PART III WRIST

chapter

17  Distal Radius Fractures

Scott W. Wolfe

With the wide array of treatment options now available, this considered these fractures to be a group of injuries with a
is an exciting era for the treatment of fractures of the distal relatively good prognosis irrespective of the treatment given.
radius. An improved understanding of kinematics, bone Until the mid-1900s, nearly all fractures of the distal radius
quality, and muscle forces acting across the fracture has led to were treated in closed fashion, with or without reduction of
increased awareness of a fracture’s relative stability, as well alignment. Patients’ expectations of treatment were in line
as the development of innovative devices to counteract these with the treatment tools available at the time, and certainly
forces and restore stability. Innovations have occurred in other public health issues outflanked the wrist in importance
closed treatment, percutaneous fixation, external fixation, to a patient’s long-term productivity. Since then, hundreds
and in particular, implants for internal fixation. However, of clinical and basic publications have contributed to our
new devices and techniques require careful assessment of improved understanding of fracture complexity, stability,
efficacy, risk, and benefit as they are applied in practice, espe- and prognosis and have consequently driven the develop-
cially since the incidence of this fracture is likely to rise in an ment of modern techniques and technology to optimize
aging population. At this time, there are few published studies patient outcomes. A brief summary of the evolution of
that definitively demonstrate the superiority of one technique modern fracture fixation follows, with the sentinel publica-
or implant over another, as long as the anatomy of the distal tions and techniques that fundamentally changed our treat-
radius is restored. ment of these challenging injuries being highlighted.
Distal radius fractures are the most common fractures seen Although closed reduction with cast treatment of distal
in the emergency department; they represent approximately radius fractures continues to be the mainstay of treatment of
3% of all upper extremity injuries, with an incidence of stable fractures, operative methods have evolved over the
greater than 640,000 annually in the United States alone.20 past century to treat fractures that defy cast management.
There is a bimodal distribution of these injuries, with a peak Casting in acute wrist flexion and ulnar deviation, or the so-
in the 5- to 24-year-old, predominantly male population who called Cotton-Loder position, even though thought to be
sustain athletic and high-energy injuries and a second peak beneficial for maintenance of reduction of unstable fractures,
in the elderly, predominantly female population character- seemed to result in more stiffness in the digits and the poten-
ized by lower-energy or “fragility” fractures. U.S. census tial for median nerve compression. The “pins and plaster”
data indicate that the percentage of persons aged 65 and technique, attributed to Bohler in 1929,12 was the predeces-
older in the United States will rise from 12% to 19% over sor of modern external fixation and consisted of the incorpo-
the next quarter century. Osteoporosis may be contributing ration of percutaneous pins in the mid-radius and metacarpals
to fractures in the elderly, and therefore improved attention into a circumferential plaster cast. Although the technique
to care of this condition may reduce the incidence of such yielded initial improvements, it fell from favor because exter-
fractures.102 nal fixation devices were easier to apply and seemed to
The goals of this chapter are to provide the surgeon with maintain the reduction with fewer complications.17 The use
a detailed understanding of fracture types, better knowledge of external fixation began in the 1940s, and the principles
of wrist and fracture mechanics, improved recognition of were best summarized by Anderson and O’Neil3:
individual fracture fragments in complex fractures, and an
understanding of expectations of fracture treatment. Using a  Strong forearm muscular forces oppose fracture fixation.
case-based approach, it is hoped that the reader will have a  Loss of radial length is secondary to crushed metaphyseal
better appreciation of the factors influencing the results of bone.
treatment and enable the surgeon to develop an effective  Distraction should be maintained for 8 to 12 weeks until
approach to this injury. the metaphysis is reconstituted.
 Open reduction of impacted articular fragments is

THE RATIONALE FOR necessary.

 Bone grafting is required to support the crushed articular
MODERN TREATMENT surface.
Beginning with Pouteau (1783), Colles (1814), and Dupuy-  “Immediate use of the fingers and arm is the keynote to
tren (1847), early reports of fractures of the distal radius near perfect functional restoration.”
561
PART Despite relative improvements in fracture fixation stabil- and Watson demonstrated changes in resting carpal posture
III ity, there remained no hard data for surgeons to link patient and aberrations in carpal kinematics caused by dorsal mal-
function or outcome with treatment variables. Surgeons used union of the radius and advocated realignment osteotomy
17  a variety of techniques ranging from casting with or without to restore the radiocarpal and midcarpal relationships.112
Kirschner wire fixation to pins and plaster or external fixa- Reports of excellent results after osteotomy and bone graft-
Wrist

tion, without comparative studies or a means to judge results. ing of painful malunions by Fernandez and others provided
In 1951, Gartland and Werley published a series of 60 further evidence to underscore the link between bony align-
patients treated by plaster immobilization and devised a ment and function.31 These important clinical and benchtop
demerit point system to score subjective and objective func- advances helped us understand how critical the articular rela-
tion that continues to be used today.35 The authors defined tionships of displaced distal radial fragments are to upper
the anatomic indices of normal volar tilt, radial length, and extremity function and solidified the tenet that there is a
radial inclination and demonstrated that 60% of treated frac- narrow tolerance of these joints for changes in radial angula-
tures assume their prereduction alignment at final follow-up tion, tilt, and variance in young, active patients.
despite adequate cast treatment. In their series, all fractures Although Scheck and others had drawn attention to the
lost some component of the initial reduction of dorsal tilt. presence and importance of impacted articular fragments as
For the first time, the authors showed that poor functional a prognostic indicator,105 Knirk and Jupiter focused attention
outcomes are associated with failure to restore and maintain on the need for longer-term functional studies, particularly
bony alignment. In this and many subsequent series over the in young adults with a high-energy articular fractures.65 Their
next several decades,27,63,85,121 compelling evidence has been long-term follow-up study documented a 91% rate of degen-
presented to link restoration of anatomy to restoration of erative arthritis, as judged by plain radiographs, in patients
function, a principle that is the basis of modern fracture with any degree of residual articular incongruity and a 100%
treatment. rate in patients with 2-mm or greater incongruity. However,
The popularity of external fixation for the treatment of a multivariate analysis was not performed to eliminate the
wrist fractures was catapulted forward by the concept of potential confounding effects of radial malalignment. The
“ligamentotaxis” by Jacques Vidal in 1979, who advocated study did draw attention to the need for restoration of
its use for comminuted articular fractures, including those of joint congruity and ignited a surge of interest in precision
the hip, knee, ankle, spine, and wrist. The principle of liga- realignment of the articular surface. Some studies would
mentotaxis involved the application of tension “by means of support their observation by linking residual articular incon-
distraction forces working through capsule-ligamentous gruency directly with the early onset of degenerative
structures” to obtain reduction.117 Though not substantially changes.29,68
different in concept from pins and plaster or the Roger With the primary goal of restoration of joint congruity,
Anderson frame, the spanning external fixator enabled the several authors advocated meticulous restoration of the artic-
surgeon to adjust ligament tension via distraction and ten- ular surface through an open dorsal or combined dorsal/volar
sioning devices. Although the author described its use for approach, rigid internal fixation, and cancellous bone graft.5,33
highly comminuted fractures that were otherwise not suited Although these techniques generally attained the goal of
for internal fixation, advocates of the technique championed accurate reduction of the articular surface, a high rate of
it widely for virtually all fractures of the distal radius, and complications was reported, primarily extensor tendon irrita-
industry responded with a plethora of external fixation tion and rupture. This caused many to reconsider the use of
devices in the 1980s and 1990s. Within 10 years of Vidal’s dorsal plates. Surgeons and manufacturers teamed to
publication, multiple centers reported extensive complica- design novel dorsal plate fixation systems that combined
tions related to overdistraction of articular injuries, including improved material strength with lower-profile plates and
severe digital stiffness, reflex sympathetic dystrophy, and screws, which seemed to decrease the incidence of extensor
nerve dysfunction, as well as an inability to maintain reduc- tendonopathy.
tion of articular fragments and radial length with traction Advances in the understanding of external fixation also led
alone.23,58,87,120 Over the ensuing 2 decades, the technique of to improvements in clinical outcomes by using combined
external fixation evolved to include “augmentation” of fixa- techniques of limited open reduction,9,38 arthroscopic indirect
tion with supplemental Kirschner wires, mini-open or reduction,29,37,123 and percutaneous “augmented” external
arthroscopic reduction (or both), and bone grafting, with a fixation. The complications of digital stiffness and overdis-
concomitant reduction in traction-related complications. traction were reduced by using the external fixator as a
Frykman called our attention to the importance of injuries neutralization device and using percutaneous Kirschner wires
on the ulnar side of the wrist to outcome of distal radius and bone graft to support impacted articular fragments.106
fractures.34 Pivotal work by Palmer and colleagues in the Use of bone graft was also thought to enable earlier removal
early 1980s unveiled the complex anatomy and the critical of the fixator77 while providing structural support for the
importance of the triangular fibrocartilage complex (TFCC) articular surface and improvements in radial length and align-
to stability of the radioulnar joint and hand function after ment. “Nonspanning” external fixation in selected patients
distal radial fractures.93,107 Through mechanical loading was reported to lead to improvements in early and late func-
experiments, the investigators provided fundamental scien- tional and radiographic outcomes,84 and the technique and
tific evidence to explain the relationship between dorsal indications for this procedure continue to be refined.
malalignment of the radius and increased ulnar load transmis- Despite the ability to improve articular congruity, a
sion, as well as the compounding effect of increased ulnar prospective assessment of displaced intra-articular fractures
variance as a result of radial settling. Concurrently, Taleisnik with computed tomography (CT) documented progressive
562
arthrosis of the radiocarpal joint in a high percentage of PART
patients.43 Interestingly, there was little correlation between III
patients’ functional outcome and the presence or severity of
arthrosis. This finding suggests that despite the best effort to
17 
restore articular alignment, post-traumatic arthrosis (perhaps

Wrist: Distal Radius Fractures

asymptomatic) may be unavoidable. In a randomized study
in which patients with unstable fractures were treated by
either closed reduction, external fixation, or open reduction,
improved functional results were directly related to restora-
tion of carpal alignment in the sagittal plane (restoration of
volar tilt), and no technique proved superior in this S
regard.86 T
The last decade has witnessed an unprecedented interest L
in internal fixation techniques: (1) columnar fixation with
TFCC
miniature or “fragment-specific” fixation74,99 and (2) fixation
of a wide variety of fractures with fixed-angle devices through RADIUS
a single volar approach.91 Improvements in imaging and rec- ULNA
ognition of unstable fracture fragments have enabled sur-
geons to customize their approach and identify and rigidly
fix highly comminuted fractures with internal fixation,
thereby enabling earlier resumption of wrist motion. Enthu-
siasm for the new wave of implants and techniques has been
tempered by reports of tendon rupture, hardware malposi-
tion, and loss of fixation, as well as by two prospective
studies that demonstrated better patient outcomes with per-
Figure 17.1  The scaphoid and lunate articulate with the distal
cutaneous techniques than with open reduction and plate articular surface of the radius, and the ulnar head articulates with
fixation.45,68 Yet with each new technique comes an expan- the sigmoid notch. The triangular fibrocartilage complex (TFCC)
sion of our understanding of fracture behavior and an is interposed between the ulnar carpus and the ulnar head. L,
improved ability to treat a multitude of fracture patterns in lunate; S, scaphoid; T, triquetrum.
a widely diverse group of patients.
The evidence on treatment of wrist fractures accumulated
in the last century suggests four principal goals of interven-
FRACTURE EVALUATION
tion (ARMS). There is both general consensus and scientific
evidence that restoration of the anatomy of the distal radius PERTINENT ANATOMY
is closely linked to restoration of function. Consequently, The distal radius functions as an articular plateau on which
closed or operative management should seek to restore: the carpus rests (Figures 17.1 and 17.2) and from which the
radially based supporting ligaments of the wrist arise (Figure
1. Articular congruity (to reduce the wear of articular carti- 17.3). The hand and radius, as a unit, articulate with and
lage and degenerative changes) rotate about the ulnar head via the sigmoid notch of the
2. Radial alignment and length (to restore kinematics of the radius (Figure 17.4). This latter relationship is maintained
carpus and radioulnar joint) primarily by the ulnar-based supporting ligaments of the
3. Motion (digits, wrist, and forearm to optimize return to wrist: the TFCC.
functional activities) The distal radius has three concave articular surfaces—the
4. Stability (to preserve length and alignment until healing scaphoid fossa, the lunate fossa, and the sigmoid notch—for
of the fracture) articulation with the scaphoid, lunate, and ulnar head, respec-
tively (Figures 17.5 and 17.6). The sigmoid notch is concave,
We may modify our treatment based on the level of patient with a poorly defined proximal margin and well-defined
understanding, bone quality, compliance issues, or expecta- dorsal, palmar, and distal margins (see Figure 17.6).
tions. When we speak of “accepting” less than full attainment The distal articular surface of the radius has a radial inclina-
of these goals, we generally do so because of patient factors tion, or slope, averaging 23 degrees and tilts palmarly an
(systemic illness, age, activity level) rather than fracture average of 11 degrees (Figure 17.7A). Radial inclination is
pattern. measured by the angle formed by a line drawn tangential to
What is clear from an analysis of the evolution of wrist the distal radial articular surface on a posteroanterior (PA)
fracture treatment is that no single technique or method will radiograph and one perpendicular to the shaft of the radius.
yield results superior to those of all other treatment methods, Palmar tilt is measured by the angle created by a line drawn
given the wide divergence in fracture subtypes, energy asso- between the dorsal and palmar lips of the lunate facet and
ciated with the injury, age, activity level, and related injuries. the longitudinal axis of the radius. This angle is probably best
The indiscriminate use of one method to treat all fractures appreciated on a facet lateral radiograph, performed with the
of the distal radius will predictably lead to cases of fixation beam inclined approximately 10 to 15 degrees distal to proxi-
failure, soft tissue injury, and inability to achieve the goals mal, to profile the articular surface of the lunate facet and
of intervention. eliminate the bony overlap of the radial styloid (see Figure
563
PART
III Scapholunate
ligament
17  Lunotriquetral
ligament
Wrist

Ulnotriquetral Radioscaphocapitate Figure 17.2  Arthroscopic anatomy of the

ligament ligament radiocarpal joint. Pictured are the articular
surfaces of the scaphoid, lunate, triquetrum,
Long radius, and triangular fibrocartilage complex.
Ulnolunate ligament
radiolunate The major extrinsic—radioscaphocapitate, long
Triangular ligament radiolunate, radioscapholunate, ulnolunate,
fibrocartilage complex and lunotriquetral—ligaments of the wrist are
shown. The very important intrinsic ligaments
Radioscapholunate
of the wrist—the scapholunate ligament and
ligament
lunotriquetral ligaments—are also shown.
(Copyright Elizabeth Martin.)

TFCC

RADIUS

DIC
Seat

RS
RT
TFCC

Figure 17.4  The ulnar head articulates with the sigmoid notch of
the radius at the “seat” of the distal radioulnar joint (DRUJ). The
triangular fibrocartilage complex (TFCC), the distal restraint of the
DRUJ, arises from the most ulnar border of the radius and inserts
into the base of the ulnar styloid process.

Figure 17.3  Dissection and illustration composite showing the

dorsal ligaments of the wrist. DIC, dorsal intercarpal ligament; RS,
radioscaphoid; RT, radiotriquetral; TFCC, triangular fibrocartilage RADIOGRAPHIC PATHOANATOMY
complex. (Copyright Elizabeth Martin.) When evaluating fracture radiographs, it is important to
appreciate several relationships and bony landmarks that
may have subtle but important aberrations because of the
17.7B). Ulnar variance averages just under 1 mm negative88 malposition of fracture fragments. Perhaps the most impor-
and ranges widely; variance is the axial difference between tant of these bony landmarks of the distal radius is the “tear-
the subchondral bone of the lunate facet at the distal margin drop,”88 which represents the volar projection of the lunate
of the sigmoid notch and the most distal articular surface of facet of the distal radius and the mechanical buttress for
the ulna, measured along the longitudinal axis of the forearm subluxation of the lunate (see Figure 17.5D). The teardrop
(see Figure 17.7A). projects 3 mm palmarward from the flat surface of the radial
The dorsal aspect of the distal radius is convex and acts as diaphysis, or 16% of the anterior to posterior height of the
a fulcrum for extensor tendon function (see Figure 17.5). The lunate facet.1 A line drawn tangent to the subchondral bone
radial styloid area may have a groove for the tendon of the of the articular surface through the tip of the teardrop nor-
first dorsal compartment, and ulnar to this is a dorsal longi- mally subtends an angle of 70 degrees with the longitudinal
tudinal prominence, Lister’s tubercle, which acts as a fulcrum axis of the radius (Figure 17.8A)88; consequently, subtle
for the extensor pollicis longus (EPL) tendon. dorsal rotation of an extra-articular fractured radius will alter
564
 PART
III
17 

Wrist: Distal Radius Fractures

A B

Figure 17.5  Artist’s drawing of the distal radius. A, Dorsal view illustrating Lister’s tubercle. B, Palmar view showing the scaphoid
and lunate fossae distally, as well as the sigmoid notch ulnarly. Vascular foramina can be noted on the palmar and dorsal aspects
of the distal radius. C, End-on view of the distal radius and radioulnar joint showing the scaphoid fossa, lunate fossa, and ulnar
head resting in the sigmoid notch. D, View of the sigmoid notch from the ulnar aspect. (Copyright Elizabeth Martin.)

this relationship and decrease the teardrop angle. Similarly, of the injured side is the lunate itself. In a normal wrist, the
an impaction injury that splits the lunate facet may drive the curvature of the lunate facet of the radius and the curvature
lunate into the metaphysis of the radius and rotate the tear- of the lunate itself are well visualized on a facet lateral pro-
drop relationship (see Figure 17.8B to D). The teardrop mea- jection and virtually concentric. In an uninjured wrist, the AP
sures just 5 mm at its greatest width, thus making it difficult distance is essentially equal to the diameter of a circle that
to gain rigid fixation with traditional volar implants.53 represents the best fit to the proximal articular surface of the
Another useful measurement on the facet lateral film is the lunate (1.04 ± 0.09) (see Figure 17.9A). Fitting of a circle to
anteroposterior (AP) distance, and it is measured between the lunate articular contour is easily performed by using the
the distal apex of the dorsal and volar rims of the lunate facet digital toolbox on most modern picture-archiving and com-
(Figure 17.9A and B). The average AP distance is 20 mm in munication systems (PACSs). Nonconcentric articular con-
males and 18 mm in females, but for improved accuracy, the tours or an altered AP/lunate diameter ratio suggests a
AP distance on the injured side should be compared with that sagittal split of the lunate facet, nonanatomic radiocarpal
on the uninjured side. An appreciably widened (or narrowed) alignment, or both (see Figure 17.9B).
AP distance, in relation to the opposite side, represents an On the normal PA view, the dorsal rim of the radius pro­
alteration in the contour of the lunate facet secondary to jects 3 to 5 mm beyond the dense subchondral bone of the
impaction or articular split. Because contralateral films are volar rim of the radius (Figure 17.10). Displaced fractures
not always available and radiographs may be magnified, a may increase, reduce, or invert this relationship, depending
useful comparative (and scalable) landmark on a lateral film on the degree of sagittal plane rotation of the distal fragment.
565
PART
III
17  D

SIGMOID
Wrist

NOTCH

P 23°

Figure 17.6  The sigmoid notch showing distinct dorsal, palmar,

and distal borders and an indistinct proximal border. D, distal; P,
proximal.
11°

X-ray beam
Breaks in the dense subchondral bone on the PA view can
be recognized as step-offs or articular gaps, and impacted 15°
articular fragments can be identified as linear densities within
the metaphyseal bone on either the PA or lateral view.
Careful analysis of fracture radiographs, thorough under-
standing of common fracture patterns, and an appreciation
B
of the mechanism of the injury will allow the examining
physician to classify the fracture and begin to formulate a Figure 17.7  A, Posteroanterior radiograph of a wrist
treatment plan. Generally, standard radiographic views (PA, demonstrating radial inclination (23 degrees) and neutral ulnar
facet lateral, oblique) are sufficient to understand a fracture’s variance. B, The “facet lateral” x-ray is performed by aligning the
pathoanatomy. However, special imaging techniques, such as x-ray beam in a plane parallel to the lunate facet of the radius,
approximately 15 degrees distal to proximal. (Drawing copyright
traction views after reduction, tomograms, or CT scans,
Elizabeth Martin.)
provide a more accurate diagnosis of the displacement
pattern, number of fragments, and degree of joint involve-
ment at both the radiocarpal and radioulnar levels (Figure
17.11A to D). Though adding significantly to cost, three- of injury, relative stability, associated soft tissue injuries,
dimensional reconstructions of CT scans of articular fractures radioulnar involvement, and prognosis. The ideal fracture
more accurately define the number and presence of articular classification should provide reproducible anatomic, diagnos-
fragments and increase the probability of a combined tic, and prognostic considerations, assess the associated soft
approach for treatment.53 Three-dimensional imaging also tissue lesions, and infer appropriate treatment. Physicians
positively influences the number of patients treated opera- dealing with distal radius fractures should adopt a classifica-
tively, but whether improved fracture visualization and tion scheme that fulfills their own needs for clinical and sci-
changes in operative planning result in improved patient entific purposes. When reporting outcomes or designing a
outcome will require further study. multicenter study, however, it is important that a system with
a high degree of intraobserver and interobserver reproduc-
RECOGNITION OF ibility be chosen.
The nature of many of the classifications mentioned later
FRACTURE PATTERNS in the section “Classification” has been analyzed with regard
Distal radius fractures tend to cluster in recognizable pat- to both interobserver and intraobserver reliability and repro-
terns, and it is important that the treating physician be famil- ducibility.2,69 Observer agreement was considered adequate
iar with the multiple fracture variants to recognize a fracture’s for the main types of the AO classification but was subopti-
“personality,” that is, its behavioral characteristics, energy mal when analyzing groups and subgroups. Interobserver
566
 PART
III
17 
83°

Wrist: Distal Radius Fractures

A B

50° 72°

C D
Figure 17.8  “Teardrop angle.” A, The angle is measured as a tangent to the articular surface of the volar teardrop with respect
to the longitudinal axis of the radius and is normally 70 degrees. B, Increased teardrop angle with a displaced volar marginal
fracture. C, Decreased teardrop angle with a dorsally angulated extra-articular fracture. D, Restoration of a normal teardrop angle
after internal fixation of the teardrop.

20.3 mm

5.1 mm

28 mm

Figure 17.10  The dorsal rim of the radius normally projects 3 to

5 mm distal to the dense subchondral bone of the articular
surface, and this relationship may be altered by post-traumatic
changes in volar tilt or die punch injuries.

B
Figure 17.9  AP distance and AP/lunate diameter ratio. A, In an
uninjured wrist, the AP distance (20.3 mm) is nearly equal to the
diameter of a best-fit circle of the lunate contour (19.8 mm).
B, In an injured wrist, the AP diameter is grossly widened 567
(26 mm), and the AP/lunate diameter ratio is 1.3.
PART
III
17 
Wrist

A B

C D
Figure 17.11  Use of computed tomography. A and B, Posteroanterior and lateral radiographs of a comminuted articular fracture
after reduction demonstrating what appears to be satisfactory reduction of the articular surface. C and D, Coronal and axial
scans of the articular surface demonstrating multiple fragmentation, articular impaction, and incongruency. Note the separate
volar lunate “teardrop” fragment that may not have been appreciated on the lateral radiograph.

agreement was rated moderate for the Mayo and fair for the Barton’s Fracture
Frykman, Melone, and AO classifications. Two studies con- Barton’s fracture is a displaced, unstable, articular fracture-
cluded that these classifications lack the capacity for predict- subluxation of the distal radius with displacement of the
ing outcome or comparing results among different studies. carpus along with the articular fracture fragment.8 Barton’s
fracture may be either dorsal or volar, as shown in Figure
17.13, and may also be classified as a Smith type II variant.
COMMONLY USED EPONYMS
There are few areas of skeletal trauma in which eponymic Chauffeur’s or Backfire Fracture
descriptions are so commonly used; contemporary authors Figure 17.14 illustrates a shear fracture with displacement of
have purposely avoided assigning their name to a particular the carpus and avulsion of the attached radial styloid. The
fracture type and instead have preferred to base classification fracture earned its now antiquated name because of the pro-
of them on a variety of measurements, observations, and pensity for the chauffeur to be struck by the backfire recoil
characteristics of the injury. of a starter crank on an early automobile engine. Despite its
seemingly innocuous name, this fracture is notorious for con-
Colles’ Fracture comitant injuries to the intercarpal and extrinsic radiocarpal
Figure 17.12 illustrates the typical features of a Colles’ frac- ligaments.
ture, or a distal radius fracture with dorsal comminution,
dorsal angulation, dorsal displacement, radial shortening, and
an associated fracture of the ulnar styloid.22 Lunate Load, Die Punch, or Medial
Cuneiform Fracture
Smith’s Fracture Figure 17.14 illustrates this fracture, which classically repre-
Figure 17.13 illustrates three types of fractures of the distal sents a depression of the dorsal aspect of the lunate fossa; a
radius with volar displacement, classified as Smith’s types I, portion of the lunate articular surface may also be impacted
II, and III by Thomas in 1957.95,113 into the subchondral bone.105
568
 to the extent of intra-articular involvement and metaphyseal PART
comminution. It is important to understand the distinction III
between type B fractures, in which some portion of the
articular surface remains in continuity with the metaphysis,
17 
and type C fractures, in which no portion of the articular

Wrist: Distal Radius Fractures

surface is in continuity with the metaphysis (Figure 17.17).
The three basic types are further subdivided into groups and
subgroups to ultimately produce 27 different fracture pat-
terns at the distal end of the forearm. Unfortunately, despite
its ability to categorize virtually each variation of fracture,
there is little interobserver agreement when the subdivisions
Lateral are made; acceptable agreement is reached only when the
three major subgroups are chosen.2

Mayo Clinic Classification

The classification system advocated by the Mayo Clinic group
allows subclassification within types 1 to 4 based on whether
the fracture is extra-articular or articular and whether the
fracture is reducible or irreducible (Figure 17.18).

