL, Diego L. Fernandez, MD,Berne, Switzerland

Using a volar approach to avoid the soft tissue problems associated with dorsal plating, wetreated a consecutive Series of 29 patients with 31 dorsally displaced, unstable distal radialfractures with a new fixed-angle internal fixation devk:e. At a minimal follow-up time of 12months the fractures had healed with highly satisfactory radiographic and functional results.The final volar tilt averaged 5°; radial inclination, 21"; radial shortening, 1 mm; and articularincongruity,.O mm. Wrist motion at final follow-up examination averaged 59° extension, 57°

flexion, 27° ulnar deviation, 17° radial deviation, 80° pronation, and 78° supination. Gripstrength was 79% of the contralateral side. The overall outcome according, to the Gartland andWerley scales showed 19 excellent and 12 good results. Our experience indicates that mo~tdorsally displaced distal radius fractures can be anatomically reduced and fixed through avolar approach. The combination of stable internal fixation with the preservation of the dorsalsoft tissues resulted in rapid fracture healing, reduced need for bone grafting, and lowincidence of tendon problems in our study. (J Hand Surg 2002;22A:205-215. Copyright ~ 2002by the American Society for Surgery of the Hand.)

Key words: Distal radius fracture, volar platg, subchond~’al peg fixation.

Open reduction and internal fixation with plates isa valid alternative treatment of displaced extra-artic-ular and intra-articular distal radial fractures.I-4 Asopposed to bridging external fixadon5 or percutane-ous pinning and casting,6 stable internal fixation per-mits early motion of the neighboring joints and op-timizes functional rehabilitation of the wrist andhand.l’7 Although the results of dorsal plating s.ys-terns have shown satisfactory overall outcomes, theincidence of extensor tendon complications includ-

From the Miami Hand Center, Miami, FL; and Department ofOrthopaedic Su~’gery, Lindenhof Hospital, Berne, Switzerland.

Received for publication December 12, 2000; accepted in revisedform December 28, 2001.

The author or one or more of the authors have received or willreceive benefits for personal or professional use from a commercialparty related directly or indirectly to the subject of this article.

~qeprint requests: Jorge L. Orbay, MD, Miami Hand Center, 8905SW 87 Ave, Suite 100, Miami, FL 33176.

Copyright © 2002 by the American Society for Surgery of the Hand0363-5023/02/27A02-0022535.00/0doi: I 0.1053/jhsu.2002.32081

ing irritation tendinitis, attrition, and ruptures see-ondary to direct contact of these structures withdorsal plates is not negligible.4’s-11 The use of volarbuttress plating for volar displaced distal radiug frac-tures has seldom been associated with flexor tendonproblern~s because’the anatomy of the volar aspect ofthe wrist offers more cross-sectional area and theimplant is separated from the flexor tendons by thepronator quadratus (Fig. 1).~2

After ~:omparing dorsal versus volar plate fixationwith regard to interference with the surrounding softtissue envelope, we developed the following workinghypothesis: If dorsally displaced unstable fracturescould be anatomically reduced through a volar ap-proach and if secondary displacement of the fracturescould be prevented by a fixed-angle internal fixationdevice, tt~e danger of attritional tendinitis and theneed for bone grafting of dorsal metaphyseal defectswould be greatly reduced. The use of a volar ap-proach would avoid the need for dorsal dissectionand maintain anatomic continuity of extensor tendon

The Journal of Hand Surgery 205

206 OrbaY and Fernandez / Volar Fixation of Dorsal Wrist Fractures

B

Figure 1. Interrupted lines represent plate applicationsites on these magnetic resonance images. (A) Dorsaltendons (*) directly contact the dorsal plate. (B) Volartendons (^) are well separated from the volar plate by thepronator quadratus.

sheaths, periosteum, dorsal retinaculum, and vascu-lar supply to dorsal metaphys.eal fragments. Thesedorsal fragments would be reduced indirectly bytraction on the soft tissues, and rapid fracture healingwould follow. The applicatign of a strong fixed-angleimplant; acting as an internal fixator, would control

fracture collapse. We describe the surgical approach,technique of reduction and fixation, and preliminaryresults obtained with this method.