“Fragment-Specific” Classification
Robert Medoff developed a simplified intra-articular fracture
classification by recognizing five major fragments, namely,
AP
the radial styloid, the dorsal wall, impacted articular frag-
ments, the dorsal ulnar corner (“die punch” fragment89,105),
and the volar rim fragment (Figure 17.19).74 Articular frac-
tures can be described by identifying their component frag-
Figure 17.12  Diagrammatic representation of the typical
deformity seen in a Colles’ fracture. Dorsal comminution and ments, either alone or in combination. To more fully
displacement with shortening of the radius relative to the ulna are understand a fracture and use this understanding to plan
present. (Copyright Elizabeth Martin.) treatment, the surgeon should also identify (1) the primary
direction of the fracture angulation (dorsal/volar) and (2) the
mechanism of the injury (see the Fernandez classification
CLASSIFICATIONS later). The fragment-specific classification is treatment ori-
ented because specific fixation with modular implants for
Frykman’s Classification each fracture component can be chosen.
In 1967, Frykman proposed a classification that distinguished
between extra-articular and intra-articular fractures of the Columnar Classification
radiocarpal and radioulnar joints and the presence or absence Daniel Rikli and Pietro Regazzoni introduced an important
of an associated distal ulnar fracture (Figure 17.15).34 This conceptual framework for the understanding and treatment
classification is useful; it is easy to learn and to communicate of articular fractures by recognizing the three columns of the
with colleagues, but it does not readily translate into prog- wrist (Figure 17.20).99 The radial column, or lateral column,
nostic or treatment utility. is composed of the radial styloid and scaphoid facet of the
radius; restoration of this column re-establishes both length
Melone’s Classification and alignment of the articular surface in the frontal and sagit-
In 1984, Melone introduced a classification of distal radial tal planes. The intermediate column includes the lunate facet
fractures in which he identified four major components of the and is the primary load-bearing column of the radius. Frac-
distal radius: (1) the shaft, (2) the radial styloid area, (3) the tures of the intermediate column include the dorsal “die
dorsal medial facet, and (4) the volar medial facet (Figure punch” fragment, impacted articular fragments, and the volar
17.16).89 This classification focused much needed attention ulnar corner fragment. Importantly, fractures of this column
on the important medial (lunate) facet of the distal radius also disrupt the sigmoid notch of the radius and consequently
(i.e., the “medial complex,” the intermediate column, and the radioulnar joint. The medial column constitutes the rota-
the teardrop). tional column of the wrist and includes the distal ulna, the
triangular fibrocartilage, and the radioulnar ligaments. It is
The AO Classification critical that one assess and treat instability of this column
In 1986, the Swiss Association for the Study of Internal Fixa- when treating fractures of the radius to restore normal rota-
tion (ASIF/AO) accepted a new classification of fractures that tion of the forearm. This, too, is a treatment-oriented clas-
was further revised in 1990. In this classification system, sification system; Rikli and Regazzoni recommended
applicable to all long bones, different fractures are broken orthogonally placed microplates to treat dual-column frac-
down into three major types: type A (extra-articular), type tures of the radius and demonstrated the biomechanical and
B (partial articular), and type C (complete articular). This clinical efficacy of the concept.98,99
classification considers the severity of the fracture according Text continued on p. 574

569
PART
III
17 
Wrist

Smith I

Dorsal Barton’s

Smith II/volar Barton’s

Smith III

Figure 17.13  Thomas’ classification of Smith’s fractures. A type I Smith fracture is an extra-articular fracture with palmar
angulation and displacement of the distal fragment. A type II Smith fracture is an intra-articular fracture with volar and proximal
displacement of the distal fragment along with the carpus. A Smith type II fracture is essentially a volar Barton’s fracture. A dorsal
Barton’s fracture, illustrated for comparison, shows the dorsal and proximal displacement of the carpus and distal fragment on
the radial shaft. A type III Smith fracture is an extra-articular fracture with volar displacement of the distal fragment and carpus.
(In type III the fracture line is more oblique than in a type I fracture.) (Copyright Elizabeth Martin.)

Figure 17.14  A chauffeur’s fracture is

illustrated with the carpus displaced ulnarly by
the radial styloid fracture. A lunate die punch
fracture is shown with a depression of the
lunate fossa of the radius that allows proximal
migration of the lunate or proximal carpal row
(or both). (Copyright Elizabeth Martin.)

Chauffeur’s fracture Lunate die punch fracture

570
 PART
III
17 

Wrist: Distal Radius Fractures

I II

Figure 17.15  Frykman’s classification of distal

III IV
radius fractures. Types I, III, V, and VII do not
have an associated fracture of the distal ulna.
Fractures III through VIII are articular fractures.
Higher-classification fractures have worse
prognoses. (Copyright Elizabeth Martin.)

V VI

VII VIII

3
Figure 17.16  Melone’s classification of distal
2 radial fractures. The four major fragments are
4 3 4 (1) the radial shaft, (2) the radial styloid
region, (3) the dorsal medial facet, and (4) the
volar medial facet. The major fragment of this
four-part fracture is the medial facet (i.e.,
fragments 3 and 4). (Copyright Elizabeth
1 1
Martin.)

571
PART
III
17 
Wrist

A A1 A2 A3

B B1 B2 B3

C C1 C2 C3
Figure 17.17  The comprehensive classification of fractures (AO). A, Extra-articular. This fracture affects neither the articular
surface of the radiocarpal nor the radioulnar joints. A1, Extra-articular fracture of the ulna with the radius intact. A2, Extra-
articular fracture of the radius, simple and impacted. A3, Extra-articular fracture of the radius, multifragmentary. B, Partial
articular. This fracture affects a portion of the articular surface, but continuity of the metaphysis and epiphysis is intact. B1,
Partial articular fracture of the radius, sagittal. B2, Partial articular fracture of the radius, dorsal rim (Barton’s). B3, Partial articular
fracture of the radius, volar rim (reverse Barton’s, Goyrand-Smith II). C, Complete articular. This fracture affects the joint surfaces
(radioulnar, radiocarpal, or both) and the metaphyseal area. C1, Complete articular fracture of the radius, articular simple and
metaphyseal simple. C2, Complete articular fracture of the radius, articular simple and metaphyseal multifragmentary. C3,
Complete articular fracture of the radius, multifragmentary.

572
 Mayo classification PART
III
Extra–articular Intra–articular
• Nondisplaced • Nondisplaced 17 
• Displaced • Displaced (reducible)
– Stable • Displaced (unreducible)

Wrist: Distal Radius Fractures

– Unstable • Complex

Type I Type II Type III Type IV

Radioscaphoid joint Radiolunate joint Radioscapholunate
(“die punch” fracture) joint

Figure 17.18  Mayo Clinic classification of distal radial fractures. Type 1 is an extra-articular fracture, and types 2 to 4 are
intra-articular fractures. Emphasis is given to whether the fracture is displaced or nondisplaced and reducible or irreducible.
(Copyright Elizabeth Martin.)

Dorsal
Intra-articular cortical

Radial Intra-articular
Dorsal column
ulnar
split
Dorsal Radial
cortical column Figure 17.19  Fragment-specific classification.

Volar
rim

Lateral
column
Intermed.
column
Medial
column

Figure 17.20  The columnar concept of the wrist. (Copyright

Elizabeth Martin.)

573
PART Fernandez’ Classification combines articular, metaphyseal, and diaphyseal disruption
III The author prefers the descriptive fracture classification and may require a combination approach, including internal
developed by Diego Fernandez,32 which is based on the fixation, spanning external fixation, or spanning internal fixa-
17  mechanism of injury (Figure 17.21A).11 In addition to the tion (distraction or “bridge” plate).
obvious bony injury to the radius, the associated ligamentous The treating physician should not lose sight of the purposes
Wrist

lesions, fractures of the neighboring carpal bones, and con- of fracture stratification when confronted by the multitude of
comitant soft tissue damage are directly related to the direc- eponyms and classifications that have been developed. The
tion and degree of trauma sustained. An understanding of the purpose of a classification should be to both (1) catalog
mechanism of the injury facilitates manual reduction through fracture types for subsequent reporting and comparison of
the application of a force opposite that produced by the outcome and (2) understand fracture anatomy and guide treat-
injury and guides definitive treatment based on the direction ment. A useful initial approach is to simultaneously appreciate
and magnitude of impact, as well as the nature of associated the complexity, mechanism, and relative energy of the injury
soft tissue injuries. Fractures of the distal radius may be by using the Fernandez system. For extra-articular fractures,
divided into the following five types, recognizable on stan- the primary determinant of treatment becomes the relative
dard PA, facet lateral, and oblique radiographs: stability of the fracture. For articular fractures, in addition
to an understanding of relative stability, the physician must
Type I fractures are extra-articular bending fractures of the obtain the necessary radiographs or advanced imaging studies
metaphysis in which one cortex fails with tensile stress and (or both) to determine the location, number, and displacement
the opposite one undergoes a variable degree of comminu- of the articular fragments, as well as the integrity of the radial,
tion (Colles’ or Smith’s type I fractures, AO type A1-3). intermediate, and ulnar columns. Careful consideration of
Type II fractures are shearing fractures of the joint surface these factors should enable the physician to develop an
(Barton’s, reversed Barton’s, and chauffeur’s fractures, AO appropriate treatment plan and, when indicated, the optimal
type B1-3). surgical approach and fixation strategy.
Type III fractures are compression fractures of the joint
surface with impaction of subchondral and metaphyseal Classification of Associated Injuries to
cancellous bone. These are generally high-energy injuries the Distal Radioulnar Joint
and usually involve disruption of both the radial and inter- Outcomes of treatment of distal radius fractures can adversely
mediate columns (Mayo type III, medial complex, die and seriously be affected by residual incongruity or instabil-
punch, AO type C1-2). ity of the radioulnar joint. Figure 17.21B illustrates a useful
Type IV, or avulsion fractures of ligament attachments, classification of concomitant ulnar injuries and guidelines for
includes dorsal rim and radial styloid fractures associated treatment. After satisfactory realignment of the radioulnar
with radiocarpal fracture-dislocations. relationship is attained by restoring radial length and sagittal
Type V fractures are high-velocity injuries that involve com- and coronal tilt, stability of the radioulnar joint depends on
binations of bending, compression, shearing, and avulsion two factors:
mechanisms or bone loss. Typically, there is diaphyseal as
well as severe metaphyseal and articular disruption (AO  Restoration of the mechanical integrity of the sigmoid
type C3). notch
 Continuity of the dorsal and volar radioulnar ligament
This classification scheme details frequent associated soft components of the TFCC, which attach at the ulnar fovea
tissue injuries and suggests a treatment algorithm for dis- (see Chapter 16)
placed fractures that incorporates each fracture category (see
Figure 17.21A). Type I displaced bending fractures are best Type I consists of stable distal radioulnar joint (DRUJ)
treated by a counterforce that will exert tension on the lesions, which means that adequate reduction of the radius
concave side of the angulation. In stable fractures, this force will render the joint clinically stable without disruption of the
can be applied with a well-molded, three-point contact cast. articular surface. Such lesions include
Unstable fractures may be treated by either percutaneous or
rigid internal fixation. Type II shearing fractures are highly 1. Avulsion of the tip of the ulnar styloid
unstable because of the obliquity of the fracture line and are 2. Stable fracture of the neck of the ulna
therefore suitable for internal fixation. Restoration of the
joint surface in type III compression fractures can be achieved In both, the primary stabilizers of the joint (foveal attach-
acutely by applying tension to the joint capsule with finger ment of the TFCC) are intact.
traps, external fixators, or pins and plaster techniques. Unsta- Type II consists of unstable DRUJ lesions. Despite satisfac-
ble or impacted articular fragments require open reduction; tory reduction of the radius, the ulna is unstable as a result of
percutaneous or internal fixation and subchondral support
with bone graft are generally necessary. Type IV avulsion 1. A massive tear of the TFCC
fractures are a constant component of radiocarpal disloca- 2. An avulsion fracture of the ulnar styloid through or below
tions caused by a combination of rotation and shear in pre- the fovea
dominantly young, healthy bone. Stabilization of large
avulsion fragments with screw, wireform, or tension band These injuries usually require supination casting, repair of
fixation generally restores ligament stability. Finally, in the the TFCC, fixation of the avulsed ulnar styloid, or temporary
type V combined fracture or high-velocity injury, the fracture cross-pinning of the radius and ulna to restore stability.
574
 Fracture type Stability/Instability: Displacement Number of Associated Author’s Other
based on the mechanism of injury risk of pattern fragments lesions preferred treatments PART
secondary carpal ligament, treatment III
displacement after fractures, median,
initial adequate ulnar nerve, 17 
reduction tendons, ipsilat.
fx upper

Wrist: Distal Radius Fractures

extremity,
compartment
syndrome

Type I Stable Nondisplaced 2 main Uncommon Cast (stable fxs) T-pin

Bending fracture Unstable Dorsal Colles fragments + Micronail
Volar Smith Percutaneous
of the metaphysis varying degree pinning
Proximal of metaphyseal
Combined comminution External fixation
Plate fixation

Type II Unstable Dorsal Barton Two part Less uncommon Open reduction Arthroscopic
Shearing fracture Radial chauffeur assisted
Volar rev. Barton Three part Fixed-angle
of the joint surface plate fixation
Combined Cannulated
Comminuted screws

Type III Stable Nondisplaced Two part Common Closed, limited, Bridge
Unstable Dorsal Three part arthroscopic (distraction)
Compression fracture Radial Four part assisted, or open plating
of the joint surface Volar Comminuted reduction, and:
Proximal Percutaneous
Combined pins
Multiple plate
(“fragment
specific”) fixation
External fixation
Plate fixation
± Bone graft

Type IV Unstable Dorsal Two part Frequent Multiple plate Bridge

Radial (radial styloid, fixation plating
Avulsion fractures, ulnar styloid)
Volar External
radiocarpal fracture Three part
Proximal Pin or screw fixation
dislocation (volar, dorsal,
Combined fixation
margin)
Comminuted Tension wiring

Type V Unstable Dorsal Comminuted Always present Combined Bridge

Radial and/or bone method plating
Combined fractures
Volar loss
(I-II-III-IV)
Proximal
High-velocity injury
Combined

A
Figure 17.21  A and B, The Fernandez classification of distal radius fractures and associated distal radioulnar joint (DRUJ) lesions.
B, DRUJ injury classification. (Copyright Elizabeth Martin.)
Continued

575
PART
Joint surface
III Pathoanatomy of the lesion
involvement
Prognosis Recommended treatment

17  Type I A + B Functional aftertreatment

Stable Encourage early pronation-
Wrist

(following supination exercises

reduction of
the radius
the distal None Good
radioulnar
joint is
congruous Note: Extra-articular unstable
and stable) fractures of the ulna at the
A Fracture of the B Stable fracture metaphyseal level or distal
tip of the ulnar of the ulnar shaft require stable plate
styloid neck fixation

Type II • Possible chronic instability A Closed treatment

Reduce subluxation, sugar
Unstable
• Painful limitation of tong splint in 45° supination
(subluxation supination if left 3 to 4 weeks
or dislocation unreduced
of the ulnar A + B Operative treatment
head present) • Possible late arthritic 1) Fix ulnar styloid
changes with tension band, screw,
None or pin plate
2) Immobilize wrist and elbow
in supination long arm cast
3) Transfix ulna and radius with
A Tear of the triangular B Avulsion fracture Kirschner wire and long arm
fibrocartilage complex of the base of cast
and/or palmar and the ulnar styloid
dorsal capsular
ligaments

Type III • Dorsal subluxation possible A Anatomic reduction and fixation

Potentially together with dorsally of palmar and dorsal sigmoid
unstable displaced die punch or notch fragments. If residual
dorsoulnar fragment instability, immobilize in
(subluxation supination with or without
possible) • Risk of early degenerative radioulnar transfixion pins
changes and severe
Present limitation of forearm B Functional aftertreatment to
rotation if left unreduced enhance remodeling of ulnar
head

If distal radioulnar joint remains

A Intra-articular fracture B Intra-articular painful:
of the sigmoid notch fracture of the Partial ulnar resection, Darrach,
ulnar head Sauve-Kapandji procedure, or
ulnar head prosthesis at a later
date

B
Figure 17.21, cont’d 

Type III includes comminuted articular injuries of either  Combined injuries with metaphyseal-diaphyseal commi-
the sigmoid notch or the ulnar head, and these injuries nution (type V)
require reduction and stabilization to restore articular con-  Fractures complicated by nerve compression, compart-
gruency and prevent degenerative changes. ment syndrome, or multiple injuries

Fracture Stability The majority of fractures, including extra-articular and

Certain fractures are unstable by definition or require surgi- simple articular fractures, are not easily sorted into operative
cal management in healthy adults and include: and nonoperative treatment regimens, and determination of
fracture stability becomes a critical crossroad for fracture
 Open fractures treatment. Treatment of inherently unstable fractures with
 Displaced shear fractures (type II) casting will fail and result in loss of radial length, carpal align-
 Comminuted and displaced articular fractures with articu- ment, or articular incongruity. Unnecessary casting in this
lar impaction (type III) scenario will prolong overall treatment time and cost, may
 Fracture-dislocations (type IV) lead to digital stiffness and trophic changes, and might require
576
 PART
III
17 

Wrist: Distal Radius Fractures

Figure 17.22  According to McQueen and colleagues,86 carpal Figure 17.23  Alternative and rapid assessment of carpal
malalignment is defined when the longitudinal axis of the capitate malalignment using the “radial box.” The center of the capitate
and the radius intersect outside the boundaries of the carpus proximal pole should fall within a box generated along the dorsal
(arrow). and palmar cortical outlines of the radius on a true lateral x-ray.

subacute surgical intervention or corrective osteotomy to

restore alignment and function, depending on the particular authors have confirmed that age, loss of radial length, and
patient needs. What is not immediately evident is how to initial dorsal angulation are the most important predictors of
identify stable and unstable fractures early to optimize collapse with cast treatment. MacKenney and colleagues pro-
patient outcome and minimize unnecessary surgery or inef- duced a quantitative, weighted formulaic approach to deter-
fective cast immobilization. mination of fracture instability in a prospective study of 3559
In a cohort of 32 patients treated nonoperatively for unsta- patients with displaced and nondisplaced extra-articular frac-
ble Colles’ fractures, Bickerstaff and Bell demonstrated that tures and demonstrated a surprising 60% malunion rate had
the two best predictors of poor functional, subjective, and all displaced fractures been treated by closed reduction.82
objective outcomes were residual dorsal tilt of the radial Advanced age was the most predictive factor, and the nature
articular surface and the associated nondissociative dorsal of the fracture on the initial fracture films was also predictive
lunate instability.11 In a group of patients who required oper- of instability and malalignment at healing. Specifically, in
ative treatment of unstable fractures that failed closed reduc- addition to a “relentless” association of instability and
tion, McQueen and colleagues also demonstrated that failure malalignment with age, dorsal comminution and increased
to restore carpal alignment in the sagittal plane, as demon- ulnar variance (>3 mm) were important predictors of subse-
strated on lateral radiographs at 1 year, was the single most quent loss of reduction in plaster. Initial dorsal angulation
predictive factor of worsening functional outcomes and was not predictive because it was confounded by the pres-
objective measures of strength.86 Failure to restore radial ence of dorsal comminution in the multivariate analysis.
length was significantly associated with diminution in grip Taken together, though not infallible, it is evident that
and pinch strength. The authors delineated a useful param- patient age and the position and comminution of the fracture
eter of carpal malalignment on neutral-positioned lateral on initial trauma films can be vital predictive tools for assess-
radiographs by defining intersecting lines of the capitate axis ment and formulation of treatment plans. Patients with a
and the longitudinal axis of the radius. Carpal malalignment constellation of instability factors should be advised of the
is defined when the two lines intersect outside the boundaries relative probability of loss of reduction, and physiologically
of the carpus (Figure 17.22).86 In a perfect lateral radiograph, young or active patients should be counseled concerning the
these two lines may be parallel and thus this method may option of early operative intervention. Patients with initial
not be accurate. I consider the carpus malaligned if the center radial shortening and dorsal comminution, particularly if
of the capitate proximal pole does not lie within a “radial older than 60 years, who elect to not undergo surgical stabi-
box” defined by the dorsal or volar cortical confines of the lization should be observed weekly for radiographic evi-
radius (Figure 17.23). dence of fracture settling. Understanding that malunion and
Numerous authors have attempted to determine parame- carpal malalignment are important predictors of diminished
ters that are predictive of radial instability in the acute strength and function in otherwise healthy adults should
setting. Lafontaine and colleagues defined five “instability enable the physician to tailor the treatment expeditiously.
parameters” and demonstrated a linear relationship between
the number of instability parameters present on displaced TREATMENT OPTIONS
fracture films and ultimate fracture collapse with closed
treatment72: Closed Reduction
The greatest challenge of closed treatment of a dorsally angu-
1. Dorsal angulation greater than 20 degrees lated fracture is to reduce the fracture and maintain the
2. Dorsal comminution position without excessive flexion of the wrist joint. Inher-
3. Intra-articular radiocarpal fracture ently unstable fractures with initially acceptable closed
4. Ulnar fracture reduction will often redisplace and shorten secondary to the
5. Age older than 60 years resting muscular tension, occasional involuntary contraction,
and the load transmitted from normal digital motion.
The authors recommended that patients with three or more Although extreme palmar flexion and ulnar deviation (the
of the five parameters be considered for surgical intervention so-called Cotton-Loder position24) may be mechanically
at an early stage of management. Although inclusion of all effective in restoring volar tilt, this position cannot be main-
five factors is the subject of some controversy, subsequent tained because a fully flexed wrist may cause compression of
577
PART
III
17 
Wrist

A B
Figure 17.24  A and B, Distal radius (Colles’)
fracture. C and D, My recommended reduction of
this fracture. After suspending the arm from finger
traps and allowing disimpaction of the fracture,
pressure is applied with the thumb over the distal
fragment. (Copyright Elizabeth Martin.)

the median nerve and is mechanically disadvantageous to the The patient is asked to relax. After allowing the arm to
digital flexors. hang from the finger traps for 5 to 10 minutes, pressure is
applied by the treating physician’s thumb to the distal frac-
Technique of Closed Reduction ture fragment in a direction that will reduce the displacement
In preparation for closed reduction, the first step is gentle (see Figure 17.24D). For a dorsally displaced fracture, the
surgical preparation of the dorsal surface of the wrist. The distal fragment is rotated with the treating physician’s thumb
hematoma associated with the fracture is then sterilely infil- into a slightly flexed position with a palmarly directed force.
trated with 1% lidocaine without epinephrine, and the anes- Care should be taken to avoid overpronation of the fracture
thetic is allowed to diffuse about the fracture site for fragment on the radial shaft. When the distal fragment is
approximately 5 minutes. If the fracture is seen late and there translated dorsally as well as angulated, I find it helpful to
is significant soft tissue swelling, a regional nerve block (axil- simultaneously distract and hyperextend the fracture first to
lary) or general anesthesia may be necessary. The arm is disimpact the fracture fragments before subsequently reduc-
gently suspended with finger traps attached to the thumb, ing the deformity with a traction/flexion maneuver. A stable
index, and long fingers (Figure 17.24) and 5 to 10 lb of coun- reduction will generally hold its position with the wrist only
tertraction across the upper part of the arm. slightly flexed and ulnarly deviated. A sugar tong splint is
578
 PART
III
17 

Wrist: Distal Radius Fractures

Figure 17.25  Sugar tong splint for a distal radius
fracture. This splint controls forearm rotation while
allowing some elbow flexion. The palmar crease
should be free to allow full metacarpophalangeal
flexion and the dorsal plaster should extend to the
metacarpal heads.

applied to maintain the position (some prefer to apply the an external fiberglass cast, is a relatively simple and effective
splint while still suspended in finger traps), and the fracture method of fixation that is applicable for reducible extra-
reduction can be fine-tuned as necessary with the splint in articular fractures and simple intra-articular fractures without
place (Figure 17.25). Molding over the index metacarpal, metaphyseal comminution but with good bone quality.
with a countermold over the palmar apex of the fracture site, A variety of different techniques have been described, and
is helpful to maintain fracture position. The recommended the most commonly used methods are shown in Figure 17.28.
position of immobilization for a dorsally angulated metaphy- These include pins placed through the radial styloid alone,
seal fracture is neutral to slight flexion, 20 to 30 degrees of crossed radial styloid and dorsal ulnar corner pins, intrafocal
ulnar deviation, and neutral forearm rotation (Figure 17.26). pinning within the fracture site, transulnar oblique pinning
Radiographs are obtained to confirm reduction. Although without transfixation of the DRUJ, one radial styloid pin and
palmarly displaced, extra-articular Smith’s fractures are gen- a second across the DRUJ, and multiple transulnar-to-radius
erally unstable, the flexion-pronation deformity of Smith’s pins, including the DRUJ.97
fractures can be reduced and occasionally stabilized effec- The procedure is done in the operating room, usually
tively in extension and supination (45 to 60 degrees) with a under brachial block anesthesia with fluoroscopic guidance.
sugar tong splint. The hand is prepared and suspended in finger traps with 5 to
Depending on the type and stability of the fracture, patients 10 lb of countertraction applied across the upper part of the
should initially be examined weekly with cast checks and arm. Closed reduction is performed and the adequacy of
serial radiographs. Patients with stable fractures can be reduction confirmed fluoroscopically. Pinning of the fracture
changed to a well-molded short arm cast at 2 or 3 weeks. may be done while traction is maintained, or the hand may
The principles of three-point bending should be used to help be removed for ease of manipulation, with 0.0625-inch
maintain reduction; dorsal molds are applied over the meta- Kirschner wires being preferred. The pins can be inserted
carpals and the mid-diaphysis of the radius and a third palmar with a minidriver by using only one hand so that the sur-
countermold over the apex of the fracture. “Six-pack” digital geon’s other hand is left free to manipulate and stabilize the
exercises are begun immediately to reduce edema and fracture. Care must be taken to avoid injury to the dorsal
prevent contractures and disuse atrophy (Figure 17.27). If sensory nerves, particularly when transfixing the radial
displacement in the cast occurs, skeletal fixation should be styloid. The styloid pin is inserted first to simultaneously
strongly considered for young or physiologically active restore length and inclination of the distal fragment. At the
patients. tip of the styloid, the surgeon brackets the tendons of
the first dorsal compartment with his fingers and identifies
the starting point of the styloid pin immediately dorsal to the
Percutaneous Pin Fixation tendons. A 0.062-inch Kirschner wire is placed by hand
Gartland and Werley warned us that upward of 60% of distal through the skin to engage the tip of the styloid and the posi-
radial fractures will displace in plaster and assume their pre- tion checked with fluoroscopy. The pin is directed obliquely
reduction position.35 Percutaneous pinning, supplemented by to engage the stout diaphyseal bone of the opposing cortex
579
PART
III
17 
Wrist