Materials and Methods

From J.anuary 1, 1998, to December 31, 1998, weundertook a prospective study to evaluate the effec-iiveness of volar fixed-angle plate fixation of. dorsallydisplaced unstable distal radial fractures in 2 institu-tions (Miami Hand Center, Miami, FL, and Linden-hof Hospital, Berne, Switzerland). The study wasapproved by corresponding institutional reviewboards, and informed consent was obtained from allpatients. Criteria for study inclusion were a dorsallydisplaced fracture of the distal radius that after aninitial attempt at closed reduction had radiographicevidence of a persisting deformity of >15" of angu-lation in any plane, >2 mm of articular displace-ment, or >2 mm of radial shortening. Patients werenot .excluded on the basis of age or bone quality.Exclusi0n -criteria were fractures of the immatureskeh;ton, a dorsal Barton fracture, fractures withmas.*:ive comminution of the joint surface or fracturesWith >-5 articular fragments, and distal radial frac-tures extending into the distal third of the radialshaft.

A consecutive series of 12 patients with 14 frac-tures who met the inclusion criteria after failure ofour initial attempts at closed reduction and castingwere included. Another 17 patients were referred byother physicians after unacceptable reduction or in-creasJing secondary displacement after closed reduc-tion and cast treatment (n = 14) or failed fracturereduction after initial external fixation (n = 3). total :29 patients with 31 dorsally displaced distalradius: fractures comprised the study. Three of thefractures had a grade 1 open wound on the volar-ulnar side of the wrist, and the remaining 28 wereclosed fractures. None of the injured wrists had staticintercarpal instability or unstable lesions of the distalradioulnar joint. The fractures (14 intra-articular and17 extra-articular) were classified according to M01-ler et al.13 There were 5 A2, 12 A3, 4 C1, 7 C2, and3 C3 fracture types. There were 12 men and 17women with an average age of 54 years (range,25-86 years). Seventeen patients were >60 yearsold. The causes of injury were simple falls on theoutstrel~.ched hand (n = 16), work-related accidents(n = 8), motor vehicle accidents (n = 5), and sportsinjuries (n = 2). Before receiving study treatment, patients: had developed median nerve symptoms that

The Journal of Hand Surger)’ I Vol. 27A No. 2 March 2002 207

persisted for >4 days de.spite anti-inflammatorymedication and elevation, and 5 had developed se-vere soft tissue swelling and pain with limitation offinger mobility as a result of constricting circumfer-ential casting. Preoperative radiographic evaluationshowed an average dorsal angulation of 30" (range,0° to 65°), average radial inclination of 10° (range,- 10° to 50°), and average radial shortening of 3 mm(range, 0-8 mm). Residual intra-articular incongru-ity in the 14 fractures with articular involvement hada step-off or gap of the articular surface averaging 3mm (range, 1-5 mm). Of 29 patients, 2 had bilateralfractures (one right dominant and the other left dom-inant). Of the remaining 27 with unilateral fractures,18 affected the right wrist (15 dominant and 3 non-dominan0 and 9 affected the left wrist (2 dominantand 7 nondominan0. The time interval between theinjury and plate .fixation averaged 9 days (range,0-26 days). Twenty-one patients had regional anes-thesia and 8 had general anesthesia.

At the .time of last follow-up visit we reviewed thefinal radiographic and functional results. Standardplain radiographs were obtained and the followingparameters, according to Castaing,’4 were measured:volar till, rhdial inclination, radial length, and artic-ular congruency. These films were compared withpreoperative films and with previous follow-up filmsto assess the correction of the original deformity andto recognize any postoperative loss of reduction. Thesurgeons measured wrist and forearm motion with agoniometer. Digital motion was assessed by measur-ing the distance from the fingertips to the distalpalmar crease. Grip strength was measured with aJamar dynamometer (Asimov Engineering Corp,Santa Monica, CA) on the second position and, whenpossible, compared with the contralateral side. Re-sidual pain was graded as mild, moderate, or severe.For clinical assessment the Stewart scale’5 and Gart-land.and. Werley methodj6 were used.

Surgical Technique

All procedures were done with fluoroscopic assis-tance. Surgical approach was through an 8- to 10-cmlongitudinal incision located directly over the distalcourse of the flexor carpi radialis (FCR) tendon (FCRapproach) (Fig. 2). When necessary this approachwas extended (see later). Distal dissection was car-ded down through the sheath of the FCR tendon, andproximal dissection was carried down between theFCR tendon and radial artery. The virtual spaceunderneath the flexor tendons (Parona’s space) wasdeveloped, and the FCR teodon, the median nerve,

Figure % The skin incision is made dfi’ectly over thecourse of the FCR tendon, zigzags across the wrist flexioncreases, and is 8 to 10 cm long.

and the ~remaining flexor tendons all were retractedulnarly. ~Pne radial artery was protected and retractedradially. The distal and radial borders of the pronatorquadratus were lifted with an L-shaped incision, andthe muscle was retracted ulnarly. In severely dis-placed flactures it frequently was found torn andinterposed in the fracture site, necessitating releaseor partial debridement. The standard FCR approachwas used in 12 extra-articular and 4 intra-articularfractures. In these 16 cases longitudinal tractioncombined with restoration of the anatomic continuityof the volar cortex automatically restored the radiallength, volar tilt, ulnar inclination, and articular con-gmency of the joint surface. These were mostly

.. .. .208,0rbay and Fernandez I Volar Fixation of Dorsal Wrist Fractures

Figure 3. At the level of the distal radial metaphysis theradial septum is a complex fascial structure consisting ofthe intermuscular membrane, insertion of the brachiora-dialis (*), and first extensor compartment (^). It is neces-sary to release this structure when treating more difficultinjuries.

Figure 4. The extended form of the FCR approach allowsthe volar management of partially healed or difficult-to-reduce intra-articular fractures. The pronated proximalradius fragment (*), dorsal die-punch fragment (^), volar dye-punch fragment (~,) are shown.

recent fractures (~:2 weeks) with unorganized frac-ture hematomas and were reduced closed easily un-der fluoroscopy.

In the remaining 5 extra-articular and 10 intra-articular fractures a more comprehensive debride-ment of organized fracture callus or direct manipu-lation of difficult-to-reduce intra-articular fragmentsor both were necessary to achieve anatomic reduc-tion. An extended form of the FCR approach, whichuses the fracture plane for exposure and allows thejoint surface to be reduced from within the fracture,was used. This extended approach was performed in3 steps. First, the radial septum was released (this isa complex fascial structure formed by the interrnus-cular membrane, the first extensor compartment, andthe insertion of the brachioradialis) (Fig. 3). Second,the proximal radial fragment was mobilized by itssubperiosteal release, a safe maneuver because thisfragment is provided with a dependable endostealblood supply. Third, the proximal fragment was ro-tated out of the way and into pronation with the helpof a bone clamp (Fig. 4). This rotation exposed thefracture site and permitted the debridement of callusand the manipulation of articular fragments (Fig. 5).When adequate reduction was obtained the proximalradial fragment was supinated back into position,"closing the book," and fixation finally was applied.

We released the brachioradialis, which forms thefloor of the proximal aspect of the first extensorcompartment, by dividing its bony insertion after

Olz~ning the proximal aspect of the tendon sheath.Incomplete release of the sheath prevented tendonsubluxation. Releasing the brachioradialis exposedthe radial styloid fragment, eliminated a major de-foffning force, and greatly facilitated reduction.Maintaining the dissection on the subperiosteal planeprevented injury to the radial sensory branches, andthe radial artery was protected in its course under-neath the first compartment. Soft tissue attachmentsto the dorsal aspect of the distal fragments alwayswere preserved carefully to ensure their blood sup-

Figure 5. Direct manipulation of articular fragmentsagainst the carpus, which acts as a template, achievesreduction.