A B

C
Figure 17.26  A, Typical radiographic appearance of a Colles’ fracture in a young adult. B, The fracture was manually reduced
and held in slight flexion, ulnar deviation, and slight pronation in a sugar tong splint for 3 weeks, followed by a short arm cast
for another 3 weeks. C, Follow-up radiographs at 1 year reveal loss of 2 mm of length but maintenance of normal volar and
ulnar tilt. Notice the asymptomatic nonunion of the tip of the ulnar styloid.

at the metaphyseal flare. Position of the fracture is assessed, ing stout volar bone well proximal to the fracture line. After
and a few additional degrees of volar tilt can be “dialed in” confirmation of reduction, a second styloid wire will increase
by rotating the fragment around the styloid wire. The second the stability of the construct. For simple articular fractures,
0.062-inch Kirschner wire is placed at the dorsal ulnar corner a fourth wire can be placed as necessary between the third
of the radius, just radial to the sigmoid notch, and between and fourth dorsal compartments to stabilize the scaphoid
the fourth and fifth extensor compartment tendons. It is facet fragment, but this is rarely necessary. Before comple-
easiest if a free Kirschner wire is placed percutaneously and tion of the procedure, the extensor tendons are checked by
its position checked before engaging the wire driver. The passive flexion of the digits and wrist flexion tenodesis to be
ideal starting position is just ulnar to the fourth dorsal com- certain that tendons have not been tethered. Any skin tether-
partment tendons in the “soft spot” of the 4-5 arthroscopy ing is relieved with a No. 11 scalpel blade. The pins are bent
portal. The wire is gently navigated through the subcutane- and cut off 1 cm above the skin and pin caps or petroleum
ous tissues to engage the bone and its position confirmed with gauze applied. A well-padded sugar tong splint in supination
fluoroscopy. The Kirschner wire is then drilled at 45-degree is applied for 3 weeks, followed by a short arm cast for an
angles to the frontal and sagittal planes to engage the oppos- additional 3 weeks. Full forearm rotation is allowed after 2
580
 PART
III
17 

Wrist: Distal Radius Fractures

1 2 3 4

Arrow Tabletop Claw Fist

5 6

In-and-out Thumb-to-tip

Figure 17.27  “Six-pack” exercises. Drawings 1 through 6 illustrate the position that the patient’s hand should assume when
performing these exercises. It is helpful to illustrate to the patient that full metacarpophalangeal (MP) extension makes the hand
look like an arrow, full MP flexion makes the hand look like a tabletop, full MP extension combined with proximal and distal
interphalangeal flexion creates a claw, complete finger flexion creates a fist, and abduction and adduction of the fingers create
an in-and-out motion; finally, to complete the exereises, the individual touches the tip of the thumb to the tip of each finger.
(Copyright Elizabeth Martin.)

weeks. The cast and pins are removed 5 to 6 weeks after tion. Under fluoroscopic guidance, one Kirschner wire is
reduction (Figure 17.29). inserted into the fracture site in a radial to ulnar direction
Kapandji has popularized the technique of “double intrafo- until the ulnar cortex of the radius is felt. The wire driver
cal wire fixation” to both reduce and maintain distal radial and wire are then moved distally to “lever” the distal radial
fractures (Figure 17.30).60 This technique is best reserved for fragment to regain normal radial inclination. The wire is then
simple extra-articular fractures and is not without complica- advanced through the ulnar cortex. A second wire is next
581
PART
III
17 
Wrist

A B C

D E F
Figure 17.28  Several different techniques of percutaneous pinning of unstable bending fractures have been described. A, Pins
placed primarily through the radial styloid. B, Crossing pins from the radial and ulnar sides of the distal fragment into the distal
shaft. C, The intrafocal technique advocated by Kapandji. D, Ulnar-to-radius pinning without transfixation of the distal radioulnar
joint (DRUJ). E, A radial styloid pin and one across the DRUJ. F, Multiple pins from the ulna to the radius, including transfixation
of the DRUJ.

inserted into the fracture 90 degrees to the first wire in a mentation of fixation allows the fixator to be placed in a
dorsal to palmar direction. The wire is advanced until the neutralization mode with only minimal distraction, thereby
palmar cortex of the radius is contacted. Next the wire and enabling immediate use of the fingers for light activity. Early
wire driver are moved distally to “lever” the fragment into controlled motion of the wrist is sometimes possible between
its normal position of 12 to 15 degrees of palmar inclination. 4 and 6 weeks after the injury by removing the fixator and
This second wire is then advanced through the palmar cortex leaving the pins in place for several additional weeks (Figure
of the radius. 17.31).
Several studies have demonstrated the efficacy of these
External Fixation combined procedures. Seitz and coauthors reported satisfac-
Since the original idea of Roger Anderson of applying skel- tory results in 92% of 51 patients with an average age of 50
etal traction with a “portable” external fixation device for years.106 Jakim and associates produced excellent results in
the treatment of comminuted distal radial fractures,3 there 83% of a series of 132 patients with a combination of exter-
has been constant evolution in both technique and design nal fixation, limited open reduction, and internal fixation
technology. One of the two most important developments with Kirschner wires.55 Leung and associates combined exter-
has been the recognition that excessive distraction was nal fixation with autogenous bone grafting in 100 fractures;
harmful and associated with multiple complications and poor the frame was removed as early as 3 weeks after the opera-
outcomes.58 The second development was that distraction tion, and functional bracing was used for another 3 weeks.76
alone (ligamentotaxis) could not reduce displaced and Patients were rated good or excellent in nearly all cases. In
impacted articular fragments. Modern techniques include a number of recent articles reporting the use of combined
limited open or arthroscopic reduction of the articular surface, techniques and a relatively short period of static external
subchondral support with bone graft or bone graft substitute, fixation, final wrist motion averaged 120 degrees of flexion-
and “augmentation” with supplemental pin fixation. Aug- extension and 140 to 150 degrees of forearm rotation.38,124
582
 PART
III
17 

Wrist: Distal Radius Fractures

A B C

D F

G H
Figure 17.29  A-H, An unstable fracture in healthy but comminuted bone can be stabilized adequately with percutaneous pins
and a cast for 6 weeks with the expectation of restoration of alignment and function.

Technique of External Fixation 3-mm self-tapping half-pins are inserted at a 30- to 45-degree
Under brachial block or general anesthesia, the anesthetized angle dorsal to the frontal plane of the hand and forearm.
upper extremity is prepared sterilely in the operating room Pin position and length are confirmed with portable fluoros-
from the fingertips to the lower part of the arm, just below copy. Next, a 4-cm skin incision is made 8 to 10 cm proximal
a pneumatic tourniquet that has been applied to the arm. to the wrist joint and just dorsal to the midline. Blunt dissec-
Sterile finger traps and a traction device may be used if pre- tion exposes superficial branches of the lateral antebrachial
ferred. Manual reduction is performed to grossly align the cutaneous nerve, the brachioradialis, the two radial wrist
fracture fragments and approximate normal length, align- extensors, and the radial sensory nerve, which exits in the
ment, and tilt (see Figure 17.24). mid-forearm from the investing fascia between the brachio-
A 2- to 3-cm-long incision is made over the dorsal radial radialis and the extensor carpi radialis longus (Figure 17.32).
aspect of the index metacarpal base. Blunt dissection with Two 3-mm half-pins (1.5 cm apart) are then introduced
scissors exposes the metacarpal while carefully preserving through a soft tissue protector between the radial wrist
and reflecting branches of the dorsal radial sensory nerves. extensors at a 30-degree angle dorsal to the frontal plane of
A soft tissue protector is then placed on the metacarpal, and the forearm. The pins should just perforate the medial cortex
583
PART
III
17 
Wrist

2 4

1 3

A B

C D

Figure 17.30  Kapandji technique of “double intrafocal wire fixation” to reduce and maintain distal radial fractures. A 0.045- or
0.0625-inch Kirschner wire is introduced into the fracture in a radial to ulnar direction. When the wire reaches the ulnar cortex
of the radius, it is used to elevate the radial fragment and recreate the radial inclination. This wire is then introduced into the
proximal ulnar cortex of the radius for stability. A second wire is introduced at 90 degrees to the first in a similar manner to
restore and maintain volar tilt. (Copyright Elizabeth Martin.)

of the radius and should be confirmed fluoroscopically. Both to the joint surface in the sagittal plane. A second pin is
wounds are irrigated and closed with 4-0 nylon sutures placed in the ulnar aspect of the distal fragment through a
before applying the frame. For relatively stable fractures and limited incision between the fourth and fifth extensor com-
when performing augmented fixation with Kirschner wires or partments. Its direction is also dorsal palmar, but it is aimed
graft (or both), a simple single-bar external fixation frame is slightly obliquely from the ulnar to radial side to engage the
ideal. The particular design or strength of the frame is less palmar ulnar cortex of the distal fragment. Having securely
important from a mechanical perspective than the degree of fixed the distal pins, closed reduction is performed by using
stability attained by the supplemental Kirschner wires (Figure the distal pins as “joysticks” to restore volar tilt.44,84 The pins
17.33).122 Some surgeons prefer more complex fixators such are assembled with separate clamps and rods to create a
as the “Wristjack” external fixator (Hand Biomechanics Lab, triangular frame (Figure 17.34).
Sacramento, CA), which allows independent palmar carpal
translation, with which the volar tilt can be adjusted. Augmented External Fixation
If nonbridging external fixation is selected for a minimally For all but minimally comminuted extra-articular fractures,
comminuted extra-articular or simple articular fracture with augmented external fixation is recommended to provide
good bone stock, proximal pin insertion remains identical but additional support to individual fracture fragments and
the distal pins are introduced exclusively into the distal frag- increase construct stability.125 For unstable fractures without
ment. A radial-sided pin is placed through a small dorsal depressed articular fragments, 0.045- or 0.0625-inch Kirsch-
radial incision between the wrist extensors in the radial half ner wires are introduced into the fracture fragments in a
of the distal fragment. Its direction is dorsal palmar, parallel crossed configuration for maximal stability according to the

Figure 17.31  Augmented external fixation. A and B, Posteroanterior and lateral radiographs of an unstable extra-articular
fracture. C and D, Crossed pin augmentation of external fixation yields optimal construct strength. E and F, The fixator is in a
neutral position to allow full flexion and extension of the digits postoperatively. G and H, Healed fracture in satisfactory
alignment. I and J, Symmetric range of motion postoperatively.

584
 17 
PART

Wrist: Distal Radius Fractures

III

585
J
F
B

H
D
C

G
A

I
PART open reduction addresses the anatomic restoration of such
III fragments after percutaneous fixation of the radial styloid
fragment.
17  After grossly aligning the fracture fragments, the external
fixator is applied in slight distraction (see earlier), and the
Wrist

wrist joint is approached through a 3- to 4-cm dorsal longi-

tudinal midline incision (Figure 17.36A-B). The extensor
retinaculum is opened over Lister’s tubercle and the EPL
transposed radially. The fourth compartment is opened and
a 2-cm section of the posterior interosseous nerve may be
excised at the discretion of the surgeon. The EPL is retracted
BR to the radial side and the finger extensors to the ulnar side.
The wrist capsule is left intact; rarely is it necessary (or
Radial helpful) to perform an open inspection of the articular surface
sensory n.
when using modern portable fluoroscopy. If examination of
ECRB
ECRL the joint is deemed necessary, the surgeon is afforded a more
complete view of all articular surfaces and associated soft
tissues with the arthroscope (see the next section). The radial
styloid fragment is then reduced anatomically and stabilized
with a single 0.062-inch Kirschner wire or cannulated screw
as mentioned previously (Figure 17.37). Any traction that
has been applied at this point is reduced, and the impacted
articular fragments are elevated en bloc with a Freer elevator
or a pointed awl by using the apposing articular surfaces of
the lunate and scaphoid as a template. The congruency of the
Figure 17.32  An external fixation device being applied after two
3-mm half-pins have already been introduced into the base of the reduction is checked with fluoroscopy, and the resultant
second metacarpal. Two 3-mm half-pins are then introduced into metaphyseal void beneath the reduced subchondral bone is
the distal radius via direct exposure of the radius. The radial nerve then packed with autogenous bone graft or structural bone
is protected by directly identifying the nerve and then inserting graft substitute (see p. 593). Most advocates of augmented
the half-pin through a tissue protector that is placed directly on external fixation routinely graft all subchondral bone defects
the radius. BR, brachioradialis; ECRB, extensor carpi radialis brevis; regardless of the size of the defect if the articular surface has
ECRL, extensor carpi radialis longus. (Copyright Elizabeth Martin.)
been elevated. The bone graft provides mechanical buttress-
ing of small cartilage-bearing fragments and may accelerate
fracture healing by providing additional osteogenic potential.
technique described earlier. One or two pins driven through A second 0.045- or 0.062-inch Kirschner wire is then directed
the radial styloid fragment and one through the dorsal ulnar from the radial styloid transversely across the radius imme-
fragment into the radial shaft combine to produce maximum diately beneath and tangent to the articular surface to engage
additional stability.125 The pins should pierce the ulnar cortex the cortical bone of the sigmoid notch. Care is taken to avoid
of the radius but not penetrate into the ulnar shaft. The pins protrusion of the wire into the radioulnar joint (see Figure
are cut off 1 cm external to the skin margin and bent at an 17.37B).
acute angle. If there is joint incongruity involving the sigmoid notch of
Impacted and severely displaced fragments that do not the radius, every attempt is made to achieve anatomic reduc-
respond to ligamentotaxis or external reduction maneuvers tion. Usually, this can be accomplished with percutaneous
require additional limited open reduction. The concept of manipulation of the fragment with a Kirschner wire and
limited open reduction is defined as selective surgical expo- Kirschner wire fixation of the fragment to the stout volar
sure of articular fragments that still remain displaced after metaphyseal bone (see earlier). If irreducible by percutane-
the application of traction, closed manipulation, or percuta- ous means, there may be soft tissue interposition, and limited
neous manipulation. The main objective of this technique is open reduction is required. To gain access to the fragment,
to achieve anatomic reduction with limited exposure and to the fourth dorsal compartment tendons are retracted radially,
minimize the use of implants in an effort to preserve ligament and the extensor digiti mimimi, which lies directly over the
attachments, thereby minimizing iatrogenic soft tissue dis- DRUJ, is exposed and retracted to the ulnar side. Great care
ruption and preserving the vascular supply of the fragments. is taken to avoid disruption of the dorsal radioulnar ligament
This technique is particularly useful for intra-articular four- when exposing and realigning this fragment, and the perios-
part fractures of the distal radius without metaphyseal com- teum is left intact to avoid vascular stripping. A 0.045-inch
minution. Articular tilt, radial length, and reduction of the Kirschner wire can be passed at a 45-degree angle to the
radial styloid fragment can usually be achieved with classic frontal and sagittal planes to engage the distal and ulnar
closed reduction maneuvers alone or combined with longitu- margin of the dorsal ulnar fragment and secure it to the
dinal traction. However, the dorsal ulnar and volar ulnar opposing palmar cortical bone. The reduction and fixation
fragments that disrupt the lunate fossa and the sigmoid notch are confirmed with fluoroscopy.
may remain displaced because of either impaction or soft If an unstable volar ulnar fragment is identified, reduction
tissue interposition (Figure 17.35). The technique of limited and fixation through a limited volar approach must be
586
 PART
III
17 

Wrist: Distal Radius Fractures

A B C

D E F

G H
Figure 17.33  Augmented external fixation of an unstable intra-articular fracture with a bone graft substitute.
A and B, Comminuted unstable fracture in an elderly woman. C, Packing of the metaphyseal void with coralline hydroxyapatite
through a limited dorsal approach. D and E, Radiographs 3 weeks postoperatively demonstrating the crossed pin configuration
and incorporation of the graft. F, Importance of neutral position and full digital motion. G and H, Three-year postoperative
radiographs.

performed to prevent subsequent volar displacement of the ulnar joint. Gross instability must be treated to avoid long-
carpus (see Figure 17.35). Percutaneous fixation of the volar term sequelae (see earlier).
ulnar fragment is not recommended because of the density The external fixator pin clusters are dressed with a com-
of neural, vascular, and tendinous structures overlying it. pressive wrap to prevent skin shear, the wounds are covered,
The fixator is then adjusted to a neutral position in the and the wrist is immobilized in a light compressive bandage
frontal and sagittal planes, and any excess traction is removed. with a supportive plaster splint. I prefer to immobilize the
Full passive flexion and extension of the digits and thumb are wrist in a supinated position with a sugar tong splint for 10
ensured at this time to be certain that there is neither residual days until the pain and swelling have subsided to promote
distraction nor tethering (see Figures 17.33 and 17.35). The DRUJ stability and facilitate resumption of full supination
wound is closed by reapproximating the extensor retinacu- postoperatively. The frame is usually removed at 6 weeks
lum while leaving the extensor pollicis transposed. DRUJ and the supplemental pins kept in place for 8 weeks postop-
stability is assessed with a manual “shuck” test of the radio- eratively. It is recommended that the patient clean the
587
PART
III
17 
Wrist

A B

C D

E
Figure 17.34  A, Radiographs of an unstable dorsally displaced extra-articular fracture of the distal radius. B, Fluoroscopic control
of the nonbridging fixator. Notice the converging position of the distal pins in the frontal plane and parallel to the joint surface
in the sagittal plane. C, Control radiographs 10 days after injury with well-maintained reduction. D, Early motion of the wrist is
allowed as soon as the swelling has subsided. E, Radiographs at 3 months. The fracture has healed without displacement and
correlates with free wrist motion and restoration of complete forearm rotation.

588
 PART
III
17 

Wrist: Distal Radius Fractures

A B C

D E F

G H I
Figure 17.35  Hybrid internal and external fixation in an elderly patient. A and B, Comminuted fracture with dorsal and volar
marginal fractures of the lunate fossa. C and D, Augmented external fixation combined with a volar implant through a limited-
incision approach to fix the volar ulnar corner fragment. E, Full motion of the digits encouraged postoperatively. F and G,
Radiographs 4 years postoperatively. H and I, Nearly symmetric range of motion.

Metaphyseal
void EDC

EPL
Excised
PIN

A B
Figure 17.36  Limited open reduction. A, Limited exposure of the radial metaphyseal void between the third and fourth dorsal
compartments enables percutaneous elevation of the articular surface and bone graft augmentation. EDC, extensor digitorum
communis; EPL, extensor pollicis longus; PIN, posterior interosseous nerve. B, Healed 3-cm dorsal incision (arrow) for articular
reduction and placement of bone graft (see Figure 17.35). (A, Copyright Elizabeth Martin.)

589
PART
III
17 
Wrist

60°
5°

C
Figure 17.37  A, Severely displaced four-part intra-articular fracture with 60 degrees of dorsal displacement and 5 degrees of
ulnar tilt. After manual reduction and pinning of the radial styloid, intraoperative fluoroscopy shows insufficient reduction of the
ulnar fragment and the large size of the metaphyseal bone defect. B, After the application of an external fixator, anatomic
reduction of the joint surface is achieved through a dorsal approach (see Fig. 17.32); while the sagittal fracture gap is maintained
with a pointed clamp, a third Kirschner wire is driven across both articular fragments and the defect grafted. C, The pins and
fixator were removed at 5 weeks. A follow-up radiograph at 9 months shows a well-preserved joint space and overall adequate
fracture alignment.

skin-pin interface with peroxide once or twice daily until the is begun at the first postoperative visit and its importance
wounds have sealed to help prevent pin track infection. re-emphasized throughout the postoperative period. Super-
Active and passive finger motion is begun as soon as the vised hand therapy is begun for patients who are unwilling,
anesthetic wears off and is encouraged for the entire time uncomfortable, or unable to mobilize their fingers and
that the frame is in place. Supination-pronation of the forearm forearm independently.
590
 radius.29,40 Arthroscopy presents a minimally invasive means PART
CRITICAL POINTS: AUGMENTED EXTERNAL FIXATION
of monitoring articular reduction, without the additional liga- III
Indications mentous and capsular damage that is inherent with open
inspection of the articular surface. In addition, the arthro-
17 
 Unstable extra-articular fractures of the distal radius
(type I bending) scope affords an unparalleled diagnostic view of the interos-

Wrist: Distal Radius Fractures

 Impacted articular fractures (type III compression) seous carpal ligaments, the carpal articular surfaces, and the
 Comminuted unstable fractures with articular and TFCC. If indicated, arthroscopic or limited open management
metaphyseal involvement of concomitant soft tissue injuries of the carpus or DRUJ may
Contraindications be undertaken simultaneously. Although the addition of
 Severe osteoporosis arthroscopic inspection and reduction adds additional operat-
 Volar shear fractures (type II, Smith’s type II, volar ing room time and equipment, there is evidence to suggest
Barton’s) that outcomes are improved. Doi and associates demon-
 Patient preference, compliance concerns, or inability to strated improvements in range of motion and fracture
care for the external fixation and pins reduction in a prospective cohort of patients treated by
Technical Points arthroscopically assisted percutaneous fixation when com-
 Closed reduction with traction, finger traps, or both pared with a group treated by conventional open reduction
 Mini-open placement of proximal and distal fixation and internal fixation (ORIF) for displaced intra-articular frac-
pins to the index metacarpal and radius tures of the distal radius.29
 Placement of fixator pins in a plane 45 degrees oblique
to the sagittal and frontal planes Technique: Arthroscopic Reduction and
 Closure of pin cluster incisions before assembly of the
Percutaneous Fixation
fixator
When considering arthroscopically assisted reduction and
 Gross alignment of the fragments by fixation in
moderate traction, flexion, and ulnar deviation fixation of an intra-articular distal radius fracture, it is prudent
 Mini-open dorsal incision over the third dorsal to reduce and stabilize the fracture in plaster for 3 to 7 days
compartment and transposition of the EPL before surgery. Treatment of fractures acutely by arthroscopic
 Reduction of traction and elevation of impacted means may limit visibility secondary to bleeding and may
articular fragments with an elevator against the carpus risk the development of compartment syndrome because
 Fluoroscopic check of reduction and support of of extravasation of fluid into the soft tissues. After 7 days,
fragments with graft or substitute. however, it becomes difficult to elevate impacted articular
 Percutaneous 0.062- or 0.045-inch Kirschner wire or
fragments without a formal open reduction.
screw fixation through the radial styloid The arm is prepared sterilely, draped in the usual manner,
 Percutaneous 0.045-inch Kirschner wire fixation
and suspended from sterile finger traps attached to the index
transversely below the reduced subchondral bone
 Crossed percutaneous 0.062-inch Kirschner wire
and long fingers (Figure 17.38). The forearm may be exsan-
through the dorsal ulnar corner guinated with an Esmarch bandage, which may be left in
 Assessment of the volar ulnar fragment and place from just proximal to the wrist up to the elbow to
performance of limited open reduction and fixation if prevent extravasation of fluid into the soft tissues. Alterna-
needed tively, an elastic bandage may be wrapped about the hand
 Revision of the fixation posture to a neutral wrist angle and forearm to reduce soft tissue swelling. I prefer to perform
to facilitate digital mobility and function the arthroscopic portion of the procedure without a tourni-
 Assessment of the DRUJ for stability and augmentation quet and save tourniquet time for any open reduction that
as needed may be required. The fracture is then evaluated under fluo-
Postoperative Care roscopic guidance and the fracture fragments manually
 Apply a sugar tong splint in supination for 5 to 10 manipulated into position. As an alternative to finger trap or
days until suture removal. tower traction, an external fixation device may be applied
 Begin digital range of motion exercises immediately. before arthroscopy of the wrist to obviate the need for sus-
 Use peroxide or dry pin care, and apply compressive
pension traction.123
wraps until the wounds are sealed.
The arthroscope is inserted through the 3-4 portal, and an
 Begin forearm rotation and gentle active wrist motion
outflow portal is established in either the 4-5 or 6U position.
exercises at the initial postoperative visit.
 Evaluate with radiographs at the initial postoperative
Immediate and copious irrigation is critical to clear clot and
visit and at 2 and 6 weeks postoperatively. debris and improve visualization. Once this is done, continu-
 Remove the fixator at 6 weeks while leaving the ous irrigation is maintained through the 6U portal, and
Kirschner wires in place for 2 additional weeks. working portals may be established in the 1-2 or 4-5 positions
(or both). Doi and associates demonstrated the additional
utility of a volar radial portal created by means of a limited
open incision over the flexor carpi radialis (FCR) tendon.29
Arthroscopic Reduction and Kirschner wires (0.0625 inch) are useful as percutaneous
Percutaneous Fixation “joysticks” when placed into the radial styloid and other
Diagnostic and therapeutic wrist arthroscopy is widely used large articular fragments. Reduction of the fragment is then
by many practicing hand surgeons. Its use in conjunction with accomplished with the joysticks under fluoroscopic control
percutaneous means of fracture fixation offers several advan- and the reduction stabilized as mentioned previously with
tages in the management of articular fractures of the distal either 0.045- or 0.0625-inch Kirschner wires (see Figure
591
PART
III
17 
Wrist

Reopposed
fragments

Joystick
Joystick (K-wire)
(K-wire)
MCU C
Ulnar MCR
n. 1-2
6U 3-4
6R
4-5

A Joystick
(K-wire)
Joystick
D (K-wire)

B E

Figure 17.38  Operative technique: arthroscopic reduction and pinning of distal radial fractures. A, The arm is suspended from
finger traps on the index and long fingers. The following anatomic landmarks are identified: arthroscopic portals 1-2, 3-4, 4-5,
6R (radial), 6U (ulnar), MCR (midcarpal radial), and MCU (midcarpal ulnar). The dorsal sensory branch of the ulnar nerve is
noted. B, The arthroscope is introduced through the 3-4 or 4-5 portal, and with a probe through the 6R portal, the comminuted
distal radial fracture is visualized. Clot and hemorrhage extrude from the fracture fragments. C, Joysticks (0.0625-inch Kirschner
wires) are introduced into the major fragments percutaneously to elevate the fracture fragments into an anatomic position.
D, Additional Kirschner wires are then introduced percutaneously into the fracture. E, The joysticks are then removed, the
fixation pins are cut off outside the skin, and caps are applied. (Copyright Elizabeth Martin.)