........ .The.Journal of Hand Surgery / Vol. 27A No. 2 March 2002 209 "

ply. The most distal fibers of the flexor pollicislongus origin on the proximal radial fragment fre-quently were released to provide better proximalexposure. Bone graft was applied through this ap-proach when necessary.

Reduction of dorsally displaced extra-articularfractures was obtained by disimpacting the volarcortex of the distal fragment with traction, hyperex-tension of the wrist, debridement of fracture callus,and use of a small periosteal elevator as a lever. Thedistal fragment was flexed to obtain an anatomicreduction of the volar cortex, and the reduction waseasily maintained because there usually was corticalcontact, which was maintained by support from arolled towel or by temporary fixation of the fracturewith a percutaneous K-wire. The reduction of diffi-cult intra-articular fractures was done through theextended FCR approach by first placing the distalfragments in hyperextension and the proximal shaftfragment in prgnation. This placement allowed ma-nipula.tion of the radial styloid, dorsal die-punch,volar die-punch, and central impacted articular frag-ments against the scaphoid and lunate surfaces fromwithin the distal fracture surface. Temporary fineK-wires could be used to maintain the articular re-duction. In the case of severe segmental metaphysealcomminution (A3 or C3 fractures), intercalary frac-ture fragments first were reduced and fixed withsmall lag screws to the proximal radial fragment. Therestored proximal radius was supinated back on tothe radial epiphysis to complete the reconstruction.Reduction was maintained with wrist flexion and arolledtowel support or 1 or 2 K-wires driven fromthe radial styloid into the proximal radius. Threefractures that had a marked metaphyseal defect withcombined dorsal and volar comminution were re-paired with bone grafting. Bone grafting was donethrough the same approach using, crushed cancellousall0graft bone.

A volar plate specially designed to meet the ob-jectives of this project provided final fixation for allfractures in this series (DVR Plate; Hand Innova-tions, Miami, FL) (Fig. 6). Because a volar platestabilizing a dorsally displaced distal radial fractureis unable to act as a dorsal buttress, screw fixation ofthe distal fragments is likely to fail, and the implantis subject to higher axial and bending forces. Toovercome these difficulties this implant provides dis-tal fixed-angle fixation through 2.0-mm subchondralsupport pegs and obtains proximal fixation through3.5-mm cortical screws, and the plate is reinforced towithstand the expected higher loads. Mechanical

Figure 6. The DVR plate is a strong fixed-angle devicedesigr~ed specifically for volar fixation of unstable distalradius fractures. Distal fixation is through 2.0-ram sub-chondral support pegs. Proximal fixation is through3.5-mm cortical screws.

testing was done at the University of Miami/MountSinai Orthopedics Biomechanical Laboratory, andthe implant was found to be 3 times as strong as othercommercially available devices when loaded in adistal radius fracture model with a segmental dorsaldefect.

After obtaining proper fracture reduction the platewas applied to the volar aspect of the radius. Acortical screw first was applied to the oval plate hole,fixing ,the plate to the proximal fragment but allow-ing proximal or distal adjustment. Next after accuratepredril]ling with a special threadeddrill guide, a pegwas in:~erted into the distal fragment. One peg andone screw offered enough fixation to stabilize mostfractures temporarily and allow fluoroscopic inspec-tion; afterward the remaining 3 pegs were applied.Placement of the subchondral support pegs 2 to 3mm below the subehondral bone is essential foroptimal fixation, especially in cases with .osteopo-rotic be,he. The design of the implant, provided thatanatomi!c fracture reduction is present, ensures thepeg’s optimal position. In fractures with intra-artic-ular dis~.’uption the radial styloid fragment was fixedby the radial-most peg, which is angled for thispurpose. The ulnar-most pegs effectively fixed dorsaldie-punch fragments, whereas the 2 central pegs sup-ported centrally impacted fragments. Sizable volardie-punch fragments were buttressed by the distalexpansion of the plate. In 2 patients a small volarmarginal’, fragment needed complementary K-wirefixation. These were applied as volar buttress wires.The final steps of the procedure were the insertion ofthe rest of the shaft screws, suturing the pronatorquadratus back in place, and wound closure. Drains