17.38D and E). Impacted articular fragments can be elevated fracture and use of bone graft; percutaneous pins are usually
through a mini-open dorsal approach (see earlier) and sup- removed 2 to 3 weeks later.
ported with bone graft or substitute. Pins can be replaced
with cannulated screw fixation at the discretion of the Additional Soft Tissue Injuries
surgeon.50,68 If using pin fixation alone, the wrist must be Concomitant complete tears of the scapholunate or lunotri-
supported in a plaster cast until healing. If using augmented quetral ligaments should be reduced anatomically and pinned
external fixation, the wrist posture is returned to neutral, and or treated by limited open reduction, repair, and pin or screw
the forearm is immobilized in a supinated position for 7 to fixation (see Chapter 15). A minimum of two divergent pins
10 days with a light sugar tong dressing. The cast or fixator or a temporary compression screw should cross the affected
is generally removed at 4 to 6 weeks, depending on the intercarpal articulation, and one or two additional pins should
592
be placed to temporarily stabilize the proximal row to the cement as an adjunct to percutaneous fixation of distal radius PART
distal carpal row across the midcarpal joint. Intercarpal pins fractures when compared with casting or external fixation III
are left in place for at least 8 weeks and a slowly graduated alone, but high complication rates and cement extrusion
program of range of motion and resistive exercises begun plagued both studies.16,104 The specific advantages and disad-
17 
thereafter. If using a temporary scapholunate screw, the vantages of several common bone graft alternative categories

Wrist: Distal Radius Fractures

device can be left in place while gentle midcarpal motion is are presented in Table 17.1. Proprietary names and specific
begun with a dart thrower’s rehabilitation protocol25 (see commercial formulations are not listed.
Chapter 15); the screw may be removed 4 to 6 months post-
operatively. Complete peripheral detachment of the articular Open Reduction and Internal Fixation
disk of the TFCC can also be treated by arthroscopically Open reduction of articular fractures of the distal radius is
guided suture placement at the time of fracture reduction (see indicated in active patients with good bone quality when
Chapter 16). anatomic restoration of the joint surface cannot be achieved
by closed manipulation, ligamentotaxis, or percutaneous
Technique of Harvesting Iliac Bone Graft reduction maneuvers or as an alternative to percutaneous
After a rolled towel has been placed under the ipsilateral fixation at the preference of the patient or surgeon. There is
sacroiliac joint, the iliac crest region is sterilely prepared and increasing evidence to support equivalent functional, clinical,
draped. A 5-cm-long incision is made over the iliac crest and radiographic outcomes of fixed-angle internal fixation
beginning 2 cm posterior to the anterior superior iliac spine when compared with percutaneous and indirect fixation
and coursing posteriorly. With straight and curved 1-cm (Jupiter J, personal communication, 2008),80,126 and it is an
osteotomes, a section of the iliac crest 3 cm in length and attractive alternative to the bulkiness and pin care issues of
1 cm thick is reflected on its medial periosteum. This exposes external fixation. Open reduction has also been demonstrated
an abundant area of cancellous bone between the two corti- to yield improved radiographic alignment when compared
cal wings. Cancellous bone is harvested and preserved in a with percutaneous and repeat closed reduction for fractures
moist saline-soaked sponge. The flap of iliac crest is then that have lost reduction after a trial of closed reduction and
turned back down into its bed and sutured in place. (This casting.86 Articular fractures in elderly, inactive patients and
technique leaves virtually no cosmetic defect to either the in those with massive osteoporosis have traditionally been
eye or touch along the iliac crest.) The wound is then closed considered a contraindication to open reduction because
in layers over a suction catheter drain. Alternatively, a bone in these patients there is a risk for complications, including
trephine set can be used to harvest one or more bicortical failure of fixation, nonunion, and reflex sympathetic dystro-
10- to 12-mm plugs from the iliac wing through a 1- to 2-cm phy. However, since the recent introduction of “fixed-angle”
incision. Each harvest site is filled with thrombin-soaked internal fixation devices, both unstable extra-articular and
Gelfoam for hemostasis and the area infiltrated with a long- simple articular fractures in elderly, active osteoporotic
acting anesthetic. This procedure reduces the pain and local patients have increasingly satisfactory outcomes with ORIF.92
morbidity of iliac crest graft harvest, can be performed under Subchondral buttressing with fixed-angle pins or screws
local anesthesia with sedation, and generally obviates the secured to the plate greatly reduce the incidence of settling
need for an overnight stay or ambulatory assistance or secondary articular displacement (Figure 17.39).
postoperatively. General factors limiting surgical reconstruction of the artic-
ular surface include the number of fragments, their size, the
Bone Graft Substitutes amount of cancellous bone impaction, and associated trau-
Bone graft substitutes may be used as an alternative to the matic lesions of the articular cartilage. Alternatives to open
harvesting of autogenous bone. With acute fractures, the need anatomic restoration should be considered if the articular
for structural support of the elevated articular surface gener- comminution involves more than four to five fairly sizable
ally outweighs the need for osteogenic stimulation of healing fragments. Every effort should be made to improve the ana-
(see Figures 17.33 and 17.35). The intact radial metaphysis is tomic relationship of the radius and ulna and ensure normal
normally a potent source of osteogenic cells, growth factors, alignment of the hand and carpus with the long axis of the
and osteoinductive cancellous bone, and fractures through forearm by percutaneous and indirect means. If secondary
this area have a strikingly low rate of delayed union or non- radiocarpal arthritic changes occur, the absence of metaphy-
union. The ability to expedite fracture healing by the addition seal malunion and shortening will greatly facilitate the per-
of biologic products has not been demonstrated, except in formance of secondary reconstructive procedures.
situations in which healing potential has been compromised The choice of surgical approach depends on the location
by disease or tobacco use.71 Thus, bone graft substitutes that and direction of displacement of the fracture fragments.
demonstrate compressive properties equal to or greater than Thus, dorsally or radially displaced fractures have been clas-
cancellous bone are of greater utility in the management of sically approached through dorsal incisions, whereas volarly
comminuted articular fractures than are purely osteogenic displaced fractures (Smith’s and reversed Barton’s) are clas-
or combined osteogenic–moldable putty formulations. For sically approached through palmar exposures. There has
unstable Colles’ fractures in elderly or osteoporotic patients, been increased interest in the management of dorsally dis-
the use of methylmethacrylate bone cement has been placed nonarticular and articular fractures with volar fixed-
attempted, but it has not been widely accepted because of angle plate fixation in an attempt to decrease the incidence
methylmethacrylate’s brittle mechanical profile and its exo- of extensor tendon irritation associated with dorsally
thermic properties. Two prospective studies demonstrated applied implants. Palmar incisions are also appropriate for
modest improvements with an injectable calcium phosphate primary repair of a torn wrist capsule in radiocarpal fracture-
593
PART
ALTERNATIVES TO AUTOGENOUS BONE GRAFT FOR MANAGEMENT OF DISTAL RADIUS FRACTURES
III
17  Type Formulation Application Indications Advantages Disadvantages

Allograft
Wrist

Demineralized Amorphous, Manual insertion Compromised Osteoinductive and Variable osteogenic

bone matrix powder, gel, host, impaired limited osteogenic capability depending
strips, putty, healing, potential on composition and
combinations nonunion formulation;
marginal to no
structural support
Cancellous chips 5- to 7-mm Manual packing Metaphyseal void, Some structural support; Variable osteoinductive
freeze-dried elevated articular osteoconductive and capability; limited
cancellous chips surface limited osteoinductive structural support
potential
Fresh frozen Corticocancellous Cut to shape, Segmental defect Customized to defect, Rarely indicated for
bone segments internal fixation high structural distal radius
support, fractures, disease
osteoinductive potential,
immunogenicity,
slow incorporation
Cancellous Substitutes
Tricalcium Mixed with Manual insertion Metaphyseal void, Osteogenic and Minimal to no
phosphate hydroxyapatite, elevated articular inductive when mixed structural support,
combinations collagen, marrow surface with marrow aspirate variable resorption
aspirate; available rates
in strips, granules
Calcium sulfate Pellets, paste, putty Manual or Metaphyseal void, Resorbable defect filler, Minimal to no
injectable; may elevated articular replaced by bone; structural support,
harden to block surface injectable through water soluble,
form minimal incision; may rapidly resorbed
be combined with
antibiotics
Nanoparticulate Blocks or granular, Manual or Metaphyseal void, Resorbable, injectable, Osteogenic and
b-tricalcium mixed with injectable elevated articular porous; moderate osteoinductive only
phosphate marrow surface compressive strength if mixed with
(beta) marrow
Coralline Blocks, granules Trimmed to Metaphyseal void, Osteoconductive and Slow resorption;
hydroxyapatite shape defect elevated articular porous; compressive radiopacity may
surface strength equal to or obscure healing
exceeding that of
cancellous bone; can
shape to fit defect
Bovine Manual, trim to Metaphyseal void, Osteoconductive, Immunogenicity,
cancellous defect elevated moderate variable
bone articular surface structural osteoinductivity; not
support approved for use in
United States
Cements
Calcium Mixed Injectable, putty Metaphyseal void, Can be injected Not osteoconductive
phosphate components, or block elevated articular percutaneously; or inductive; slow to
hardens with surface animal models remodel and
time demonstrate reabsorb; lacks shear
resorption/ or tensile strength
remodeling; high
compressive strength

594
 PART
ALTERNATIVES TO AUTOGENOUS BONE GRAFT FOR MANAGEMENT OF DISTAL RADIUS FRACTURES—cont’d
III
Type Formulation Application Indications Advantages Disadvantages 17 
PMMA Mixed Injectable Bone defect, Can be injected Not osteoconductive

Wrist: Distal Radius Fractures

components, metaphyseal percutaneously; high or inductive;
hardens in void; augment compressive strength exothermic; may
minutes ORIF in cause thermal
osteopenic bone necrosis; brittle,
poor shear or tensile
strength; limited
indications for distal
radius
Biologics
Recombinant Powder, strips, Manual, Compromised host Osteoinductive; may Limited indications for
BMP putty injectable or tissue bed, accelerate healing distal radius
nonunion or application; dosage
delayed union and timing not well
studied

BMP, bone morphogenetic protein; ORIF, open reduction and internal fixation; PMMA, polymethyl methacrylate.

Table 17.1  Alternatives to Autogenous Bone Graft for Management of Distal Radius Fractures

tendinopathy and implant removal. A 3- to 10-cm straight

dorsal incision is made just ulnar to Lister’s tubercle, centered
over the radial metaphysis. Full-thickness skin flaps are
raised at the retinacular level, including the dorsal sensory
branches of the radial and ulnar nerves. An ulnar-based reti-
nacular flap is begun just radial to the second compartment
and elevated to expose the EPL and the tendons of the fourth
compartment. A 2-cm segment of the posterior interosseous
nerve is removed at the discretion of the surgeon. Subperi-
osteal exposure yields direct visualization of the fracture
fragments, and rarely is it necessary to violate the wrist
Figure 17.39  Ideal positioning of a volar fixed-angle plate. Notice capsule. Direct and indirect reduction of the fracture frag-
the subchondral positioning of the distal fixed-angle pegs, by
virtue of which axial loading is transmitted to the pegs and the
ments is performed and confirmed with fluoroscopy, and
volar plate and to the radial shaft. The dorsal comminuted area temporary fixation is performed with Kirschner wires through
has not been grafted in this case. the styloid and dorsal ulnar corner. Articular reduction is
facilitated with the use of a Freer elevator and subchondral
dislocations and whenever primary median nerve decom- elevation, with the carpus being used as a template for reduc-
pression or fasciotomy of the flexor compartment is indicated. tion. Placement of the plate may be facilitated by removal
When using multiple plate or “fragment-specific fixation,” of Lister’s tubercle and insertion of conventional screws or
dorsal, radial palmar, ulnar volar, and ulnar incisions are 2.0- and 2.7-mm fixed-angle pegs and screws to support the
used in combination, as dictated by the particular fracture subchondral bone. The tendons of the second and fourth
configuration. compartments are replaced over the plate, and a portion of
the retinaculum can be used as an interposition flap between
Dorsal Plate Fixation the tendons and the distal plate. The EPL tendon is primarily
Although overall satisfactory outcomes have been reported transposed to a subcutaneous position when closing the
with dorsal plating systems, the incidence of extensor tendon dorsal retinaculum (Figure 17.40).
complications, including irritation, synovitis, attrition, and When performing conventional dorsal plate fixation of the
tendon rupture because of direct contact of these structures distal radius, use of autogenous iliac bone graft or an appro-
with the dorsal plates, is not negligible.5,15,59 Low-profile and priate structural bone graft substitute to support comminuted
stainless steel plates may have a decreased incidence of or impacted articular fragments is important. Bone grafting
dorsal tendinopathy,108 but with the increased versatility, may biologically compensate for the relatively extensive
mechanical strength, and ease of application of fixed-angle exposure required for application of the plate. If fixed-angle
volar devices, isolated dorsal plate fixation for distal radius devices with subchondral buttressing are used, the need for
fractures is decidedly less common. bone grafting is reduced because the chance of secondary
displacement of articular fragments is diminished by the
“Universal” Dorsal Approach to the Distal Radius increased structural properties of the fixed-angle plate. A
If a single dorsal plate is used to stabilize an unstable distal compilation of published series of internal fixation since 2000
radius fracture, the patient should be informed of the risk of demonstrated that bone graft was used in 33% of cases when
595
PART
III
17 
Wrist

A B C

D E F

G
Figure 17.40  Comminuted articular fracture treated by dorsal plate fixation. A and B, Posteroanterior and lateral films
demonstrate marked dorsal comminution. C, Subperiosteal exposure through a universal dorsal approach demonstrates dorsal
fragmentation. D, A low-profile fixed-angle dorsal plate is applied after removal of Lister’s tubercle. E, Retinacular closure. F and
G, Healed postoperative radiographs demonstrate restoration of length and alignment. (Courtesy of Andrew J. Weiland, M.D., with
permission.)

596
 PART
OUTCOMES OF PERCUTANEOUS, FRAGMENT-SPECIFIC, AND PLATE FIXATION OF DISTAL RADIUS FRACTURE
III
No. C C3 Follow-up Loss of 17 
Year Author Patients Age Female Type Type (mo) Grafted Compl Reduction GE F/E Grip

Wrist: Distal Radius Fractures

Volar Plate Fixation
2002 Orbay 31 54 55% 45% 10% 12 10% 3% 0% 100% 82% 77%
2004 Orbay 24 79 71% 10% 4% 12 38% 17% 13% 82% 79%
2005 Musgrave 32 57 91% 66% 0% 13 0% 34% 0% 80%
2005 Kamano 40 57 70% 15% 3% 12 10% 5% 0% 100% 85% 78%
2006 Ruch 14 46 50% 100% 71% 22 14% 29% 0% 86% 85% 78%
2006 Rozental 41 53 63% 46% 12% 17 7% 22% 10% 100% 70% 94%
2007 Rein 15 54 47% 100% 100% 48 0% 13% 7% 47% 80% 90%
Average 197 57 64% 55% 29% 19 11% 18% 4% 87% 81% 83%
Dorsal Plate Fixation
2005 Grewel 29 46 62% 100% 100% 18 86% 72% 0% 60% 86%
2006 Kamath 30 59 53% 70% 13% 18 33% 13% 3% 93% 85% 78%
2006 Ruch 20 49 55% 100% 75% 21 45% 20% 25% 75% 75% 74%
2006 Simic 51 55 59% 16% 0% 24 0% 12% 0% 78% 81% 92%
2007 Rein 14 45 71% 100% 100% 48 0% 50% 14% 36% 70% 85%
Average 144 50 60% 77% 58% 25.8 33% 33% 8% 71% 74% 83%
Multiple Plate Fixation
2000 Jakob 74 60 70% 66% 41% 12 51% 22% 6% 97% 84% 90%
2002 Konrath 25 53 44% 70% 33% 29 0% 28% 4% 92% 82% 83%
2006 Benson 85 50 68% 89% 21% 32 76% 20% 0% 100% 88% 92%
Average 184 54 61% 75% 32% 24 42% 23% 3% 96% 85% 88%
External Fixation
2001 Sakano 25 49 40% 76% 8% 30 100% 0% 0% 100% 88% 89%
2003 Werber 50 58 70% 60% 0% 6 0% 14% 0% 90% 65% 60%
2004 Harley 25 43 52% 80% 44% 12 12% 56% 0% 48% 81% 79%
2005 Grewal 33 45 36% 100% 85% 18 45% 24% 65% 97%
2005 Kreder 88 40 43% 83% 24 13% 11% 0% 94% 90%
2005 Gradl 25 60 12% 44% 20% 24 0% 16% 4% 96% 92%
2008 Leung 74 38% 100% 39% 24 22% 13% 0% 94%
Average 320 49 42% 78% 33% 20 27% 19% 1% 86% 81% 83%

Compl., Complications; F/E, flexion/extension; GE, good to excellent.

Table 17.2  Outcomes of Percutaneous, Single Plate, and Multiple Plate Fixation of Distal Radius Fractures

single dorsal plates were used, in 42% of cases in which  Anatomic reduction of the volar cortex facilitates restora-
multiple fragment-specific plates were used, and in only 11% tion of radial length, inclination, and volar tilt.
of procedures using volar fixed-angle plates (Table 17.2).  Avoidance of additional dorsal dissection helps preserve
the vascular supply of comminuted dorsal fragments.
 Because the volar compartment of the wrist has a greater
Technique of Volar Plate Fixation cross-sectional space and the implant is separated from the
Regardless of the displacement of the distal fragment (dorsal, flexor tendons by the pronator quadratus, the incidence of
volar, radial), volar plating of both articular and nonarticular flexor tendon complications is lessened.
fractures is an effective fixation method that may reduce  The use of fixed-angle volar plate designs avoids screw
some of the soft tissue complications associated with dorsal “toggling” in the distal fragment and thus reduces the
plating. Advantages of palmar exposure and volar plating danger of secondary displacement.
include the following:  When stabilized with a fixed-angle internal fixation device
that uses subchondral pegs or screws, control of shortening
 Minimal volar comminution facilitates reduction of dor- and late displacement of articular fragments are improved
sally displaced fractures. and the need for bone grafting reduced (see Figure 17.39).
597
PART Incision
III
Quadratus m.
17 
Wrist

Brachioradialis
tendon

Figure 17.41  Volar approach to the distal radius. The

Pronator quadratus brachioradialis tendon may be split and elevated
retracted palmarly with subperiosteally to expose the radial and intermediate
palmar portion of split columns and the volar aspect of the distal radius. APL,
brachioradialis tendon abductor pollicis longus; EPB, extensor pollicis brevis.
Lateral
antebrachial (Copyright © 2001, Virginia Ferrante.)
cutaneous n.

Radial sensory n.

APL and EPB retracted dorsally Brachioradialis split

Fracture of distal radius exposed

Fractures are exposed through the distal part of the Henry deemed necessary to stabilize small marginal or volar ulnar
approach between the FCR and radial artery via an 8- to fragments, the author recommends consideration of tension
9-cm longitudinal incision directly over the distal course of band fixation19 or a low-profile miniplate or wireform as an
the FCR tendon. The subsheath of the FCR is opened along alternative solution to avoid the serious complication of
its radial border to avoid inadvertent injury to the nearby flexor tendon rupture (see later).
palmar cutaneous branch of the median nerve. The virtual When optimal plate position is confirmed, the plate is pro-
space beneath the flexor tendons is developed and the FCR visionally fixed with Kirschner wires or with a single screw
and flexor tendons are retracted to the ulnar side, thus pro- in the oval hole of the plate. Distal or proximal fine-tuning
tecting the median nerve and its palmar branch. The radial of plate position can be performed, as determined with fluo-
vascular bundle is retracted radially to expose the flexor pol- roscopy, to align the projected angles of the distal pegs imme-
licis longus (FPL) and the pronator quadratus. Some distal diately beneath the subchondral bone on the facet lateral
fibers of the FPL may require release from the radius for fluoroscopic image. It is important that nearly anatomic res-
adequate exposure of the radial shaft. The brachioradialis toration of volar tilt be restored before finalizing plate posi-
tendon is sharply separated from overlying soft tissues and tion to optimize peg placement beneath the subchondral
split longitudinally at the level of the pronator quadratus for bone and minimize articular penetration. This is particularly
5 to 8 cm to its insertion on the radial styloid. It is not neces- important when dealing with osteoporotic bone because sub-
sary to completely transect the brachioradialis tendon in chondral buttressing will effectively control fracture settling
most acute cases. Elevation of the pronator in continuity with or dorsal displacement, provided that the pegs are placed
the volar half of the split brachioradialis tendon facilitates directly below the subchondral plate. It is also important to
anatomic suture repair and ensures plate coverage at the contour the plate to match the patient’s normal metaphyseal
conclusion of the procedure (Figures 17.41 and 17.43). The volar flare—undercontouring of the plate can translate the
distal border of the pronator is sharply incised at the volar articular surface dorsally or rotate the articular fragment into
lip of the radius and the muscle sharply reflected ulnarly from an unacceptable position of dorsal tilt when associated with
the radius and volar fragments. The fracture is reduced with extensive dorsal comminution.
an initial hyperextension maneuver, followed by flexion of Distal fixation is achieved by inserting smooth pins or
the wrist while the surgeon stabilizes and manually manipu- screws that lock into threaded holes in the distal plate.
lates the apex of the deformity with a thumb. If anatomic Dozens of different plates are available, and several feature
reduction is confirmed with fluoroscopy, the fracture is tem- “multi-axial” screw projection to enable alteration of screw
porarily fixed with an oblique 0.062-inch Kirschner wire or peg angle to suit a particular fracture anatomy. Precise
inserted percutaneously through the radial styloid. A volar drilling with special drill guides that are screwed or snapped
plate is chosen and contoured as necessary to fit the volar into the distal holes is necessary when using fixed-angle
metaphyseal flare of the radius. Care is taken to avoid place- devices to ensure engagement of the threaded heads on the
ment of the plate distal to the transverse radial ridge because plate. After placement of the subchondral pegs and screws,
implants on the volar lip of the radius are in direct continuity the plate is fixed proximally to the diaphysis with self-tapping
with the flexor tendons and risk tendon irritation and rupture screws. The implant is easily covered with the pronator qua-
(Figure 17.42).26 If fixation of the plate distal to this ridge is dratus by repairing the split portion of the brachioradialis to
598
 PART
Volar rim III
17 

Wrist: Distal Radius Fractures

Transverse
ridge

A B
Figure 17.42  A, Incorrect placement of a volar fixed-angle
device. The plate is placed too far distally, on the transverse ridge
of the volar marginal lip of the radius; without coverage by the
pronator, the flexor tendons are in direct contact with the plate
and may rupture. B, Correct placement of the implant, recessed Figure 17.43  Splitting the brachioradialis distally and leaving its
proximally and with sufficient soft tissue coverage to prevent volar tendinous portion attached to the pronator quadratus allow
flexor irritation and rupture. (Copyright Elizabeth Martin.) a stout repair over the volar plate on closure.

the remaining tendon on the radius (Figure 17.43). The incidence of extensor tendinopathy as advantages of this
wound is closed in layers, with suction drainage used at the exposure.
discretion of the surgeon. Stability of the radioulnar joint is Alternatively, displaced fragments of the dorsal rim or
assessed and addressed as necessary. A plaster sugar tong intermediate column can be reduced and fixated by direct
splint is applied in full supination until suture removal 10 exposure through a limited dorsal incision with the applica-
days postoperatively, followed by a removable wrist brace tion of fragment-specific implants (see later). Similarly, if
for comfort. Patients are encouraged to mobilize the digits complete capture of a large or comminuted radial styloid
immediately after surgery. Light functional use of the hand fragment cannot be attained with one or two of the locked
and wrist (eating, dressing, writing, typing) is permitted after pegs, the surgeon should strongly consider the addition of a
suture removal (Figure 17.44). For elderly patients with 2.0-mm radial column plate (see later) to complement volar
osteoporotic bone, the postoperative regimen may be modi- fixation and prevent undesirable settling and consequent
fied accordingly; if insufficient screw purchase was attained, incongruity of the styloid and its scaphoid facet (Figure
a light forearm cast is applied after suture removal for a total 17.46). Finally, volar fixed-angle plate fixation is not ideal
of 5 weeks. for small volar ulnar corner or “teardrop” lunate facet frag-
If anatomic reduction of the articular surface and dorsal ments. Failure to adequately capture this fragment with plate
marginal fragments cannot be achieved with manual reduc- coverage and one or two locked pegs may result in loss of
tion through the volar Henry incision, Orbay and Fernandez fixation and palmar translation of the entire carpus in the
recommend an extended Henry approach to enable direct postoperative period51 (Figure 17.47). Additional fixation of
articular reduction.91 To gain this degree of exposure, the this fragment may be achieved with Kirschner wires, a
entire proximal radius is pronated away from the fractured tension band, a 2.0-mm miniplate, or a volar buttress pin.
articular components by performing an extensive soft
tissue release. It is thought that complete subperiosteal eleva-
tion from the metaphyseal-diaphyseal portion of the radius
is tolerated because of a rich endosteal blood supply. CRITICAL POINTS: VOLAR FIXED-ANGLE PLATE FIXATION
The first step in the exposure is release of the radial septum
(insertion of the brachioradialis and the palmar sheath of the Indications
 Extra-articular fractures of the distal radius (including
first extensor compartment) to facilitate reduction of the
osteoporotic bone)
radial styloid fragment. Next, the surgeon performs a
 Nascent and established distal radius malunion
subperiosteal exposure of the distal third of the radial diaph-
 Articular fractures
ysis. Finally, to visualize the dorsal die punch and centrally
impacted fragments through the fracture plane, the proximal Contraindications
 Marginal shear fractures, very distal
shaft fragment is fully pronated with a bone clamp.
fracture-dislocations
Under direct vision, the fragments can be manipulated into
 Small volar ulnar corner fragment
a reduced position against the proximal carpal row (Figure
17.45). Thereafter, the proximal fragment is supinated Technical Points
back into place and a volar fixed-angle plate applied. An  Make a longitudinal incision along the FCR tendon.
 Expose the pronator quadratus between the FCR and
attempt is made to fix large dorsal ulnar fragments
the radial artery.
with locking screws through the plate. The authors cite
preservation of the extensor tendon sleeve and a reduced Continued

599
PART
III
17 
Wrist

A B C

D E F
Figure 17.44  Coronal split Smith type II fracture fixed with a volar locked plate and immediate motion. A and B, Coronal split
through the articular surface (arrow). C and D, Volar locked-plate fixation. E and F, Range of flexion and extension 12 weeks
postoperatively.