210 Orbay and Fernandez / Volar Fixatioff of Dorsal Wrist Fractures

Figure 7. (A) Posteroanterior and 03) lateral views of a dorsally displaced distal radius fracture caused by a fall from height.

were used in our study at the discretion of the oper-ating surgeon. In 9 patients with persistent mediannerve symptoms and in 5 patients with severe swell-ing and increasing preoperative pain, the mediannerve was decompressed through a separate incision.The release was performed according to the sur-geon’s preference and instrument availability by aformal open technique along the axis of the fourthray in 6 wrists and an endoscopic technique (Agee)in 8 wrists.

Six patients with severe soft tissue swelling, in-cluding the 2 with bilateral fractures requiring ele-vation and edem~ control, were hospitalized for anaverage of 3 days. The remaining 23 were. treated asoutpatients. Postoperative management included ac-tive finger motion and forearm rotation encouragedimmediately after surgery and short arm postopera-tive dressing for an average of 7 days. After the firstpostoperative visit a removable short arm splint orcast was used for an average of 4 weeks. Rehabili-

tation was adjusted to the patient’s clinical course.Generally patients with substantial wrist swellingand pain recovered digital motion faster if their wristwas immobilized; these patients usually were given ashort .arm cast. Patients with little wrist swelling andearly recovery of finger motion progressed faster ifallowed to move the wrist early and were given aremovable plastic splint. Functional use of the handfor light daily activities was allowed in patientswith good bone quality, as judged by the purchaseof the implants in bone during surgery. Patientsw.ere referred to formal physiotherapy if they hadnot recovered full digital motion at the first post-operative visit, had not recovered full forearmrotation at the second visit, or had disproportionatepain and swelling at any time after surgery. Ra-diographs were taken at every visit. These werescheduled the week after surgery, 4 to 6 weeksafter surgery, at monthly intervals as needed, andat late follow-up evaluation.

............... ~fhe Journal of Hand Surgen//Vol. 27A No. 2 March 2002 211

Figure 8. (A) Posteroanterior and (B) lateral views after fracture healing. Dorsal cortical comminution is still apparent ¯The soft tissue attachments and blood supply to these fragments have l:een preserved by the volar approach, facilitatingfracture heali~ig and avoiding the need for bone grafting.

Results

All cases were accounted for and had an averagefollow-up time of 12.5 months (range, 53-98weeks). The average time to radiographic healingwas 5.6 weeks (range, 5-8.2 weeks). Seventeenpatients who were employed at the time of injuryall were able to return to work within 16 weeks ofinjury. The remaining 12 patients, including 10elderly patients (>65 years old) and 2 students,returned to their preinjury everyday activities.Nineteen patients attended physical therapy and 10did rehabilitation by themselves under supervisionof the attending surgeon. At final follow-up visitthe average volar tilt was 5° (range, ° dorsal tiltto 12° volar tilt), radial inclination averaged 21°

(range, 15° to 26°); radial shortening averaged mm (range, 0-2 mm), and articular congruity av-eraged 0 mm (range, 0-1 mm) (Figs. 7, 8). parison of the first postoperative radiographs with

films taken at final evaluation (average, 66 weeks;range, 53-98 weeks) revealed complete mainte-nance of reduction in all except 2 cases. These 2cases had slight settling (I mm of loss of radiallength) but no angular displacement and were se-verely osteopenic cases in which the fixation pegshad been applied >3 mm proximal to the subchon-dral plate.

At final evaluation all patients had achieved fullfinger range of motion, that is, they were able totouch the distal palmar flexion crease with finger tipsand fully extended fingers. Wrist range of motionassessed by the physician with a goniometer aver:aged 59° wrist extension (range, 45° to 85°), 57°

wrist flexion (range, 40° to 80°), 27° ulnar deviation(range, 15° to 40°), 17° radial deviation (range, 10°

to 25°), 80° pronation (range, 65° to 90°), and 78°

supination (range, 70° to 90°). Grip strength mea-sured with a Jamar dynamometer in the second po-

.... . 2~i2 Orbay and Fernandez / Volar Fixation of Dorsal Wrist Fractures

Figure 9. At 12 weeks this patient returned to work with almost ,.~ymmetric range of motion, (A) extension, .(B) flexion,(C) supination, and (D) pronation. (Figure continues)

sition averaged 79% of the contralateral side at finalevaluation (range, 60% to 110%) (Fig.

Residual pain in the wrist w~s graded as mild,moderate, or severe. Mild pain was present only atthe extremes of the active range of motion of thewrist, and the patient was neither physically norpsychologically disturbed by the pain. Moderate painoccurred during heavy manual labor and caused thepatient to be disturbed physically or psychologicallyor both. Severe pain occurred during activities ofdaily living and at rest. At final evaluation, 26 pa-tients were free of pain, 1 had mild pain, and 2 had.moderate pain. The 3 patients with residual pain hadC3 intra-articular fractures. Despite anatomic or al-

most anatomic reduction of the joint surface (0-1mm) and normal carpal alignment, additional chon-dral damage or partial nonrecognized carpal ligamentinjuries may explain the .persistence of discomfort.According to the Stewart scale there were 21 excel-lent and I0 good results, and according to the Gart-land and Werley scale there were 19 excellent and 12good results.

Complications consisted of 1 case of dorsal tendonirritation from an excessively long peg, which wastreated with hardware removal. Of the 9 patients withpreoperative median nerve symptoms who had carpaltunnel release, the final neurologic examination (2-point discrimination test, median nerve motor func-

¯ -. - ~ ~ .. ........ The.Journal ¢,f Hand Surgery ! VoL 27A No. 2 Marcli 2002 213

Figure 9. (Continued) At 12 weeks this patient returned to work with 90% of grip strength (E) right and (F) left.

tion) showed complete resolution at the time of latefollow-up. The K-wires used in 2 fractures for addi-tional fixation of volar marginal articular fragmentswere removed 7 and 8 weeks after surgery. Exceptfor the case with the excessively long peg, all DVRplates were left in place. There were no cases ofinfection, reflex sympathetic dystrophy, or implantfailure.

Discussion

. The primary goal in treatment of unstable fracturesof the distal radius is to achieve optimal restorationof the disrupted anatomy and allow quick return ofhand function, while preventing secondary fracturedisplacement. If the fracture has a displaced intra-articular component, additional efforts to secure andmaintain anatomic reduction of the joint surfaceshould be undertaken. If these goals are achieved,better final functional results are to be expected.Early wrist motion has been shown to enhance handand finger function.~7 Advances to achieve thesegoals have been sought with modern refinements ofinternal and external fixation techniques. The majordrawback of conventional dorsal plating systems has

been inritation, adhesion formation, and ruptures ofthe extensor tendons as a result of the limited spacebetween the ektensor tefidons and the dorsal cortex.Investigators using dorsal plating systems have mod-ified the implants to provide low-profile smootherplates or have used double plating systems withsmaller implants to diminish tendon irritation.3"s’9"ts

Refinements of fragment-specific limited open re-duction of intra-articular fractures~9 with the devel-opment of low-profile stable implants that wouldallow early functional aftertreatment have been un-dertaken.2° Direct fixation of the distal radius frag-ment with nonbridging wrist fixators currently isadvocated.2 ~