Dorsal die punch

APL fragment

EPB
1st extensor
compartment

Radial a.

BR

A B

Figure 17.45  The extended volar approach enables direct disimpaction of articular fragments by subperiosteal exposure of the
distal third of the radius and pronation of the proximal fragment. APL, abductor pollicis longus; BR, brachioradialis; EPB, extensor
pollicis brevis. (Adapted from Orbay JL, Fernandez DL: Volar fixation for dorsally displaced fractures of the distal radius: a preliminary
report, J Hand Surg [Am] 27:205-215, 2002. Redrawn by Elizabeth Martin.)

600
 PART
III
17 

Wrist: Distal Radius Fractures

A B C

E F

G
Figure 17.46  Hybrid fixation of the radial styloid. A and B, Posteroanterior (PA) and lateral radiographs demonstrating a
comminuted articular fracture with palmar displacement and a large radial styloid fragment. C, PA radiograph 3 weeks
postoperatively demonstrating incomplete fixation of the radial styloid. D and E, Computed tomography confirms insufficient
styloid fixation with articular incongruency. F, Revision stabilization of the radial column with a radial column plate and bone
graft. G and H, PA and lateral radiographs of the healed construct.

A B
Figure 17.47  A and B, Palmar subluxation of the carpus after volar plate fixation. Note the palmar and proximal translation of
the carpus as a result of loss of fixation of the volar ulnar fragment on the lateral radiograph.

601
PART cal studies using an unstable metaphyseal fracture model have
CRITICAL POINTS: VOLAR FIXED-ANGLE
III PLATE FIXATION—cont’d demonstrated that dual 2.0-mm plates, when placed at 50- to
90-degree angles to each other in the axial plane, provide
17  fixation that is statistically superior to that of either Kirschner
 Detach the pronator quadratus with an “L”-shaped
incision and leave a portion of the split brachioradialis wire–augmented external fixation or a traditional 3.5-mm
Wrist

attached to the pronator for subsequent closure. dorsal “T”-plate.28,94 Thus, the use of the term “fragment-
 Reduce the fracture by restoring the volar cortex. specific fixation” in this text does not refer to a particular
 Provide temporary fracture fixation with an oblique implant type, but to the concept of the use of two or more
Kirschner wire through the radial styloid. low-profile implants placed strategically along the columns of
 Apply the plate volarly and fix it to the shaft through the distal radius to fix individual fracture fragments.
an oval hole. Three recent single-cohort clinical series totaling more than
 Determine the ideal plate position with fluoroscopy.
180 patients and using bicolumnar low-profile miniplate or
 Insert fixed-angle smooth pins in a subchondral
wireform fixation documented good to excellent results in
position.
 Use a facet lateral fluoroscopic view to control drilling
96% of patients with an average follow-up of 24 months.10,56,66
and pin insertion. The fractures were predominantly AO C-type fractures
 Complete fixation of the plate to the shaft. (75%), and supplemental bone graft was used in 42%. Grip
 Assess the adequacy of reduction and fixation of the strength was restored to 88% of the opposite side and flex-
dorsal ulnar fragment and augment as necessary with a ion-extension to 85% (see Table 17.2). Disabilities of Arm,
2.0-mm intermediate column plate. Shoulder, and Hand (DASH) scores on 85 of the patients
 Consider additional radial column fixation for a large measured 9 on a 100-point scale. Fragment-specific fixation
or comminuted radial styloid fragment. is indicated for most unstable and high-energy articular frac-
 Consider alternative or additional fixation of the volar
tures of the distal radius and is generally contraindicated for
lunate facet fragment if not adequately captured by
fractures with substantial metaphyseal-diaphyseal extension
the volar plate.
or severe osteoporosis.
 For irreducible intra-articular fractures, an extended
FCR approach is an option: The radial styloid fragment is regarded as the keystone of
 Perform a tenotomy of the brachioradialis tendon. reduction and stability of articular fractures of the distal
 Release the first dorsal compartment. radius and is therefore addressed first in the sequence of
 Pronate the proximal fragment to expose the multiple fragment reduction and fixation. The other key frag-
articular surface. ments to be considered include the volar lip fragment, the
Postoperative Care dorsal wall, the dorsal and volar components of the lunate
 Apply a sugar tong splint in supination for 5 to 10 facet, and the impacted articular fragments (see Figure
days until suture removal. 17.19). Five to 10 lb of traction, applied via finger traps on
 Begin digital range of motion exercises immediately. the index and long fingers or through the use of a formal
 Begin forearm rotation and gentle active wrist motion traction table, is helpful to grossly align the fragments. Fluo-
exercises at the postoperative visit. roscopic images in traction are a valuable adjunct to assess
 Evaluate with radiographs at the initial postoperative the nature of the fracture and key components.
visit and at 6 weeks postoperatively. The radial styloid is approached through a 4- to 5-cm inci-
sion on the volar radial aspect of the metaphyseal flare, just
radial to the radial artery and palmar to the tendons of the
Fragment-Specific Fixation first dorsal compartment.7 Superficial branches of the radial
In an attempt to minimize the morbidity of extensive surgical sensory and antebrachial cutaneous nerves are retracted in
dissections associated with conventional dorsal plate fixation the skin flaps, and the first dorsal compartment is opened to
of distal radius fractures, Robert Medoff devised a hybrid expose and retract its tendons. The brachioradialis tendon is
technique of percutaneous wire and plate fixation designed to split longitudinally and the tendon and periosteum elevated
fix individual fracture fragments through several small inci- in a dorsal and palmar plane to expose the radius (see Figure
sions.7,74 His “fragment-specific” classification (see earlier) 17.43). Complete palmar exposure of the radius is accom-
defines articular fractures of the radius by recognition of five plished by elevating the pronator quadratus in continuity with
elemental fracture fragments that are present alone or in the palmar margin of the brachioradialis. If necessary, the
combination in every fracture. The technique involves the use entire radial styloid can be exposed by dorsal elevation
of ultrathin modular implants that can be shaped to customize beneath the second dorsal compartment. The styloid fragment
fixation for different fragment configurations and builds on is reduced anatomically and fixed provisionally with a 0.045-
the work of Rikli and Regazzoni99 by placing these implants inch Kirschner wire. At this time, attention is directed to the
strategically along the radial and intermediate columns to intermediate column of the radius for reduction and fixation
maximize construct rigidity.56 The key component of the of the lunate facet and impacted articular fragments.
implant system is the so-called pin plate (TriMed, Inc., Valen- Dorsal intermediate column fragments are most commonly
cia, CA), which combines the versatility of a Kirschner wire approached through a 4- to 5-cm universal dorsal incision
with the rigidity of plate and screw fixation. The bending stiff- over the third dorsal compartment, where the dorsal wall,
ness of conventional Kirschner wire fixation is dramatically articular fragments, and the dorsal ulnar corner can be simul-
increased by passing the wire through the free end of a min- taneously addressed. The EPL is isolated and primarily trans-
iature 2.0-mm plate, secured proximally to the radial shaft, to posed out of its compartment, and the radial metaphysis can
create a pin plate hybrid with a three-point fixation. Mechani- be widely exposed by elevating the second or fourth (or
602
 PART
III
17 

Wrist: Distal Radius Fractures

A

B
Figure 17.48  A, Intraoperative fluoroscopy demonstrating subchondral support for the articular surface and fixation of the
comminuted dorsal cortex with a dorsal wireform implant. B, Posteroanterior view of a wireform implant used to secure a
shear-type fracture of the articular surface.

both) compartments in a subperiosteal fashion. The commi- distal holes and the two wires sequentially measured, cut,
nuted dorsal cortical wall can be lifted to expose the and bent 180 degrees at their tips before being impacted back
radial metaphysis and a Freer elevator used to disimpact the into a free hole in the plate (Figure 17.49).
articular fragments and elevate the articular surface en bloc A frequently overlooked but critically destabilizing inter-
against the template of the proximal carpal row bones. It is mediate column fragment is the volar ulnar or “teardrop”
not generally necessary to open the dorsal capsule to directly fragment. This fragment constitutes the volar half of the
inspect the articular surface because fluoroscopy is used to lunate facet and is thus the primary restraint to volar sublux-
document reduction of the fracture fragments and the articu- ation of the carpus. It also represents the volar rim of the
lar surface. Autogenous bone graft or a suitable structural sigmoid notch and contains the origin of the volar radioulnar
bone graft substitute (see Table 17.1) is recommended to ligament, a prime stabilizer of the radioulnar joint. Failure to
augment and hold reduction of the impacted articular frag- recognize or adequately stabilize this fragment can result in
ments. The dorsal intermediate column fragments are then dramatic palmar subluxation of the carpus, articular incongru-
directly reduced and fixed in position with any of a series of ency, radioulnar instability, and ulnocarpal impaction. The
modular “wireform” implants that capture and hold the small fragment is often too small, too distal, and too ulnar to be
periarticular fragments (Figure 17.48). adequately captured by the pegs of a fixed-angle palmar plate
An isolated dorsal ulnar fragment may be accessed and and, consequently, can complicate volar plate fixation by the
reduced via a limited approach through the fifth dorsal com- delayed development of carpal subluxation (see Figure
partment. It is important to note that this incison is not 17.47).51
extensile and cannot be readily enlarged to gain access to
larger metaphyseal and impacted articular fragments; thus, if Surgical Approach to the Volar Ulnar Fragment
multiple dorsal fragments require reduction and fixation, a Because only the volar aspect of the DRUJ and the ulnar
standard dorsal approach is preferred. A 3- to 4-cm incision corner of the radius need to be visualized, a limited incision
is made directly over the radioulnar joint. The extensor digiti that parallels the flexor carpi ulnaris tendon just proximal to
minimi is identified and transposed out of its compartment the transverse wrist crease provides sufficient exposure. Sur-
after dividing the extensor retinaculum of the fifth dorsal gical release of the transverse carpal ligament can be per-
compartment. Great care is taken to avoid iatrogenic disrup- formed if needed by extending the incision in a zigzag fashion
tion of the dorsal radioulnar ligament as the dorsal ulnar across the wrist crease and into the palm (extended carpal
fragment is exposed and reduced. Reduction is facilitated tunnel incision). The interval between the flexor tendons and
with the use of a dental pick to anatomically align the proxi- the ulnar artery and nerve is easily developed by blunt dis-
mal cortical margins of the fragment. A 0.045-inch Kirschner section, through which the pronator quadratus and volar
wire is placed obliquely from the dorsal and ulnar margin of wrist capsule are exposed. Usually, the distal border of the
the fragment into the stout volar metaphyseal bone. A three- pronator quadratus has been disrupted by the fracture; this
hole ulnar pin plate is contoured to fit over the fragment and allows ready visualization of the metaphyseal fracture line
slid over the Kirschner wire, with care taken to not overlap and displaced volar ulnar fragment with minimal soft tissue
the radioulnar joint. The plate is secured proximally with two dissection. The pronator quadratus is partially released from
bicortical screws. A second wire is driven through one of the its ulnar insertion and retracted radially and proximally to
603
PART
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Wrist

A B
Figure 17.49  An ulnar “pin plate” or 2.0-mm miniplate can be used to fix unstable dorsal intermediate column fragments.
B, The ulnar pin plate uses 0.045-inch Kirschner wires and 2.0-mm screws and can be placed through a limited fifth dorsal
compartment incision. It is important for most fractures that fixation of the intermediate column be supplemented with
orthogonal (90-90) fixation of the radial column. (A, Copyright Elizabeth Martin.)

expose the fracture site. Extreme care must be taken to avoid a radial column implant lies directly beneath and oblique to
injury to the volar arm of the radioulnar ligamentous complex. the first dorsal compartment tendons, such that the distal tip
The volar ulnar fracture fragment is then carefully reduced of the plate is dorsal to the tendons and the proximal end of
to restore continuity of the palmar cortex at the metaphyseal the plate is palmar to the tendons. If the previously placed
area by applying a dorsally directed force with an awl or provisional styloid Kirschner wire is in optimal position, a
periosteal elevator. Though not rigid fixation, the fragment three-, five-, or seven-hole radial column pin plate is slid over
may be fixed with a Kirschner wire introduced obliquely in the wire and positioned beneath the first dorsal compartment
a volar to dorsal direction. The wire is retrieved through the tendons. The plate is fixed to the intact metaphyseal-diaph-
dorsal skin while making sure that its palmar end lies flush yseal flare with two or more 2.0-mm bicortical screws proxi-
with the cortical level of the fragment to avoid impingement mally. A second wire is passed through the plate distally and
of the flexor tendons. For more stable fixation, the wire obliquely across the styloid to engage the apposing cortex.
should be augmented with a suture or figure-of-8 wire placed Each Kirschner wire is sequentially measured, cut, and bent
through the proximal metaphyseal cortex in a tension band 180 degrees before being impacted into a neighboring hole
configuration.19 I find that a volar buttress pin (TriMed, in the pin plate. Final reduction and position of the implants
Valencia, CA) provides the most stable fixation for this are checked with fluoroscopy, and the brachioradialis tendon
fracture fragment and prevents carpal subluxation (Figure is closed over the radial column plate with a single running
17.50). The two prongs of the implant serve as a fixed-angle suture to interpose soft tissue between the implant and the
support for the subchondral bone, and the proximal implant overlying first dorsal compartment tendons. By closing the
is rigidly secured to the intact diaphyseal bone with washers brachioradialis tendon, the attached pronator quadratus
and 2.0-mm screws. This restores palmar stability of the simultaneously covers the volar implants. The dorsal wound
fracture and provides a solid base on which the overlying is closed by transposing the EPL out of its compartment and
dorsal ulnar or “die punch” fragment can be reduced. Alter- closing the extensor retinaculum of the second and fourth
native implants include a 2.0-mm plate or a Kirschner wire, extensor compartments beneath it. The DRUJ is then care-
with or without a tension band.19 Additional volar rim frag- fully assessed for stability, and appropriate treatment is ren-
ments of the scaphoid facet can be stabilized with a 2.0-mm dered for residual instability. The wrist and forearm are
volar buttress plate or a fixed-angle volar plate, at the sur- temporarily immobilized with a sugar tong plaster splint in
geon’s discretion. supination for 5 to 10 days to allow soft tissue healing.
The construct is completed by returning to the radial Rehabilitation is predicated on the strength of fracture fixa-
styloid to complete the fixation with a 2.0-mm radial colum- tion, but generally patients can be started on a program of
nar plate and screws (Figure 17.51). It is important to place active, unresisted motion exercises within a week of surgery.
the radial styloid implant in a plane 50 to 90 degrees counter Strengthening exercises are begun after radiographic evi-
to the plane of fixation of the intermediate column to maxi- dence of fracture consolidation, generally at 6 to 8 weeks
mize stability of the fixation construct. The ideal position for postoperatively.
604
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Wrist: Distal Radius Fractures

A B C

D E
Figure 17.50  Fixation of the volar ulnar corner. A, Palmar subluxation of the carpus secondary to a volar ulnar “teardrop”
fracture. B and C, A volar buttress pin is contoured to support the articular surface and can be placed immediately atop the
palmar ridge of the radius and secured proximally beneath the pronator quadratus. D and E, Posteroanterior and lateral
radiographs of the healed fracture at 1 year. (B and C, Copyright Elizabeth Martin.)

CRITICAL POINTS: FRAGMENT-SPECIFIC FIXATION  Elevate the pronator quadratus with a portion of the
split brachioradialis as needed to expose the volar
Indications surface.
 Unstable extra-articular fractures of the distal radius  Reduce the fracture with traction and direct

(type I, AO type A) manipulation of the fragment.

 Articular fractures, simple to complex,  Provide temporary fracture fixation with an oblique

multifragmentary fractures, shear fractures, fracture- Kirschner wire through the radial styloid.
dislocation (types II to IV; AO types B and C, all  Expose the intermediate column fracture via dorsal,

subtypes) volar, or both approaches and reduce it.

 Volar ulnar “teardrop” fracture with carpal  Elevate impacted articular fragments through a

subluxation dorsal 3- to 4-cm incision under fluoroscopic

 In combination with percutaneous or fixed-angle plate guidance.
fixation for unstable fragments  Support impacted articular fragments with a graft or

 Nascent and established distal radius malunion substitute.

 Choose a dorsal wireform, 2.0-mm plate, or a pin
Contraindications plate to secure the intermediate column.
 Severe osteoporosis
 Complete fixation of the volar rim or teardrop as
 Extensive diaphyseal comminution (type V)
needed with a 2.0-mm fixed-angle implant or a volar
Technical Points buttress pin.
 Place multiple incisions directly over unstable  Apply a radial columnar plate or radial pin plate along
fragments. the reduced styloid and fix proximally with a minimum
 Make a volar radial incision to the radial column, and of two to three screws.
split the brachioradialis
Continued

605
PART provide highly satisfactory results. Ginn and colleagues
III recently published collaborative data on 22 patients who
were treated with this technique and monitored for 25
17  months and demonstrated highly satisfactory results in a very
difficult injury cohort.42
Wrist

Technique of Distraction Plating

Incisions 4 cm long are centered over the long metacarpal
and the dorsal radial aspect of the radial midshaft and a third
2-cm incision over the radiocarpal joint at Lister’s tubercle.42
A 3.5-mm low-contact compression plate that will span the
fracture from the metacarpal shaft to a point at least three
screw holes proximal to the most proximal fracture line is
chosen. The plate is passed bluntly beneath the extensor
tendons and across the fracture site to lie in the floor of the
fourth dorsal compartment. To facilitate its passage, the EPL
is freed from the retinaculum and an elevator used to develop
a plane below the fourth dorsal compartment tendons,
through which the plate is tunneled proximally into the most
proximal wound (Figure 17.52). The plate is fixed to the third
metacarpal with a single screw, ideally in the midshaft of the
Figure 17.51  A 2.0-mm radial pin plate incorporates 0.045-inch metacarpal to enable fine-tuning of fracture reduction. The
Kirschner wires and two bicortical screws in a tension band hand and forearm are supinated approximately 60 degrees
configuration to capture unstable radial styloid fracture fragments. to avoid fixing the fracture in pronation, and a provisional
fracture reduction clamp is applied to hold the plate to the
radius proximally. The forearm is taken through a full range
of rotation and gross alignment assessed with fluoroscopy.
CRITICAL POINTS: FRAGMENT-SPECIFIC FIXATION—cont’d
Care is taken to prevent excess radiocarpal or midcarpal
distraction when setting the final position, and the author
 Assess distal radioulnar stability manually and repair or
use internal fixation as needed. recommends a maximum radiocarpal gap of 5 mm. Proximal
and distal fixation is finalized with a minimum of three bicor-
Postoperative Care tical screws. Attention is directed to the radiocarpal joint,
 Apply a sugar tong splint in supination for 8 to 10
where articular congruency is restored by subchondral eleva-
days until suture removal.
tion of the impacted fracture fragments, generous subchon-
 Begin digital range of motion exercises immediately.
 Begin forearm rotation and gentle active wrist motion
dral support with allograft, and percutaneous fixation of the
exercises at the initial postoperative visit. periarticular fragments with Kirschner wires or screws (see
 Evaluate with radiographs at the initial postoperative mini-open fixation earlier). It is helpful to place one screw
visit and 2 and 6 weeks postoperatively. through the plate and immediately beneath the subchondral
bone of the intermediate column. Contraindications to bone
grafting include grade III open fractures, prior contamination,
or insufficient soft tissue coverage. After assessing the radio-
Other Fixation Methods ulnar joint for stability and treating as necessary (see earlier),
Virtually all fractures of the distal radius can be managed the wounds are closed and splint immobilization applied.
with the fixation strategies detailed previously, namely, per- Within 3 days of surgery, the splint is removed (except in
cutaneous/external fixation, dorsal plate fixation, fixed-angle cases of radioulnar instability), and patients may begin
volar locked-plate fixation, and multiple low-profile implant forearm supination-pronation and digital range of motion
fixation. A surgeon versed in each of these techniques can exercises. A 5-lb weightlifting limit is advised. The percuta-
apply them in isolation or in combination to effectively reach neous wires are generally removed at 6 weeks and the plate
each of the distal radius fracture treatment goals. Conversely, at 4 to 6 months when healing is complete.
failure to understand the indications and contraindications or Hanel and colleagues recommend placement of a smaller,
an inability to execute these techniques when necessary can 2.4-mm locking plate on the index metacarpal, beneath the
corner the surgeon into inappropriate application of more second dorsal compartment tendons at the radiocarpal level
familiar techniques to a particular fracture, with potential and fixed to the dorsal radial surface of the midshaft of the
consequences of instability or loss of reduction. radius beneath the tendons of the two radial wrist extensors
On occasion, a highly comminuted distal radius fracture, if (see Figure 17.52C). This is a rapid and simple approach that
not amenable to complex periarticular reconstruction as minimizes interference with extensor tendon function post-
detailed earlier or when associated with multiple extremity operatively, and the internal position of the low-profile
trauma, will need rapid, stable, and durable fixation to device allows it to be used for an extended period if neces-
grossly restore radial alignment and length. In selected cases, sary49 (Figure 17.53).
the technique of distraction plating with an internal bridge Recently, novel methods have been developed to achieve
plate, as initially described by Burke and Singer,14 can rapid restoration of radial length, alignment, and tilt and are
606
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17 

Wrist: Distal Radius Fractures

A B C

Figure 17.52  A, Distraction plating is performed through a limited dorsal incision with tunneling of the plate beneath the fourth
dorsal compartment. Screws are placed proximally and distally to span the fracture site, and (B) additional screw or wire fixation
of the articular fragments may be performed through or outside the plate. C, Alternative positioning of a low-profile 2.4-mm
plate below the second dorsal compartment and affixed to the index metacarpal. (Copyright Elizabeth Martin.)

indicated as low-profile, minimal-incision alternatives to bilization is impractical. Complex articular fractures with
volar plate, fragment-specific, or bridging external fixation. multiple small articular fragments (AO type C3) are relative
These techniques are indicated primarily for unstable nonar- contraindications to fixation with this device (Figure 17.54).
ticular or simple articular fractures and combine the stability Another novel technique is a “crossed pin” nonbridging
and early mobility of internal fixation with the minimal addi- external fixation system that combines the rapid placement
tional surgical intervention of percutaneous fixation. The and simplicity of percutaneous Kirschner wires with the rigid-
techniques lack long-term outcome or prospective compara- ity of external fixation while enabling immediate wrist range
tive data and are offered as alternative fixation methods for of motion. The device is applied on the radial border of the
predominantly lower-energy injuries (Figure 17.53). wrist and gains stability through the crossed nature of inter-
The first is an intramedullary device that uses locked, locked pins placed in two clusters at the radial styloid and in
diverging screws distally to support the articular surface and the proximal metaphyseal-diaphyseal junction. The pin clus-
interlocking screws proximally to provide stability across the ters on the implant enable adjustable wire angulation, and
fracture. The implant is inserted percutaneously in a retro- the radiolucent implant can be placed slightly dorsal or volar
grade manner at the radial styloid “bare spot” between the to the mid-axial line to minimally interfere with visualization
first and second dorsal compartments. Care must be taken to of the fracture (Figure 17.55).
prevent injury to branches of the radial sensory nerve during
the procedure. In the setting of acute fractures, indications The Ulnar Column
for this intramedullary implant include extra-articular frac- The most frequent complaints of residual disability and func-
tures that are unstable and whose reduction cannot be main- tional loss after fractures of the distal radius emanate from
tained by closed treatment (AO types A2 and A3) and simple the ulnar column. Therefore, the ulnar column deserves as
intra-articular fractures with large articular fragments that thorough an evaluation in the acute stage as the distal radial
can be reduced percutaneously (AO types C1 and C2). Other fracture itself to address these injuries and prevent long-term
relative indications include AO type B fracture patterns (pro- dysfunction.
vided that the distal fragment can be captured with at least Some element of DRUJ involvement is present in every
two screws), potentially unstable fractures in active patients displaced distal radius fracture. The acute pathoanatomy of
who desire wrist motion during the healing period, and indi- the ulnar column can be reduced to several discrete entities:
viduals requiring early return to work for whom cast immo- intra-articular incongruity (sigmoid notch, ulnar head),
607
PART
III
17 
Wrist

A B

C D

E F

608
 PART
III
17 

Wrist: Distal Radius Fractures

A B C

D E F
Figure 17.54  A and B, Posteroanterior and lateral radiograph of an intra-articular distal radius and ulnar styloid base fracture. C
and D, A locked intramedullary nail (Micronail, Wright Medical, Arlington, TN) was used to stabilize the distal radius fracture,
and suture fixation of the ulnar styloid was performed. E and F, Range of motion 2 months postoperatively; no immobilization
was used postoperatively. (Courtesy of Virak Tan, M.D., with permission.)

disruption of the TFCC, and avulsion of the ulnar styloid. Anatomic reduction of the radius usually results in reloca-
Fernandez has classified these injuries into a simple and tion of the ulnar head in the sigmoid notch, as occurs after
useful three-group system that is helpful in defining treat- reduction of Galeazzi-type fractures of the distal shaft. Any
ment (see Figure 17.21B).32 The key to a successful result residual instability of the DRUJ requires disruption of at least
depends on precise restoration of the anatomic relationships one margin of the TFCC and its associated radioulnar liga-
of the radioulnar joint; identification of residual DRUJ insta- ment, the ulnar insertion being more commonly disrupted
bility through manual assessment, repair, or reconstruction; than the radial origin. A manual “shuck” test of the ulna is
and maintenance of stability throughout the first 4 to 6 weeks performed by grasping the ulnar head between the examin-
after injury. er’s thumb and index finger and translating it dorsally and

Figure 17.53  Bridge plate fixation. A 20-year-old man sustained life-threatening polytrauma in a fall from a height, including
bilateral distal radius fractures (A) and a Monteggia fracture-dislocation on the left (B). C, The ulnar fracture was stabilized with
a plate, the volar rim of the left radius was reconstructed with volar 2.5-mm implants, the impacted subchondral bone was
elevated and supported with allograft cancellous bone, and the severely comminuted dorsal metaphyseal bone was stabilized
with a spanning plate in the second dorsal compartment. D, Healed fracture at the time of removal of the spanning plate 4
months postoperatively. E, The volar plates were removed at 1 year. F, Radiographs at 1 year demonstrating active range of
motion. (Courtesy of Douglas P. Hanel, M.D., University of Washington, Seattle.)

609
PART
III
17 
Wrist

A B C

D E
Figure 17.55  A-E, Cross-pinned nonbridging external fixation of the distal radius (CPX, AM Surgical, Smithtown, NY). For
selected unstable fractures with large articular fragments and healthy bone, nonbridging fixation enables early wrist motion and
compares favorably with bridging external fixation.

palmarly within the sigmoid notch to detect residual DRUJ supination.114 Grossly unstable DRUJ dislocations may
stability. Gross instability is manifested by frank dislocation, require percutaneous transfixion of the ulna to the radial
but more subtle instability can be appreciated by the loss of shaft in the position of greatest stability with dual 0.062-inch
a firm endpoint to translation and by increased subluxation Kirschner wires. The Kirschner wires are placed just proximal
relative to the uninjured wrist. I find it helpful to have to the joint, and it is helpful to leave the tips of the wires
assessed the contralateral wrist’s DRUJ stability before pre- protruding through both the radial and ulnar cortices in the
paring and draping the injured wrist. It is important that the unlikely event that wire breakage occurs in the interosseous
shuck test be performed in all positions of rotation to specifi- space. The wires may be removed at 4 weeks postoperatively
cally test both the palmar and the dorsal ligamentous con- and rotation exercises begun (Figure 17.56).
straints to ulnar translation (see Chapter 16). For type II unstable DRUJ lesions with a large ulnar styloid
fragment that has avulsed from its base (the so-called basi-
Treatment Options for Distal Radioulnar styloid fracture), fracture fixation should be considered if the
Joint Lesions DRUJ is unstable. The styloid is exposed with a 3- to 4-cm
As outlined in Figure 17.21B, three treatment options are incision midway between the extensor carpi ulnaris and the
possible: (1) early mobilization, (2) closed treatment and cast flexor carpi ulnaris. Care is taken to identify and preserve
immobilization with or without radioulnar pinning, and (3) the dorsal sensory branch of the ulnar nerve, which courses
operative management, including open and arthroscopic through the ulnar “snuffbox” just distal to the styloid tip.
techniques. Functional aftercare with early active forearm Tension band or interosseous wiring is the technique most
rotation exercises and no additional external support is rec- frequently used because the ulnar styloid fragment may be
ommended for type I stable injuries and also for fractures of too small for a compression screw. A 24-gauge wire or non-
the distal ulna or ulnar styloid in which radioulnar stability absorbable suture can be passed either around or preferably
has been restored with rigid internal fixation. Early motion through the styloid fragment and then through the ulna at
is likewise recommended for type III comminuted fractures the axilla of the shaft and the articular surface. The suture/
of the ulnar head that are not amenable to internal fixation wire is tensioned and tied with the forearm in neutral rota-
to allow fracture remodeling. tion. The forearm is immobilized in neutral rotation for 4 to
Type II subluxation can be treated successfully by 4 weeks 6 weeks, depending on the degree of stability attained. Alter-
of cast immobilization with the forearm in the most stable natively, the fragment can be stabilized with two Kirschner
position of rotation; most often this is partial to complete wires and a tension band wire passed proximally through the
610
 PART
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17 

Wrist: Distal Radius Fractures

A B C

E F
Figure 17.56  A-F, Gross instability of the radioulnar joint after anatomic realignment of a distal radius fracture can be treated
satisfactorily with 4 weeks of cross-pinning of the ulnar and the radius. Dual 0.062-inch Kirschner wires are recommended, and
perforation of all four cortices is important.

ulnar shaft (Figure 17.57). With the advent of ultrathin “pin styloid fragment. The articular disk is palpated and should be
plates,” basilar styloid fractures can be rigidly fixed with two taut and have an intact “trampoline effect” when probed.
Kirschner wires and an ulnar pin plate contoured to the ulnar When the articular disk is taut by palpation, the majority of
shaft (Figure 17.58). Immediate stability of the DRUJ is the TFCC is still attached to the ulna and to the ulnar capsule.
restored, and gentle forearm rotation can be initiated within When the articular disk has lost its tension, a peripheral tear
7 to 10 days of surgery. Implants on the ulnar side of the of the triangular cartilage is diagnosed. Arthroscopic repair
wrist can, on occasion, cause irritation and discomfort when of the peripheral tear can restore the tension of the articular
patients rest their hands on a tabletop—consequently, ulnar disk in selected cases. If gross instability of the DRUJ is also
styloid hardware may require removal in 10% to 20% of present, it is likely that the entire TFCC has been avulsed
patients. from the fovea, with or without a basilar fracture of the ulnar
Reattachment of peripheral TFCC tears by arthroscopic styloid. Simple arthroscopic repair of the articular disk to the
repair and placement of 2-0 resorbable sutures tied over the floor of the extensor carpi ulnaris subsheath is unlikely to
floor of the extensor carpi ulnaris sheath with the forearm in adequately restore DRUJ stability in these cases. Repair of
supination has been reported.39 Arthroscopy can also provide the ulnar styloid or immobilization in the position of
information regarding indications for fixation of an ulnar maximum stability in an above-elbow cast or splint for 4
611
PART
III
17 
Wrist

Figure 17.58  A 2.0-mm ulnar pin plate can be applied over a

percutaneous Kirschner wire to rigidly fix unstable basilar ulnar
styloid fractures with two proximal screws.
A

ated with a dorsally displaced dorsal ulnar fragment of the

distal radius as in type III lesions, exact anatomic reduction
and fixation of the sigmoid notch are imperative to restore
stability. Associated TFCC lesions should be addressed simul-
taneously as described previously.

AUTHOR’S PREFERRED TREATMENT:

ULNAR COLUMN INSTABILITY
Anatomic restoration of length, alignment, and tilt of the
fractured radius is performed with internal or percutaneous
fixation at the surgeon’s discretion. Unstable fractures of the
dorsal and volar margins of the sigmoid notch are rigidly
stabilized because unstable fragments have been demon-
strated to mechanically lead to radioulnar subluxation.21
Neck or head fractures of the ulna are anatomically reduced
and fixed with 2.0- or 3.5-mm plates, interfragmentary
B screws, cerclage wiring, or tension bands, depending on the
nature of the fracture and the degree of comminution. Resid-
Figure 17.57  A, Severely displaced radiocarpal fracture- ual instability of the DRUJ, as determined by a dorsal and
dislocation. After open reduction and Kirschner wire fixation of
the radial styloid, the distal radioulnar joint (DRUJ) was grossly
volar “shuck” test in neutral, pronation, and supination, is
unstable. Bony avulsion of the triangular fibrocartilage complex treated aggressively. If a basilar styloid fracture is present, I
was treated by tension band wiring. B, Follow-up radiographs at prefer open reduction and fixation followed by early range
2 years show a congruent DRUJ. of motion (see Figure 17.58). If no fracture is present and
stability can be restored in full or partial supination, simple
immobilization in a sugar tong splint is performed in the
to 6 weeks is indicated to allow the TFCC to heal. When operating room and converted to a long arm cast at 10 days.
external fixation has been used as primary treatment of the The cast is removed 4 weeks postoperatively and supination-
associated distal radius fracture, Ruch and colleagues dem- pronation exercises begun. If stability cannot be restored
onstrated that the addition of an “outrigger” pin and bar to with positioning, augmentation with parallel 0.062-inch
temporarily fix the radioulnar joint in supination was as transfixion wires is performed and maintained for 4 weeks.
effective as internal fixation of the ulnar styloid, with fewer I have not found arthroscopic repair of the TFCC to add
operative complications.103 When DRUJ instability is associ- appreciably to this algorithm.
612
 alignment and a reduced incidence of lost reduction but has
EVIDENCE-BASED DECISION MAKING PART
III
not been demonstrated to provide improved outcomes over
Is there sufficient “evidence” in the literature in the form of cast treatment alone.6 Again, relative instability of the frac-
randomized, prospective clinical trials to derive individual ture (dorsal comminution, radial shortening) and patient age
17 
treatment decisions for distal radius fractures? Outcomes of (bone quality) appear to be the prime determinants of

Wrist: Distal Radius Fractures

treatment for distal radius fractures have been the subject of outcome for the treatment of these fractures.
several large Cochrane meta-analyses performed by Handoll For unstable extra-articular and articular fractures, exter-
and colleagues over the last several years.46-48 Not surpris- nal fixation provides improved anatomic and clinical outcome
ingly, the heterogeneity of the injuries, variations in report- over cast treatment alone,61,67 and augmented external fixa-
ing outcomes, and differences in operative techniques and tion provides improved articular reduction over percutane-
patient populations have made the extrapolation of any firm ous pin and cast treatment.50 Use of the Kapandji pin
conclusions difficult. The authors made a plea for future technique for unstable fractures did not demonstrate
investigators to use a common classification system and stan- improved results over cast treatment alone or augmented
dardized validated outcome measurements so that data can external fixation and was associated with higher rates of
be compared and contrasted. complications.48,111 Taken together, the data suggest that
That said, the Cochrane results demonstrate that both per- unstable fractures or displaced articular fractures in active
cutaneous pin fixation and external fixation provide improved individuals require more effective fixation than can be pro-
anatomic restitution and diminished frequency of lost reduc- vided with casting or percutaneous pins and that augmented
tion when compared with cast treatment of unstable frac- external fixation or internal fixation is warranted. The role
tures. However, their exhaustive meta-analysis, which of nonbridging external fixation requires further definition,
compared all operative treatments on 3371 patients in 48 but in selected fractures (large fragments, good bone stock),
randomized studies through 2002, concluded that there was nonbridging external fixation provides improved radio-
insufficient data to provide “robust” credible support for graphic parameters when compared with spanning external
any particular treatment method in terms of the long-term fixation.4,84
functional benefits of operative management versus closed For displaced, comminuted, and unstable articular frac-
treatment. tures, several operative options exist. Cast treatment is not
Since publication of the last Cochrane analysis and in part appropriate in physiologically young or active patients. Aug-
a reflection of the need for standardized outcome assessment, mented external fixation has been demonstrated to result in
several well-executed randomized trials have added to our fewer complications than has low-profile fixed-angle dorsal
“evidence” for treatment decisions. Table 17.3 summarizes plates.45 However, with the advent and relative ease of appli-
the available evidence of two dozen randomized trials over cation of volar fixed-angle plates, the use of dorsal fixed-
the last decade. Although individual fractures cannot be angle plating has diminished. At the time of this writing,
pigeon-holed into a convenient treatment niche, successful there were no published randomized trials that compared
treatment strategies can be gleaned from the compiled data volar fixed-angle devices with low-profile multiple implant
in large groups of patients. fixation or augmented external fixation; thus, treatment com-
For minimally displaced or nondisplaced fractures that do parisons have been simplified into percutaneous/indirect/
not require reduction, a simple dorsal splint is as effective as mini-open fixation versus ORIF. For comminuted articular
a cast and leads to improved motion and strength soon after fractures with primary dorsal angulation, two series compar-
fracture healing when compared with above- or below-elbow ing modern fixation techniques and using validated outcome
casting.90 For extra-articular and simple articular fractures scoring demonstrated improved results with indirect reduc-
without incongruity that require closed reduction, two studies tion and percutaneous fixation.45,68 Similarly, range of motion,
demonstrated that a well-applied sugar tong splint, short arm anatomic restoration, articular congruity, and the incidence
cast, or three-point custom fracture brace was essentially of degenerative disease are improved with arthroscopic
equally effective in maintaining the initial reduction.13,115 The reduction and percutaneous fixation when compared with
cumulative data suggest that loss of reduction with closed ORIF.29 The data suggest that if indirect or arthroscopic
treatment is more dependent on the inherent stability of the reduction and percutaneous fixation can restore articular
fracture than on any particular cast technique. Though some- alignment, 1- to 3-year outcomes will be superior to those of
what nihilistic, one may conclude from the available evi- arthrotomy and ORIF. For comminuted articular fractures
dence that specific casting techniques, wrist position, and with primary volar displacement and volar rim or volar ulnar
plaster molding may be less relevant to the treatment of corner fragments, percutaneous and augmented external
these injuries than close observation, early identification fixation is not generally appropriate and internal fixation is
of unstable fractures, and selective operative treatment. the preferred option. Whether fixed-angle volar plating or
Importantly, re-reduction and casting of fractures that have multiple implant fixation will lead to improved functional or
lost their original reduction cannot be expected to improve radiographic results (or both) over indirect reduction and
outcomes.86 percutaneous fixation cannot be stated based on the evidence
With minimally comminuted extra-articular or simple available. Limited retrospective79 and unpublished prospec-
articular fractures without a step-off in healthy bone, casting, tive data suggest that the techniques of modern volar fixed-
percutaneous pin fixation, and external fixation are virtually angle plating and percutaneous/external fixation yield
interchangeable.67,81,127 In studies that combine patients with comparable functional and radiographic results. Interest-
both stable and unstable fractures, the addition of percutane- ingly, nonbridging external fixation resulted in improved
ous pin fixation to cast treatment leads to improved anatomic radiographic volar tilt, diminished perioperative pain, and
613
PART
EVIDENCE FOR TREATMENT DECISIONS
III
17  First Author/ Demographic/ Validated Outcome
Country Date N Exclusion Criteria Measurement? Results Comments
Wrist

Casting vs Splinting
O’Connor,90 2003 66 Minimally No. Increased motion in splint 1 loss of reduction in
Ireland displaced, no Gartland-Werley at 6 wk. No difference in each group
reduction radiologic, functional,
objective results at 12 wk
Tumia,115 2003 329 Displaced and No. Increased grip in brace Age and initial
Scotland nondisplaced. Gartland-Werley group early. No displacement correlated
SAC vs 3-point difference in radiologic with loss of reduction
brace findings, pain, or
function at 24 wk
Bong13 2006 85 Displaced, stable DASH No difference. 40% lost 30% of stable group and
and unstable reduction at 1 wk. DASH 50% of unstable group
favored splint group lost reduction
Casting vs Calcium Phosphate Cement
Sanchez- 2000 110 AO types A3 or C2. No. Green & Statistical improvements in Cement extrusion in 69%,
Sotelo,104 50-85 yr old. O’Brien, VAS motion and grip early for 1 intra-articular. 18%
Spain Cement casted cement, not sustained. malunion rate with
2 wk. Unstable 42% malunion rate in cement
fractures control group
Casting or External Fixation vs Calcium Phosphate Cement With or Without Kirschner Wires
Cassidy,16 USA 2003 323 Displaced, SF-36, Jebsen Early improvement in pain, Cement extrusion in 70%,
unstable dexterity, Green motion, strength but 4 intra-articular. 55%
& O’Brien unsustained in cement fair to poor results.
group. Greater loss of 29% lost reduction with
radial length cement
Casting vs Pin Fixation
Azzopardi,6 2005 57 Unstable Nonblinded. SF-36 Nonsignificant No functional benefits in
Scotland extra-articular, and VAS improvements in elderly population
age >60. SAC function, pain but
vs percutaneous improved radial tilt and
pins/cast inclination in pin group
Stoffelen,111 1999 98 Extra-articular No Increased radial shortening Unstable fractures had
Belgium fractures. in Kapandji pin group significantly worse
Average age (1 mm). No other outcomes in both
60 yr differences groups. No excellent
results in pin group
Casting vs External Fixation
McQueen,86 1996 90 Redisplaced No. Nonblinded Improved correction of Carpal alignment best
Scotland fractures, dorsal tilt in EF group predictor of function
extra-articular
Young,127 UK 2003 85 Displaced, mostly No. Gartland- No differences in objective, 51% rate of malunion. No
extra-articular Werley. dorsal tilt, or Gartland- augmented EF
fractures, all Nonblinded Werley scores. Fewer performed. Improved
ages malunions in EF group radial length and
inclination in EF group
Kapoor,61 India 2000 60 Displaced, No. Sarmiento 57% fair-poor with cast vs Augmented EF not used
articular 20% fair-poor with EF
fractures
Kreder,67 USA 2006 113 Displaced, MFA, SF-36, Jebsen. Trend for improved 40% augmented. 9% of
extra-articular. Nonblinded functional, radiographic, cast group required
Unstable and clinical outcomes conversion. All excellent
fractures with EF radiographic outcomes
excluded
Pins/Cast vs External Fixation
Harley,50 USA 2004 50 Unstable, age <65 DASH, SF-36, Significant improvement in Percutaneous treatment:
Gartland-Werley. articular surface with EF. excellent results with
Blinded No difference in tilt, difficult fractures
function

614
 PART
EVIDENCE FOR TREATMENT DECISIONS—cont’d
III
First Author/ Demographic/ Validated Outcome 17 
Country Date N Exclusion Criteria Measurement? Results Comments

Wrist: Distal Radius Fractures

Ludvigsen,81 1997 60 Unstable, articular No. Gartland- No difference in grip, Ulnar variance increased
Norway Werley. motion, radiologic results in both groups after
Nonblinded. removal of fixation
Static vs Dynamic External Fixation
Sommerkamp,109 1994 50 Unstable fractures No. Greater loss of radial More complications in
USA Gartland-Werley length, motion, and dynamic group
Gartland-Werley scores in
dynamic group
McQueen,86 1996 60 Redisplaced No. Nonblinded No difference in grip, Carpal alignment best
Scotland fractures, motion, radiologic results predictor of function
extra-articular
Bridging vs Nonbridging External Fixation
McQueen,84 1998 60 Displaced No Significant improvement in No augmented external
Scotland intra-articular grip, motion, and carpal fixation. 42%
excluded alignment in nonbridging complication rate
group. NS increase in
ulnar variance
Krishnan,70 2003 60 Intra-articular No. Nonblinded No functional, radiologic, 70% complication rate; 3
Australia fractures only or objective differences EPL ruptures in
nonbridging group
Atroshi,4 Sweden 2006 38 Age >60. DASH, SF-12. No functional, or objective No augmented external
Displaced Blinded differences. Significant fixation. Motion
articular improvement in variance improved 10-26 wk
excluded in nonbridging group postoperatively
ORIF vs Arthroscopic Reduction and Percutaneous Fixation
Doi,29 Japan 1999 88 Articular fractures No. Gartland- Improved radiographic, Strong correlation
Werley, Green & functional, anatomic between step-off and
O’Brien scores in arthroscopic DJD in both groups
group, reduced DJD
ORIF vs External Fixation
McQueen,86 1996 90 Redisplaced No. Nonblinded Improved correction of Carpal alignment best
Scotland fractures, dorsal tilt in ORIF group predictor of function
extra-articular
Kapoor,61 India 2000 60 Displaced, No. Sarmiento Equivalent functional Augmented EF not used
articular outcomes. ORIF
fractures improved articular
alignment and tilt
Kreder,68 USA 2005 179 Displaced, MFA, SF-36, Jebsen More rapid and improved Arthrotomy used in all
articular functional results in ORIF. 2-mm articular
indirect group step associated with
DJD
Grewal,45 2005 62 Unstable, DASH, SF-36, VAS Significant increase in Similar functional results
Canada displaced complications, pain, favor EF over dorsal
articular, age operative time with ORIF ORIF
<70
Leung,75 Hong 2008 144 Displaced, No. Gartland- 97% ORIF vs 94% external No subjective or
Kong articular, age Werley, Green & fixation good-excellent functional differences
<60 O’Brien results, favored ORIF between groups. >50%
group using Gartland- DJD in both groups.
Werley criteria Hardware removal in
50%

DASH, Disabilities of Arm, Shoulder, and Hand; DJD, degenerative joint disease; EF, external fixation; EPL, extensor pollicis longus; MFA, multiple factor
analysis; NS, nonsignificant; ORIF, open reduction with internal fixation; SAC, short arm cast; SF-36, short form health survey (36 items); VAS, visual analog
scale.

Table 17.3  Evidence for Treatment Decisions

615
PART statistically fewer reoperations for hardware-related compli- fractures. Treatment recommendations are based on frac-
III cations than did fixed-angle volar plate fixation (Jesse Jupiter tures in a physiologically young and active patient cohort;
et al., 2008, personal communication). Patient preference for treatment may be tempered according to the patient’s age,
17  an internal implant rather than an external device because activity level, functional impairments, and general medical
of the perceived benefit of early wrist motion, as well as condition.
Wrist

avoidance of pin cleaning and pin track infections, may sway

individual surgical decisions in favor of open reduction. Treatment of Nonarticular Fractures of
However, bridging and nonbridging external fixation tech- the Distal Radius
niques continue to demonstrate excellent outcomes in prop- For all injuries, the patient’s history and physical examina-
erly selected cases and should not be abandoned. tion should include age, handedness, occupation, aerobic
activity level, sports and leisure activities, an extensive
AUTHOR’S PREFERRED TREATMENT: medical history, and list of medications. Particular attention
A CASE-BASED APPROACH TO OPERATIVE must be paid to conditions that might affect bone mass or
MANAGEMENT bone quality, including endocrine disorders, inflammatory
… it is neither the fixation nor the implant which dictates diseases, renal disease, steroid use, and other factors. The
the outcome but the ability of the surgeon to meet the goal wrist should be inspected for wounds and tendon and nerve
of satisfactory reduction and vascular preservation with function and special attention paid to function of the median
the least invasive procedure possible. nerve. Nondisplaced distal radius fractures in the physiologi-
—KREDER, H.J., ET AL., 2006 cally young and active cohort can be treated with either a
splint or short arm cast at the surgeon’s discretion while
It is no surprise that randomized trials fail to show convincing leaving the elbow, fingers, and thumb free to avoid stiffness.
evidence of the superiority of one technique of treatment Patients should be advised of the possibility of EPL rupture,
over another for the entire spectrum of “distal radius frac- which although rare, can complicate treatment of nondis-
tures.” The variety and complexity of fracture patterns, placed fractures. Follow-up radiographs should be obtained
associated injuries to the distal radioulnar and intercarpal at 2, 4, and 6 weeks, with closer scrutiny given to elderly or
ligaments, and widely divergent patient factors (osteoporosis, osteoporotic patients.
activity level, systemic illness) mitigate against a single treat-
ment modality for all types of injuries. Instead, a treatment Bending Fractures—Type I
strategy must be developed to customize the treatment to the The prime determinant in dorsally displaced, nonarticular
injury, with the overarching principle that the least additional bending (Colles’) fractures is the predicted stability of the
surgical disruption of the soft tissue sleeve that is necessary fracture (see earlier). In younger patients with minimal com-
to gain fracture stability and articular congruency will gener- minution of the dorsal cortex and less than 3-mm loss of
ally impart the best functional outcome. radial length, an adequate closed reduction will be predict-
To paraphrase Lee Trevino, “It’s the archer, not the ably quite stable. For active patients with a stable fracture
arrow.” Although the literature is replete with a bewildering type and excellent reduction, I prefer a sugar tong splint,
array of techniques and implants, it is important to under- which permits acute swelling for the first 2 to 3 weeks and
stand that it is the judgment and skill of the surgeon in reach- then conversion to a short-arm cast for 3 weeks, until the
ing the operative goals that will be the most important fracture is healed both clinically and radiographically. Radio-
determinant of success. As stated earlier, the goals of opera- graphs are taken at 1, 2, or 3, and 6 weeks to ensure main-
tive treatment (ARMS) are tenance of reduction. A simple removable splint may be
needed for comfort and support for an additional 2 weeks
1. Articular congruity (to prevent shear on articular cartilage after cast removal. By providing patients with a removable
and degenerative changes) splint that they can wean themselves from as they regain
2. Radial alignment and length (to enable normal kinetics wrist motion and upper extremity confidence, much of their
and kinematics of the carpus and radioulnar joint) anxiety of reinjury is relieved and their rehabilitation process
3. Motion (digits, wrist, and forearm to optimize return to is shortened.
functional activities)
4. Stability (to preserve length, alignment, and congruency Minimizing Hand and Shoulder Stiffness
until healing of the fracture) During the period of immobilization and weaning from the
splint, all patients are instructed to keep their fingers, elbow,
My approach is built around three fundamentally different forearm, and shoulder mobile. The “six-pack” of hand exer-
categories of fixation that when matched to the particular cises was popularized by Dobyns and is illustrated in Figure
fracture pattern, enable the surgeon to plan and execute suc- 17.27. Passive and active shoulder, elbow, and forearm
cessful wrist fracture surgery for nearly all of its variations: motion should also be targeted as priorities as soon as the
injury pain subsides and specific immobilization require-
 Percutaneous/indirect fixation ments permit. In general, motion should be encouraged at
 Fragment-specific fixation least three times a day. Some patients benefit from super-
 Volar fixed-angle plating vised hand therapy, as well as a home program under the
guidance of a hand therapist.
For treatment purposes, I present an algorithm based on Unstable dorsal bending fractures are suspected in patients
the Fernandez mechanism-based classification of distal radius with comminution of greater than 50% of the lateral width
616
of the radial diaphysis at the fracture site and initial radial begin range of motion of the digits and shoulder immediately. PART
shortening of greater than 3 mm. As MacKenney, Lafon- Wrist and forearm motion is begun in a removable splint at III
taine, and others have demonstrated, advancing age is the the time of dressing change, and return to activity is initiated
most important predictor of instability, and the presence of at 6 to 8 weeks as permitted by radiographic evidence of
17 
these two factors in a patient older than 60 years should be healing.