Encouraged by the ease of application of volarplates for volarly displaced fractures and the absenceof tendon irritation reported with these techniques,we decided to investigate the possibilities and limi-tations of open reduction and internal fixation ofdorsally displaced distal radius fractures through avolar approach. The volar anatomy of the wrist pre-sents an obvious advantage over the dorsal aspectbecause there is more space between the volar cortexand the flexor tendons. The pronator quadratus sep-

......... 214 Orbay and Fernandez I Volar Fixation of Dorsal Wrist Fractures

arates these structures, preventing soft tissue compli-cations and allowing application of larger implants.Under some circumstances a volar plate fixing adorsally displaced fracture is subject to higher loadsthan a dorsal plate. The bending strength of our platewas therefore augmented by increasing its cross-sectional area. Secondary displacement with loosen-ing and toggling of the distal screws had been ob-served frequently with the use of conventionalT-plates, particularly in osteopenic bone. We se-lected a device based on the fixed-angle principle andone with subchondral support pegs. These do notdepend on the buttress effect, carry all the loadsacross the fracture site, and effectively fix weakmetaphyseal bone.22 The distal pegs were introducedas closely as possible to the subehondral plate toprevent loss of reduction of the distal fragments as aresult of the axial loads generated by early function.

Our preliminary results show that open reductionand internal fixation with a volar fixed-angle deviceis effective for the treatment of dorsally displacedunstable distal radius fractures. Except for 1 ease thatwas reduced and fixed in 5° dorsal tilt, all other¯ patients had a satisfactory restoration of the volar tiltz-averaging 5°. Restoration of ulnar .inclination and~radial length also was highly satisfactory. Absence of.settling, secondary angular displacement, and short-ening seems to correlate with accurate placement ofthe distal pins in the immediate subchondral position,especially in patients with osteopenic bone. Thefunction of this implant as an internal, fixator incombination with the preservation of the vascularityto the dorsal comminuted area accounts for the rapidrestoration of the anatomic continuity of the dorsal¯ cortex, despite the infrequent use of bone graft. Sim-ilarly subchondral buttressing of anatomically re-duced intra-articular fragments with the fixed-angleprinciple accounts for the absence of secondary dis-placement of articular fracture components.

The functional outcomes of our patients are com-parable with other reports of open reduction andinternal fixation and functional aftercare of dorsallydisplaced distal radial fractures.3"8’~ The excellentdegree of pain relief we observed correlates with therestoration of extra-articular and intra-articular wristanatomy, restoration of radial length and the distalradioulnar joint, absence of associated intercarpalligament injuries and radioulnar.joint instability, andavoidance of extensor tendinitis. Except for the onepatient with extensor tendon irritation caused by along protruding peg, the result of faulty .technique,there were no tendon-related complications, and all

other implants have-remained in place. Articularfragments of adequate size involving the radialstyloid, the central portion of the articular surface,and dorsal and palmar die-punch fragments could beadequately reduced and fixed. This reduction wasdone when necessary with the extended FCR ap-proach and intrafocal manipulation of tl~e fragmentsthrough the metaphyseal fracture area. Small butcrucial volar lunate fossa fragments that requiredseparate fixation could be addressed with the use ofw)lar buttress K-wires. A possible difficulty of thisvolar technique could be the fixation of a smalldorsal marginal fragment of the sigmoid notch thatmight prove essential for distal radioulnar joint sta-bility, a. situation that may require a small separatedorsal incision. Although this implant could be usedalternatively for the fixation of volar Barton fracturesand extra-articular Smith fractures, it is contraindi-ca~ted for the less common massively comminutedfractures of the joint surface and in eases with im-portant comminution extending into the distal thirdof the radius shaft.

,Ilais method represents a valuable treatment mo-daIity for the most frequent types of unstable frac-tures of the distal radius in young and elderly pa-tients. The surgical approach is simple and can beextended depending on the complexity of the frac-ture. The biomechanical features of the DVR plate incombination with preservation of the vascularity ofthe dorsal comminuted area rendered additional bonegrafting rarely necessary except for unusual cases ofimportant dorsal and volar comminution seen withhigl~-energy injuries.

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