Wrist: Distal Radius Fractures

considered unstable.72,82 Volar extra-articular bending frac-
tures are decidedly less common than their dorsal counter-
parts and usually involve comminution of the important stout Algorithm for Management of Articular
metaphyseal flare; consequently, these fractures are implic- Fractures of the Distal Radius
itly unstable and generally require operative stabilization. Type II—Shear Fractures
Patient education is extremely important in this group of The basic feature common to shearing marginal fractures of
injuries because the patient is likely to wish to take an active the joint surface is that a portion of the metaphysis of the
role in the decision for treatment. In healthy and active indi- distal radius is intact and in continuity with the unaffected
viduals, regardless of age, I counsel the patient concerning area of the joint surface. These fractures are inherently unsta-
the nature of the injury, its inherent instability, and the addi- ble because of the high deforming forces and fare poorly with
tional treatment time that would be required should the nonoperative treatment. The ultimate prognosis of these frac-
fracture demonstrate late instability and collapse in a cast. If tures is generally good because the displaced articular frag-
the patient elects nonoperative treatment, close observation ment or fragments can be precisely reduced and solidly fixed
of unstable fractures with weekly visits is necessary for the to the intact radius. Furthermore, fractures with a distinct
first 3 to 4 weeks, along with several cast changes as neces- shearing component usually occur in young adults, whose
sary to maintain optimal three-point fixation. The surgeon firm cancellous bone offers ideal holding power for internal
should be vigilant for early signs of collapse and avoid the fixation.
“slippery slope” of accepting a few degrees of additional Volarly displaced shear fractures are not generally ame-
dorsal tilt or loss of radial length on successive radiographs nable to percutaneous fixation because of the gross instabil-
(Online Case 17.1). The patient should be attuned to the ity, the strong deforming forces of the flexor tendons, and
potential need for relatively urgent operative intervention if the vulnerability of major nerves and vessels to percutaneous
the fracture collapses because a second attempt at closed implant insertion. The obliquity of the fracture line and loss
reduction and casting is ineffective.86 I am not as aggressive of palmar support of the carpus make these fractures inher-
in the treatment of unstable extra-articular fractures in ently unstable. Shortening and palmar displacement of the
elderly and sedentary patients because of the mitigating fragment are always associated with volar subluxation of the
effect of advanced age (>80 years old) on perceived hand carpus. This fracture may affect only the most radial aspect
dysfunction caused by malunited fractures.36 of the palmar articular surface, or it may extend ulnarly into
Because the articular surface is intact, this group of injuries the sigmoid notch. Depending on the quality of bone and the
enjoys a high rate of functional return and patient satisfaction severity of the impact, a variable amount of comminution of
after several different types of treatment, provided that ana- the volar fragment may be present. Particular attention must
tomic indices of reduction are reasonably restored. Treat- be given to rule out the presence of a separate volar ulnar
ment possibilities include, but are not limited to closed or “teardrop” fragment (see earlier); its presence demands
reduction and pinning, augmented bridging external fixation, that the implant or implants rigidly capture and maintain
nonbridging external fixation, low-profile columnar fixation, reduction of this fragment to prevent postoperative carpal
intermedullary fixation, and volar locked plating (Online subluxation52 (see Figure 17.50) (Online Case 17.5). An
Case 17.2). I discuss the limitations and advantages of differ- increase in the AP distance on the lateral film (see earlier)
ent techniques with the patient and tailor my treatment to a suggests that a sagittal split in the articular surface is present
patient’s preferences and individual needs, with each of these and is concerning for a lunate facet or teardrop fragment. If
fixation techniques being used with some frequency. If I there is any question about whether a separate lunate facet
anticipate a sizable metaphyseal bone void because of the fragment is present, a CT scan is indicated.
extremes of dorsal displacement or osteoporosis, the balance For volarly displaced shear fractures with a single frag-
is tipped in favor of volar locked plating (Online Case 17.3) ment, I prefer a volar fixed-angle plate, although a traditional
augmented by bone graft or substitute as needed. Similarly, 3.5-mm volar buttress plate or low-profile plate fixation is
if the fracture is several weeks old and I anticipate takedown also applicable (Online Case 17.6). The standard FCR
of a “nascent” malunion, volar locked plating is my preferred approach is performed, and provisional fixation of the frag-
treatment (Online Case 17.4). More and more frequently, ment with one or more 0.062-inch Kirschner wires is helpful
active patients express the desire to avoid a 6-week period to maintain reduction before the application of permanent
of casting when presented with a viable alternative; similarly, fixation (see earlier). For injuries with a separate “teardrop”
when given an option, many patients in the urban setting in fragment, I prefer to fix this lunate facet fragment with a
which I practice choose internal fixation over external fixa- volar buttress pin placed through a volar flexor carpi ulnaris
tion devices because of the associated pin cleaning and the approach (see earlier), followed by support of the radial
risk for pin track infection. For elderly and active patients column fragment with a 2.0-mm radial column plate. I am
who need or request operative fixation, especially those with not impressed by the ability of most volar plates to ade-
decreased bone mass, I prefer the increased rigidity of volar quately capture a small lunate facet teardrop fragment (see
locked-plate fixation. After surgery, I immobilize the patients Figure 17.47), and advancement of the plate distally to cover
in a sugar tong splint for 7 to 10 days postoperatively and the volar rim is not recommended because of concern for
617
PART flexor tendon rupture (Figure 17.59; also see Figure 17.42).26 work or sports are forbidden for 5 to 6 weeks after surgery,
III In the event of primary median nerve symptoms associated at which time fracture healing is complete.
with a volar shear fracture, I prefer to release the carpal Isolated dorsal shearing fractures (dorsal Barton’s frac-
17  tunnel through a separate 3-cm incision in the palm because tures) are rare. As a group, dorsal marginal shear fractures
extension of the volar radial approach into the palm risks represent less than 2% of all distal radius fractures and share
Wrist

injury to the palmar cutaneous branch of the median nerve. the defining characteristic of (1) a fracture of the dorsal
A volar plaster splint with the wrist in neutral position is articular rim and (2) dorsal radiocarpal subluxation. This is a
worn for 7 to 10 days, followed by a removable wrist splint high-energy injury that occurs in a predominantly young
for 4 to 5 weeks until healing. The patient is encouraged to male cohort. The injury is characterized by an intact volar
use the hand for activities of daily living, but heavy manual metaphyseal rim in most cases. Lozano-Calderón and col-
leagues have identified four discrete subtypes based on the
degree of articular surface involvement (Figure 17.60).78
The least common subtype is characterized by extension of
the fracture line across the volar cortex with a relatively large
and dorsally rotated volar lip component and no appreciable
articular impaction. Fractures of this subtype can often be
indirectly reduced and stabilized via a volar approach and
fixed-angle plate. For the remainder of these fractures,
however, adequate articular disimpaction and support cannot
be achieved without direct visualization, carpal reduction,
and stabilization through a dorsal or combined approach.
I prefer to approach these fractures through dual incisions:
a volar radial columnar approach (see earlier) and a universal
dorsal approach through the third extensor compartment
(see earlier). First, the radial styloid fragment is carefully
reduced through the radial column incision, checked for
proper realignment at the metaphyseal level, and pinned
provisionally to the proximal radial shaft with an oblique
0.45-inch Kirschner wire. Then the dorsal rim fragment is
reduced against the scaphoid and lunate, and dorsal sublux-
ation of the carpus is corrected. The fragments are provision-
ally pinned and intra-articular congruity is confirmed with
fluoroscopy. Depending on the extent of metaphyseal com-
minution, autogenous bone graft or structural bone graft
Figure 17.59  Advancement of a palmar plate onto the palmar substitute (see earlier) may be required to support the
rim of the radius should be avoided because there is no soft tissue reduced articular surface. The dorsal rim fragment can then
buffer between the plate and the overlying flexor tendons. be secured to the intact volar radius with a dorsal wireform

C
A

B D

Figure 17.60  Four discrete types of dorsal shear fractures have been described by Lozano-Calderón and colleagues.78
A, A relatively common variant has a large rotated volar fracture fragment that constitutes the majority of the articular surface.
B, The most common subtype demonstrates a small volar lip (teardrop) fragment, from which the important short and long
radiolunate ligaments originate. C, The central impaction pattern, associated with the shear fracture of the dorsal margin, is
relatively uncommon, as is the true radiocarpal fracture-dislocation (D), which constitutes a serious combined ligamentous and
bony injury. (Copyright Elizabeth Martin.)

618
 PART
III
17 

Wrist: Distal Radius Fractures

A B C

D E F
Figure 17.61  Type A dorsal shear fracture. A and B, Posteroanterior and lateral radiographs demonstrating shear of the entire
articular surface with little attached subchondral bone. C, Dorsal view of the highly comminuted dorsal surface after closed
reduction. D, Fixation of the thin dorsal rim and articular surface fragment with a dorsal wireform implant. E and F,
Postoperative radiographs demonstrating restitution of articular alignment and length.

A B C
Figure 17.62  Mechanism of injury of intercarpal ligament disruption. A, Extension and radial deviation produce a proximally
displaced shearing fracture of the radial styloid, scapholunate dissociation, and an avulsion fracture of the ulnar styloid. B, Axial
compression with severe impaction of the lunate fossa accounts for shearing loading of the scapholunate junction and tearing of
the ligaments at this level. C, Axial compression and ulnar deviation with severe radial shortening produce acute ulnocarpal
abutment and disruption of the lunotriquetral and triangular ligaments.

(typically a dorsal buttress pin or small-fragment/buttress pin and forearm range of motion on removal of the sutures and
combination) (see earlier) (Figure 17.61). As an alternative, the postoperative splint at 7 to 10 days.
use of the recently introduced 2.0-mm fixed-angle dorsal Shear fractures of the radial styloid (chauffeur’s fracture)
plates may provide sufficient stability to obviate the need for are not uncommon and can be associated with intercarpal
structural bone graft.78 A three- or five-hole radial column bony and soft tissue injuries. Scaphoid fractures and perilu-
pin plate or 2.0-mm fixed-angle radial column plate is then nate injuries, ranging from partial or complete scapholunate
applied directly on the radial column to maintain reduction ligament disruption to lunate dislocation, may on occasion be
of the styloid fragment and provide the increased mechanical associated with this injury (Figure 17.62A). If the radial
stability of orthogonal fixation, with the implants placed in styloid fragment shows substantial proximal and radial dis-
two planes at least 50 to 70 degrees apart (see Figure placement and the fracture line enters the joint at the level
17.61).7,56 Fixation should be sufficiently stable to begin wrist of the interfacet ridge between the scaphoid and lunate
619
PART fossae, there is a distinct possibility of disruption of the
III scapholunate ligament. The scaphoid displaces proximally
with the radial fragment, whereas the lunate remains in its
17  anatomic position. Treatment should be directed at (1) diag-
nosis and management of associated soft tissue injuries and
Wrist

(2) rigid fixation of the styloid fragment.

I recommend a low index of suspicion for concomitant
scapholunate ligament disruption, and a large radial styloid
fracture is my prime indication for arthroscopically assisted
percutaneous reduction and fixation (see earlier).37,123 In this
procedure, irrigation of the articular hematoma, direct inspec-
tion of the scapholunate ligament from both the radiocarpal
and midcarpal portals, and arthroscopic/fluoroscopic reduc-
tion of the articular surface is performed (see Figure 17.38).
For incomplete disruptions of the scapholunate ligament,
fluoroscopic and arthroscopic stress testing of the ligament is
performed with a scaphoid shift maneuver to determine the
degree of instability (see Chapter 15). After assessment of
the ligament, the cartilage-bearing fragment is manipulated
with an awl or a periosteal elevator through a small skin
incision under fluoroscopic and arthroscopic guidance, with
a minimum of soft tissue dissection. Most of these cases may
be stabilized with percutaneously inserted implants, such as
cannulated screws, Kirschner wires, external fixation, or any
combination (bridging or nonbridging), provided that there
is good bone quality (Figure 17.63). Care must be taken to
protect the superficial radial nerve, the radial artery, and the
extensor tendons at the anatomic snuffbox level. For larger
or more unstable fragments, I prefer the rigidity of a radial
column plate applied through a 3- to 4-cm volar radial
approach (see earlier text and Figure 17.51). Bone graft or
bone graft substitute may be required if there is a subchon-
dral metaphyseal void after fragment reduction. I repair com-
plete ruptures of the dorsal component of the scapholunate
ligament through a limited dorsal approach that involves the
use of a bone anchor in the scaphoid. Although there are
limited data available, I immobilize the reduced scapholunate
joint with a temporary cannulated screw inserted just distal
to the radial styloid. The advantage of a temporary screw
over wires is that it may be left in place while radiocarpal
wrist motion is initiated. For incomplete tears (e.g., Geissler
grade 2) with fluoroscopic or arthroscopic evidence of scaph-
olunate instability during a scaphoid shift examination, I Figure 17.63  Combined radial styloid and dorsal shearing
perform percutaneous temporary pin or screw fixation fracture (dorsal Barton’s) in a 23-year-old woman. Notice the
without open ligament repair. If radial styloid fixation alone intact volar ulnar portion of the joint surface in the lateral view.
is performed, wrist and forearm range of motion is begun at Both fragments were securely stabilized with lag screws, which
the first postoperative dressing change. If the scapholunate permitted early wrist motion after suture removal.
ligament was repaired and fixed with pins or a temporary
screw, gentle wrist range of motion is begun 6 to 8 weeks
postoperatively, and the screw is removed 4 months after
surgery.
maintenance of reduction are essential for an optimal
outcome. Critical to their treatment is a thorough under-
Type III—Compression Fractures of the standing of the fracture anatomy, and I recommend the
Joint Surface “fragment-specific” classification (see earlier) to identify
Compression fractures have a variety of fracture configura- critical fracture components and guide treatment options.
tions, but all variants share comminution of the articular The surgeon should have a low threshold for advanced
surface of the intermediate column,56,99 the so-called die imaging studies (CT with or without three-dimensional
punch fracture.89 These fractures occur most commonly in reconstruction) of these challenging injuries to better under-
young and active individuals, so accurate reduction and stand the fracture anatomy and plan the operative approaches.

620
Single-Fragment Fractures of the Three- and Four-Part Injuries PART
Intermediate Column Further fragmentation of the intermediate column produces III
If the intermediate column fracture is characterized by more complex diagnostic and treatment challenges. Delinea-
a simple nondisplaced or minimally displaced articular tion of the location, relative stability, and number of frag-
17 
fragment (and is without significant metaphyseal comminu- ments is essential in planning the operative approach and

Wrist: Distal Radius Fractures

tion), closed reduction and cast application may be all that is fixation strategy. CT in these cases is paramount and has
necessary. In many cases, however, the higher energy of this been demonstrated to alter not only the decision to operate
fracture group displaces the intermediate column fragment, but also the surgical approach in nearly 50% of cases.53
and operative reduction and stabilization are required. Joint In general, these fracture types will require a combination
distraction with horizontal finger trap traction is not gener- of (1) longitudinal traction or reduction of the metaphyseal
ally capable of disimpaction and realignment of small carti- fracture, (2) open reduction for restoration of joint congruity,
lage-bearing fragments, nor can it accomplish reduction of (3) bone grafting of the defect, and (4) some form of percu-
rotated volar lip and dorsal ulnar corner fragments. taneous or internal fixation. Many of these fractures can be
Isolated and displaced fractures of the dorsal or volar ulnar treated with augmented external fixation consisting of bone
corner are rare, but potentially serious injuries (Online Case graft and Kirschner wire fixation as described earlier. New
17.7). It is important to recognize these fractures and treat implant technology, including the fixed-angle devices and
them aggressively to avoid late subluxation of the carpus. miniplate and wireform techniques described earlier, have
More commonly, the combination of a radial column or enabled stable internal fixation of these complex injuries and
dorsal bending fracture and a dorsal or volar intermediate have reduced the need for combined internal and external
column fragment is seen. These fractures may be misdiag- fixation. Subchondral placement of smooth pegs that buttress
nosed as Colles’ fractures because the small (but critically the small articular fragments and simultaneously control
important) ulnar corner fragment may be overlooked. An shortening and angular displacement are particularly helpful
unreduced intermediate column fragment can lead to carpal in osteoporotic bone.92 Although fixed-angle volar plating is
subluxation, distal radioulnar incongruency, or both. If closed straightforward and provides outstanding fixation strength
manipulation fails to provide anatomic congruity and stabil- for the less comminuted fracture variants, it is difficult
ity of the joint surface, open reduction with direct fragment to adequately reduce and stabilize small or unstable dorsal
fixation is my preference (Online Case 17.7), although mini- rim, central articular, and dorsal ulnar corner fragments with
open reduction with percutaneous/external fixation is a suit- a volar fixed-angle device unless an “extended Henry
able alternative for many fractures with a dorsal ulnar corner approach” is used (see Figure 17.45). I avoid this particular
component and good bone quality. approach for the more comminuted fractures because of the
I begin with closed reduction under fluoroscopy and use extensive subperiosteal exposure required and the potential
finger trap traction as necessary to maintain the reduction for fragment devascularization.
during the surgical exposure. The radial column is approached Management of these complex articular fractures through
first through the volar radial column approach (Online Case a traditional dorsal approach and dorsal single- or double-
17.7; see earlier) and, after reflection of the first dorsal com- plate fixation enables reduction of the dorsal carpal sublux-
partment tendons, fixed provisionally with an oblique 0.045- ation, the radial styloid, central articular impaction fragment,
inch Kirschner wire to the proximal radial shaft. I expose dorsal rim, and the dorsal ulnar fragment (see Figure 17.40).
dorsal ulnar corner fractures that are not associated with an Although it may be used with a nondisplaced volar ulnar
impacted articular or dorsal wall component with a limited, fragment, the risk for iatrogenic displacement of this frag-
nonextensile incision over the fifth dorsal compartment (see ment is relatively high. The major disadvantage of the dorsal
earlier). A provisional 0.045-inch Kirschner wire is directed exposure is its inability to permit direct control and manipu-
across the fragment at a 45-degree angle to both the coronal lation of the volar ulnar “teardrop” fragment, which is the
and sagittal planes and secured to the proximal radial shaft. keystone of the distal radial articular surface. Failure to
A three-hole ulnar pin plate or a 2.0-mm fixed-angle plate is restore the anatomy of the volar ulnar corner, the concavity
affixed to the proximal metaphysis to stabilize the fragment of the lunate fossa, and the corresponding area of the sigmoid
(see Figure 17.49). A radial pin plate or 2.0-mm radial column notch gravely compromises both the radiocarpal joint and the
plate is used to stabilize the radial styloid fragment. The DRUJ. Furthermore, traditional dorsal plates placed directly
wrist is taken through a full range of motion under fluoros- under the extensor tendons have a higher incidence of irrita-
copy to confirm a stable reduction. Stable fractures are tion, attrition tendinitis, and late tendon rupture.
mobilized with early hand therapy beginning 7 to 10 days For these reasons, I prefer fragment-specific fixation for the
postoperatively. more highly comminuted fracture patterns because it allows
Volar intermediate column fractures (volar ulnar corner, me the greatest latitude for multifragmentary fixation. A
teardrop) are exposed through a limited volar ulnar approach combination of radial, dorsal, and volar incisions is used,
(see p. 603), as well as the radial column approach, and radial depending on the number and displacement of the fracture
columnar fixation is performed as described previously. Fixa- fragments, as determined by preoperative radiographs and
tion of the volar teardrop fragment is performed as described CT. Through a volar radial approach (see earlier), the radial
earlier, with volar buttress pin or tension band fixation, fol- column can be reduced anatomically and provisionally
lowed by fixation of the radial column plate. Patients with pinned in position. Elevation of the pronator gives access to
stable fracture reductions are begun on an early mobilization the volar rim through the same incision (see Figure 17.41),
protocol (Online Case 17.8). and manual reduction is readily performed. Large scaphoid

621
PART facet or volar rim fragments can be stabilized with a buttress
III plate or volar fixed-angle device as needed. If there is a sepa-
rate volar ulnar fragment, it is next reduced and stabilized
17  with a volar buttress pin through a volar ulnar incision paral-
lel to the flexor carpi ulnaris (see earlier). The forearm is
Wrist

pronated and a universal dorsal approach (see earlier) is used

to gain access to the dorsal rim, dorsal ulnar corner, and
impacted articular fragments. I often find it helpful to make
all incisions before final fixation of any particular fracture
fragment to ensure simultaneous and optimal reduction in all
planes. Lifting of one of the larger metaphyseal fragments
enables access to the subchondral impaction zone, where the
articular fragments are elevated en bloc against the template
of the scaphoid and lunate. Bone graft or structural graft Figure 17.64  Radiocarpal fracture-dislocation with minimal bony
substitute is packed into the resultant defect, and the dorsal avulsion. Treatment must be directed at the necessary subtotal
rim and dorsal ulnar corner fragments are reassembled. ligamentous disruption with the use of multiple Kirschner wires.
Dorsal fixed-angle wireforms and pin plates are contoured to Alternatively, a temporary bridge plate could be considered.
support the elevated articular surface and simultaneously (Reprinted with permission from Dumontier C, Meyer zu Reckendorf
G, Sautet A, et al: Radiocarpal dislocations: classification and
secure the articular and metaphyseal cortical fragments to
proposal for treatment. A review of twenty-seven cases, J Bone Joint
intact volar bone. The articular surface reduction and fixation Surg Am 83:212-218, 2001.)
are checked with fluoroscopy. The radial styloid fragment is
fixed with a three-, five- or seven-hole radial pin plate along
the radial column. Stability of the ulnar column is checked tion customized. Cannulated screw fixation, isolated Kirschner
manually before closure and treated as necessary. The wrist wires, or a tension band can also be used, depending on the
is immobilized in neutral and the forearm in supination for size of the styloid fragment and surgeon preference.
10 days in a sugar tong splint. Digital and shoulder motion
exercises are initiated immediately, and the operative splint Type V—Combined/Complex Injury
and sutures are removed when the edema and swelling have Finally, for more complex fracture patterns, such as type V
subsided, at which point wrist and forearm range of motion or C3-3 high-energy fractures (combined articular, metaphy-
exercises are begun. seal, and diaphyseal injuries), no single implant or treatment
paradigm is appropriate to solve all the components of the
Type IV—Radiocarpal Fracture-Dislocation fracture and the soft tissue injuries. If the fracture has a rela-
These are high-energy injuries in a young patient cohort that tively simple intra-articular component and extensive
combine bony and soft tissue components and have the metaphyseal-diaphyseal comminution with large butterfly
potential for marked wrist dysfunction. Dumontier and col- fragments, internal fixation with interfragmentary screws and
leagues describe two distinct variants of radiocarpal fracture- a fixed-angle device is the method of choice to simultane-
dislocation, with important treatment implications.30 Though ously restore radial alignment and radial length and bridge
distinctly uncommon, a radiocarpal dislocation with only a the metaphyseal-diaphyseal comminution. Initial application
small fleck of attached bone has by necessity disrupted each of a bridging external fixator to gain length and alignment
of the volar and dorsal extrinsic ligamentous stabilizers of may be helpful, and it may be left in place at the surgeon’s
the carpus and will predictably progress to an ulnar transla- discretion for additional stability (Online Case 17.11). For
tional deformity unless meticulous repair of the volar liga- more comminuted articular fractures, a combined dorsal and
ments is performed through an extended volar carpal tunnel volar exposure with compartment and median nerve release,
incision (Figure 17.64). Multiple Kirschner wire or temporary autologous cancellous bone grafting of the metaphyseal
dorsal distraction plating (see earlier) should be performed defect, and a combination of external and internal or frag-
to stabilize this injury during ligament healing. ment-specific fixation may be required (Figure 17.65).
More commonly, a large fragment of the radial styloid, For cases with extensive articular and metaphyseal-
with or without a portion of the articular surface and its diaphyseal disruption, particularly in multitrauma patients or
attached dorsal radial rim, is avulsed at the time of those who require load bearing on their injured wrist in the
injury. Treatment consists of anatomic reduction and rigid immediate postoperative period, bridge (distraction) plating
fixation of the styloid and dorsal rim fragments. Fragments is a comparably rapid and effective solution that preserves
that comprise at least a third of the scaphoid facet of radial length during the healing process. I prefer the use of a
the radius preserve the radioscaphocapitate and long radiolu- smaller 2.4-mm bridge plate spanning the second extensor
nate ligaments in continuity with the carpus such that ana- compartment and affixed to the index metacarpal distally
tomic reduction and healing restore stability to the carpus.30 (see earlier and Figure 17.52C).
I prefer rigid columnar fixation of the styloid piece with a
radial pin plate or a 2.0-mm radial column plate through a
volar radial incision (see earlier), combined with dorsal rim
ASSOCIATED INJURIES
fixation using a dorsal wireform (Online Case 17.10) or Distal radius fractures may be the result of significant trauma
2.0-mm dorsal plate. Fixation stability is tested in the operat- to the entire upper extremity. Whether evaluating a patient
ing room under fluoroscopy and postoperative immobiliza- with an acute or chronic distal radius fracture, a complete
622
 PART
III
17 

Wrist: Distal Radius Fractures

A B C

D E F

G
Figure 17.65  A, Radiographs of a severely displaced type V complex distal radial fracture with intra-articular and metaphyseal
comminution. B, Partial insufficient reduction obtained with the application of an external fixator. C, Intraoperative fluoroscopic
views showing reconstruction of the metaphyseal fracture with two transverse lag screws, provisional fixation of the radial and
ulnar fragments with Kirschner wires, and application of a volar fixed-angle device. An oblique Kirschner wire inserted palmarly
to dorsally has been applied to the volar ulnar fragment. D, Postoperative radiographs showing acceptable reduction and
restoration of radial length. The fixator was maintained for 3 weeks. E, Fracture healed at 6 weeks after surgery. Notice healing
of the dorsal and ulnar comminuted area. At this time the additional Kirschner wire was removed. F, Radiographs at 1 year show
good restoration of the joint surface and a well-remodeled distal radius. G, Adequate arc of flexion and extension and free
forearm rotation restored.

623
PART examination of the entire upper extremity should always be show no improvement over the first 24 to 48 hours or if the
III undertaken to identify and treat associated musculoskeletal reduction cannot be obtained or maintained in the presence
and neurovascular injuries. Conversely, on occasion, serious of median nerve compression, I favor early closed reduction
17  associated injuries such as shoulder dislocation or scapulo- under anesthesia, carpal tunnel release, and operative stabi-
thoracic dissociation, elbow fracture/dislocation, plexus lization of the fracture. There are no data to support routine
Wrist

injury, or vascular injury can overshadow a concomitant release of the carpal tunnel at the time of operative fixation
distal radius fracture. The associated injuries, particularly in patients without preoperative evidence of median nerve
injuries to a peripheral nerve, often lead to more problems compromise.
than the distal radius fracture itself.
Associated Carpal Ligament Injuries
Open Fractures Carpal ligament disruption can occur with both intra-
Most fractures of the distal radius are closed injuries, but I articular and extra-articular fractures of the distal radius.
consider any fracture that communicates with the external Certain fracture patterns, such as radiocarpal fracture-
environment to be an open fracture. The associated skin dislocations and severely displaced radial styloid fractures
injury may be massive, or it may be a pinpoint, with the only entering the ridge between the scaphoid and lunate fossae,
real indication that the wound communicates with the frac- are particularly at risk for associated carpal ligament injury
ture being a small amount of fatty fluid exuding from the (see earlier). The incidence of associated carpal ligament
wound. All open fractures should be treated as surgical emer- disruption with fractures of the distal radius has been docu-
gencies. My treatment plan for open distal radius fractures mented with arthroscopy by several authors, and an approxi-
calls for clinical and radiologic evaluation in the emergency mate incidence of 30% for partial or complete scapholunate
department followed by local cleansing, wound irrigation, tears and 15% for lunotriquetral tears has been demon-
and temporary stabilization in plaster. Specimens should be strated.41 There is no clear association between fracture type
obtained from the wound for culture after initial cleansing, and location or the extent of interosseous ligament injury.
and intravenous broad-spectrum cephalosporin antibiotics Arthroscopic assessment is recommended when injury to
are initiated before transport to the operating room. Farm the interosseous scapholunate or lunotriquetral ligament is
injuries or grossly contaminated wounds should receive addi- suspected. Complete interosseous ligament injuries in young
tional anaerobic and aminoglycoside coverage. The patient and active individuals require aggressive operative treat-
is transported to the operating room expeditiously, where the ment. Open repair of scapholunate disruptions is recom-
wound is enlarged, the skin and fracture margins débrided, mended after reduction and fixation of the distal radial
and the wound irrigated with abundant quantities of saline. fracture. Arthroscopic pinning or cannulated screw fixation
Restoration of stability is paramount to control of infection; is appropriate for partial scapholunate lesions with instability
thus, if the fracture is unstable, there is adequate soft tissue and for unstable or complete lunotriquetral injuries.
coverage, and the wound has been suitably cleaned, I prefer
to stabilize the fracture with internal or percutaneous fixa-
tion, depending on the particular fracture characteristics. If OUTCOME AND PATIENT
the fracture is stable, the wound extensions can be closed
primarily (while leaving the traumatic wound open) and the
EXPECTATIONS
fracture immobilized in a cast. If the wound cannot be suit- Table 17.2 (see earlier) summarizes a compilation of data
ably cleaned or if the wound has been open for more than from single-cohort studies published since 2000, broken
12 hours, the fracture is stabilized with an external fixator, down into broad fixation categories. One can generalize from
the wound left open, and the patient returned to the operat- these data that the use of modern fixation techniques gener-
ing room at 48 hours for definitive treatment and wound ates highly successful physician-reported outcomes in the
closure as possible. vast majority of patients, with restoration of grip strength to
80% to 90% of preinjury values, restoration of range of wrist
Associated Median Nerve Injury flexion-extension to 80% to 85%, and nonvalidated outcome
Varying levels of median nerve compromise, usually caused measures indicating 85% to 95% good to excellent results.
by blunt contusion or stretch of the nerve over the angulated The patient cohorts are largely comparable, with a trend
distal radius, commonly accompany acute distal radius frac- toward less comminuted fractures in the fixed-angle volar
tures. Fracture hematoma can also compromise the nerve plate group and higher use of bone graft in the fragment-
within the carpal tunnel, particularly in patients who may specific and dorsal plate cohorts. It should be noted that the
have mild or nocturnal symptoms preceding the injury. It is outcome data for volar plating and external fixation are
essential to record the degree of nerve involvement with nearly identical, which runs contrary to the conventional
careful measurements of two-point discrimination and, if pos- wisdom that rigid internal fixation with early motion neces-
sible, thenar motor function before treatment. Closed reduc- sarily leads to improved outcomes. This finding, however, is
tion is performed under adequate local or regional anesthesia, substantiated by a recent meta-analysis involving more than
and if satisfactory reduction is obtained, observation plus 1500 patients in 46 studies over the past 3 decades.83 The
careful follow-up is all that is necessary in most instances. If data for dorsal plate fixation, though including slightly more
the reduction can be maintained, the nerve compression syn- highly comminuted C3-type fractures, demonstrate overall
drome will generally improve substantially over the subse- lower satisfaction scores, higher rates of soft tissue complica-
quent 24 to 48 hours. If neurologic symptoms worsen or tions, and a higher percentage of lost reductions and may

624
correlate with the recent apparent diminution in enthusiasm that volar plate fixation resulted in nearly anatomic reduction PART
for dorsal plate fixation. in almost all of their patients, and this may have limited the III
Factors that lead to a patient’s perception of a successful outcome variability and any potential correlations. Authors
outcome after any surgical intervention are poorly under- in all three series commented on the relative weakness of the
17 
stood and abundantly illustrated by the lack of consensus on traditional Gartland and Werley, Green and O’Brien, and

Wrist: Distal Radius Fractures

primary outcome measures for management of distal radius Mayo scoring systems, which in addition to arbitrary alloca-
fractures. After an exhaustive review of 3371 treatment com- tion of points for pain, motion, and radiographic alignment,
parisons in 48 randomized trials of treatment of distal radius have not been validated for responsiveness to change and
fractures, Handoll and colleagues were unable to definitively repeatability. Furthermore, Ring and associates believe that
identify particular surgical interventions that produced con- the dominance of subjective measures, including pain and
sistently improved long-term patient outcomes when com- grip strength, as predictors of outcome may increase the
pared with nonsurgical treatment. Their 2003 review was vulnerability of these scoring systems to psychosocial con-
hampered by inconsistency in reporting and the paucity of founding variables.110
validated outcome tools in most publications. The authors In a study of 78 patients treated by either closed reduction
made a plea for a validated “standard core data set” for clas- or external fixation, Wilcke and coauthors found that dor-
sification and uniform reporting of objective and patient- sally malunited fractures or fractures with greater than 2-mm
derived outcomes.47 Clearly, data in both domains must be radial shortening correlated with decreased DASH outcome
collected and reported to provide a comprehensive assess- and visual analog scale (VAS) satisfaction scores at 22 months
ment of outcome and to make comparisons between different postoperatively.121 Similarly, grip weakness and loss of
clinical trials at different centers. extension, ulnar deviation, or pronation were all statistically
Although we have made excellent progress over the past associated with lower satisfaction scores, and all but loss of
decade with the increased use of validated outcome instru- pronation correlated with lower DASH scores as well. One
ments such as the DASH, PRWE, and Michigan Hand can summarize from the available data that there is a correla-
Outcome questionnaires, the publication of several well- tion between restoration of radiographic indices of bony
executed prospective randomized trials, and improved alignment and patient-perceived outcome. Moreover, it
reporting of objective radiographic and clinical data, there is seems apparent that patient satisfaction early in the recovery
little evidence to identify with certainty factors that are the process is largely dominated by pain, that grip strength and
best determinants of patient-derived outcomes of distal especially forearm rotation continue to improve over the first
radius fracture treatment. The degree to which objective 12 months after surgery, and that in the long-term, dorsally
determinants of physical impairment (such as range of motion malunited or shortened fractures may result in pain, loss of
and radiographic alignment) or the largely subjective mea- grip strength, and diminished extension or rotation and will
sures of disability (such as functional assessment, grip and adversely affect active patients’ perception of outcome.
pinch strength, and pain) influence patients’ perception of Going forward, it will be increasingly important for wrist
outcome is poorly understood. investigators to use common classification and outcome
Karnezis and Fragkiadakis performed a multivariate analy- parameters if we are to successfully collect data with which
sis of objective outcomes after the percutaneous treatment to compare and contrast treatment interventions for wrist
of 31 unstable distal radius fractures to identify which factors injuries. At a minimum, it would seem prudent to collect a
correlated best with patient functional outcome as deter- “standard core data set” that includes the following:
mined by the PRWE.62 Surprisingly, only grip strength at
each follow-up interval up to 24 months postoperatively cor-  AO classification of the wrist fracture type
related with patient function as assessed by the PRWE;  One or more validated, preferably “disease-specific”
neither forearm rotation nor wrist flexion-extension corre- patient outcome instruments such as the PRWE, Michigan
lated with outcome. In a later study by the same authors, the Hand Outcome questionnaire, or the DASH
radiographic parameters of dorsal malunion and radial short-  Range of motion of the digits, wrist, and forearm
ening were found to correlate significantly with worsening (bilateral)
outcomes in the pain domain of the PRWE. Similarly, articu-  Grip strength (bilateral)
lar incongruency of 1 mm or greater correlated with increas-  Pain and satisfaction assessment (VAS score)
ing wrist dysfunction on the PRWE.63 Ring and colleagues  Radiographic parameters (inclination, volar tilt, ulnar vari-
studied a larger group of patients treated surgically with ance, articular congruency)
locked volar plate fixation and found at an average of 22
months postoperatively that pain was more strongly corre-
lated with the DASH score and the Gartland-Werley demerit
COMPLICATIONS
score system; grip strength explained a high degree of the Although it was once believed by many that all patients with
variability when using the Mayo wrist scoring system. The distal radius fractures did relatively well regardless of treat-
authors pointed out that these scoring systems are somewhat ment, it is now well recognized that treatment of distal radius
arbitrary in their allocation of points; the former is heavily fractures is associated with a high complication rate. As can
weighted toward pain and the latter toward grip strength, be seen in Table 17.2, surgical complications with modern
and this helps explain the correlations in part. Among the fixation techniques, particularly after articular or high-energy
objective parameters measured, only forearm range of injuries (or both), are still reported in upward of 50% of
motion correlated with the DASH score. The authors concede patients.

625
PART The complications that continue to plague treatment of complications. In general, ulnar-sided wrist pain is the factor
III distal radius fractures include persistent neuropathy, radio- that leads most patients with malunited distal radius fractures
carpal or radioulnar arthrosis, malunion, nonunion, tendon to seek treatment. Recognition of associated carpal malalign-
17  rupture, chronic regional pain syndrome (CRPS), ulnar ment and DRUJ derangement is mandatory to decide whether
impaction, loss of rotation, finger stiffness, and rarely, com- additional procedures together with radial osteotomy are
Wrist

partment syndrome. An understanding of these complica- necessary to help ensure a good result. Assessment of carpal
tions should lead us to be more aggressive in the original care malalignment with malunited Colles’ fractures includes
of such fractures. determination of the presence of (1) dorsal subluxation of the
carpus, (2) a type I (adaptive) dorsal intercalated segment
Chronic Regional Pain Syndrome instability (DISI) that is reducible by radial osteotomy, or (3)
Although full-blown reflex sympathetic dystrophy is a rela- a type II or fixed DISI pattern that does not improve after
tively infrequent problem, milder variants are surprisingly radial osteotomy. A reducible deformity is usually character-
common in conjunction with distal radius fractures. Early ized by a mobile lunate on flexion and extension lateral
recognition and attention to patients with an inordinate radiographs. A fixed DISI is generally associated with a more
amount of pain, finger stiffness, swelling, allodynia, or par- chronic deformity and may be associated with an unrecog-
esthesias may prevent many of the problems of this serious nized disruption of the scapholunate ligament. Correction of
complication. Removal or splitting of a dressing or cast to post-traumatic wrist deformity must be tailored to the spe-
relieve pressure, elevation of an edematous hand, and inten- cific site of deformity and depends on whether the malunion
sive hand therapy are frequently very helpful in preventing is extra-articular, involves the radiocarpal or radioulnar
the development of full-blown CRPS. More often than not, joints (or both), or is complex (metaphyseal and articular
an irritated or entrapped peripheral nerve underlies most deformity). The decision to perform a simultaneous proce-
cases of early dystrophy, and the surgeon should have a low dure at the DRUJ depends on the amount of radial shortening
threshold for performing electrodiagnostic studies or surgical and the presence of osteoarthritic changes or instability of
decompression (or both) for suspected nerve entrapment. For the joint. Instability or ulnocarpal impingement that results
patients who do not respond to early local measures, sympa- from radial shortening, angulation, or malrotation without
thetic blocks, even with a cast in place, should be considered associated degenerative changes can generally be corrected
(see Chapter 59). In patients who have a previous history by restoration of radial anatomy alone. My indications for
of CRPS, there may be value in preemptive treatment corrective osteotomy in a young, symptomatic, and active
with a long-acting sympathetic block or indwelling catheter individual include 15 degrees or more of dorsal tilt, 5 mm of
for regional nerve blockade for any proposed surgical radial shortening, or marked radial angulation. Less com-
procedure. monly, increased volar tilt will result in carpal subluxation
and be manifested as painful deformity and loss of extension,
Nonunion rotation, or both. If an impending malunion is recognized in
Nonunion of distal radius fractures is rare but presents unique the subacute stage, before complete bony healing, and the
treatment challenges because of the associated pain, joint patient is medically stable, early intervention provides easier
contractures, tendon imbalance or rupture, and occasional radial and DRUJ realignment because of the absence of soft
severe bony deformity.96 In contrast, nonunion of ulnar tissue and capsular contractures. Early intervention results in
styloid process fractures in conjunction with distal radius a considerable decrease in total disability and earlier return
fractures is quite common and yet is rarely symptomatic. to work.57 In fully healed deformities, however, it may be
Treatment of distal radius nonunion must be individualized prudent to wait until the soft tissues have stabilized and the
and based on the patient’s symptoms, functional deficit, and patient has regained maximal wrist, digital, and forearm
bony substance. Basically, however, one should strive to motion before osteotomy and fixation.
achieve union with rigid internal fixation and autogenous
bone grafting. Symptomatic nonunion of the ulnar styloid is Technique of Extra-articular Radial Osteotomy
best treated by excision of the styloid unless the ulnar styloid The aims of radial osteotomy are to restore function and
fragment is quite large, in which case the fragment should be improve the appearance of the wrist by correcting the
treated by ORIF. It is essential, however, for the examiner deformity at the level of the fracture site. The osteotomy
to discriminate between radioulnar instability secondary to should reorient the joint surface to restore normal load dis-
TFCC detachment and ulnar styloid nonunion or impinge- tribution, re-establish the mechanical balance of the midcar-
ment. If DRUJ instability is suspected clinically, magnetic pal joint, and improve the anatomic relationships of the
resonance imaging (MRI) of the radioulnar ligaments or CT DRUJ. Because radial shortening is a constant component of
of both wrists in full supination and pronation (or both) can the deformity in both volar and dorsal malunions, an opening
help discriminate between the different conditions (see wedge osteotomy that is transverse in the frontal plane
Chapter 16). If a styloid nonunion is accompanied by distal and oblique (parallel to the joint surface) in the sagittal plane
ulnar instability, the TFCC should be reattached to the fovea is used to permit radial lengthening. Such an osteotomy
at the time of fragment excision or fixation. allows

Malunion  Radiallengthening of up to 10 to 12 mm

Malunion of distal radius fractures may result in wrist pain  Correction of volar tilt in the sagittal plane
(radiocarpal, radioulnar, ulnocarpal), decreased range of  Correction of radial inclination in the frontal plane
motion, midcarpal instability, or any combination of these  Correction of rotational deformity in the axial plane

626
 PART
III
17 

Wrist: Distal Radius Fractures

Correct

Incorrect Figure 17.66  It is imperative that the osteotomy be parallel to

the articular surface to avoid creating a secondary deformity.
(Copyright Elizabeth Martin.)

Correct Incorrect

It is important that the osteotomy be parallel to the articu- that the angle of correction in the sagittal plane is subtended
lar surface. If it is parallel to the long axis of the radius, a on both sides of the future osteotomy (see Figure 17.67).
secondary deformity will be created when the osteotomy is These wires not only control intraoperative angular correc-
opened (Figure 17.66). tion but also help manipulate and maintain the distal frag-
With large defects, a corticocancellous bone graft from the ment in the corrected position with a small external fixator
iliac crest may be used to fit the bone defect created by the bar until the graft is inserted in the defect. The osteotomy is
osteotomy. If partial or complete resection of the distal end performed with an oscillating saw, with care taken to not
of the ulna is performed simultaneously, the resected ulnar osteotomize the volar cortex completely. It is then opened
head can be sculpted and used to fill the radial defect. Pre- dorsally and radially by manipulating the wrist into flexion,
operative planning and the use of Kirschner wires to mark by applying a laminar spreader dorsally, or by using 2.5-mm
the angle of deformity are mandatory to guarantee accurate Schanz screws as joysticks. The osteotomy is opened until
angular correction, simplify the procedure, and reduce the both wires are parallel in the sagittal plane.
degree of exposure to fluoroscopy.31 Radiographs of the unin- A small external fixator bar with two clamps is attached
jured wrist are mandatory to determine the physiologic ulnar between both Schanz screws to maintain reduction of the
variance and calculate restoration of radial length (Figure distal fragment. Opening up the osteotomy on the radial side
17.67). can be difficult, and complete tenotomy of the brachioradialis
Corticocancellous grafts shaped and interposed in the tendon is recommended to facilitate realignment.
defect restore cortical continuity and increase intrinsic stabil- The iliac bone graft is shaped to conform to the dorsal
ity, provided that bone quality is adequate. Nonstructural radial bone defect and is inserted while making sure that the
cancellous grafts can also be used, but only in combination fit is snug. At this point, a 1.6- or 2.0-mm Kirschner wire is
with an implant that maintains stable correction of the distal driven obliquely from the radial styloid across the graft and
fragment throughout the time required for bony healing.101 into the proximal fragment, after which the threaded screws
Fixed-angle plates are ideal for corrective osteotomies in and the external fixator bar may be removed. Then, with the
osteopenic bone and nascent malunions and when using non- elbow in 90 degrees of flexion, intraoperative forearm rota-
structural bone grafts. tion and wrist motion are checked. Radiographic control with
the image intensifier may be advisable at this point to assess
Technique: Dorsal Approach for Osteotomy of the quality of correction and radial lengthening before defini-
Malunited Distal Radius Fractures tive internal fixation of the osteotomy is undertaken. The
Dorsal malunions may be exposed through a universal dorsal osteotomy can be stabilized by a variety of methods. In
incision between the third and fourth extensor compartments young adults with good bone quality and especially when the
(see earlier). For severe deformities, this has the benefit of a volar cortex is not disrupted, simple Kirschner wire fixation
single approach through which soft tissue release, bone graft- (one through the radial styloid and one through Lister’s
ing, and internal fixation can be performed. The healed frac- tubercle in an oblique dorsal palmar direction) offers ade-
ture site is identified with fluoroscopy. If dorsal plate fixation quate stability. However, this method requires more pro-
of the osteotomy is planned, Lister’s tubercle should be longed immobilization.
removed with a rongeur to provide a flat surface on which Rigid fixation with plates may be used alternatively; they
to apply the plate. If Kirschner wire or low-profile columnar offer the advantage of early wrist rehabilitation after suture
fixation of the osteotomy is planned, Lister’s tubercle may removal, usually 2 weeks after surgery. The use of lower-
be left undisturbed. To be sure that the osteotomy, as seen profile implants has helped diminish extensor tendon irrita-
in the sagittal plane, is parallel to the joint surface, a 25-gauge tion. Low-profile 2.7-mm condylar plates or any of a number
needle is introduced through the dorsal part of the capsule of dorsal fixed-angle devices can be placed beneath the
into the radiocarpal joint and along the articular surface of fourth dorsal compartment. For dorsal fixation, I prefer the
the radius. In accordance with the preoperative plan,31 two use of a radial pin plate and a fixed-angle “buttress pin”
2.5-mm Kirschner wires with threaded tips are inserted so wireform implant that spans the opening wedge osteotomy
627
PART
III
17 
Wrist

A B

15° 30°
3mm

R 25°

22° 6°
0

D E
Figure 17.67  A, Radiographs of a malunited Colles’ fracture with 30 degrees of dorsal tilt, 15 degrees of ulnar inclination, and
an ulnar-plus variance of 3 mm. B, Comparative radiographs for preoperative planning. C, Preoperative planning for the opening
wedge dorsal osteotomy and fixation with the minicondylar plate. D, Immediate postoperative radiographs. E, Radiographs 1.5
years after osteotomy with anatomic restoration of wrist anatomy and carpal alignment.
 PART
III
17 

Wrist: Distal Radius Fractures

A B C
Figure 17.68  A, A dorsally malunited distal radius fracture is corrected with a dorsal opening wedge osteotomy and the use of a laminar
spreader to correct volar tilt. A pre-bent dorsal wireform implant is in place, but final screw tightening has not yet been performed. B,
Radiograph 2 weeks postoperatively demonstrating correction of volar tilt and biplane fixation. C, Posteroanterior radiograph at 2 weeks
demonstrating an iliac crest graft and reduction of the radial inclination and length.

and provides rigid fixation when combined with corticocan-  Apply a short arm cast for 4 to 6 weeks until
cellous graft (Figure 17.68). radiographic healing when using pin fixation.
 Apply a palmar splint and initiate gentle range of
motion exercises if fixed-angle fixation is used.
CRITICAL POINTS: RADIAL OSTEOTOMY FOR MALUNITED  Large dorsal implants may produce tendon irritation
COLLES’ FRACTURE and require removal at a later date.

Indications
 Symptomatic malunion (pain, weakness, cosmetic
disturbance)
 Limited palmar flexion
Technique: Volar Approach for Osteotomy of
 DRUJ incongruency, limited forearm rotation a Malunited Distal Radius Fracture
 Adaptive carpal instability Alternatively, malunited dorsally angulated fractures can be
corrected through a volar approach to avoid the extensor
Technical Points
 Use a 6- to 7-cm dorsal approach with the incision
tendon irritation that may be associated with dorsal plate
centered on Lister’s tubercle fixation. A fixed-angle volar device anatomically designed to
 Expose the distal radius between the third and fourth match the normal anatomic contours of the palmar radial
compartment. surface may be used as a guide for precision restoration of
 Mobilize the EPL tendon. palmar tilt (Figure 17.69). I prefer to calculate the degree of
 Mark the osteotomy at the previous fracture line. correction in the sagittal and coronal planes, apply the volar
 Use 2.5-mm Kirschner wires to determine the angle of plate to the distal fragment with parallel smooth pegs before
correction (they may also be used as joysticks). osteotomy, and then remove the plate to cut the osteotomy
 Perform an osteotomy parallel to the joint surface in
(Online Case 17.12). The plate is then reapplied distally by
the sagittal plane and transverse in the frontal plane.
inserting the parallel smooth pegs into the predrilled holes
 Open the osteotomy dorsally until the Kirschner wires
and rotated into position on the proximal radial shaft to
are parallel (use a laminar spreader or temporary
external fixator). simultaneously realign the articular surface in both planes.
 Fill the defect with preshaped corticocancellous bone Fixation is completed both proximally and distally with addi-
graft. tional screws and pegs. Large deformities may require a
 Use temporary Kirschner wire fixation and fluoroscopic concomitant dorsal incision, periosteal division, and the use
control (for position of the distal fragment and DRUJ of a laminar spreader to gain length. The resultant defect
congruency). should be filled with cancellous bone graft, corticocancellous
 Perform internal fixation of the osteotomy (2.7-mm bone graft, or demineralized bone matrix, provided that fixa-
dorsal fixed-angle device with a radial pin plate and a tion is secure. The presence of severe degenerative changes
fixed-angle buttress pin). in the DRUJ mandates resection of the distal ulna or pros-
 Morcellized cancellous grafts or bone substitutes can
thetic replacement of the joint.
alternatively be used in combination with fixed-angle
dorsal plate. If the length discrepancy between the ulna and the radius
is more than 10 mm, a combined radial osteotomy and simul-
Postoperative Care taneous ulnar shortening can be performed. Rigid fixation of
 Apply a dorsal and palmar splint for 14 days, until
both the radius and the ulna, combined with autogenous
suture removal. Use a sugar tong cast in supination
graft, is recommended. If the radial shortening is greater
when concomitant distal ulna excision is performed.
than 2 to 3 cm, progressive lengthening with distraction
629
PART Dynamic midcarpal instability in a malunited fracture
III with 10° of dorsal tilt. Painful “clicking” on ulnar deviation

17 
Wrist

R L
A B

Carpal
malalignment
10°

10°

10° + 10° = 20°

R L
C

Dorsal opening wedge

osteotomy with
palmar plate fixation

D E
Figure 17.69  A, Dynamic midcarpal instability in a malunited Colles’ fracture with 10 degrees of dorsal tilt. The patient has
painful clicking on ulnar deviation. B, Comparative radiographs of the left wrist showing normal carpal alignment.
C and D, Preoperative radiographs and planning. The opening wedge osteotomy was performed through a volar approach and
fixed with a fixed-angle plate and morcellized cancellous bone. Preapplication of the fixed-angle plate to the distal fragment at
the anticipated angle of correction with two parallel pegs allows the surgeon to subsequently remove the plate, make the
osteotomy, and then reattach the plate to precisely rotate the distal fragment into position. E, Realignment of the distal radius
with restoration of a 10-degree volar tilt, improved carpal alignment, and controlled instability. Notice the subchondral
positioning of the central fixed-angle pegs. (D, Copyright Elizabeth Martin.)

osteogenesis techniques may be necessary to prevent nerve omy is made parallel with the articular surface and approxi-
or tendon dysfunction, or both. mately 1 cm proximal to it. In a biplanar mode, to correct
the loss of radial tilt and volar inclination, the osteotomy is
Watson’s Trapezoidal Osteotomy opened and held in position with a laminar spreader while a
In 1988, Watson and Castle described the technique of bipla- radiograph is obtained. If the correct amount of tilt has been
nar osteotomy plus a trapezoidal distal radial local autoge- produced to restore normal radial inclination and volar tilt,
nous bone graft for the treatment of malunion of the distal a trapezoidal corticocancellous graft is obtained from the
radius (Figure 17.70).118 These authors recommend exposure radius just proximal to the osteotomy site dorsally. The bone
of the distal radius through a transverse dorsal incision, graft is removed from the radius, rotated 90 degrees, and
although a universal dorsal approach may also be used. The then reinserted into the osteotomy site. If correction of the
articular surface of the radius is visualized, and the osteot- volar tilt is insufficient, it is increased by flexing the wrist
630
 PART
III
17 
Normal radial Normal volar

Wrist: Distal Radius Fractures

tilt tilt

Volar Dorsal

A B Figure 17.70  The operative technique of trapezoidal

Ulnar Radial osteotomy for the treatment of malunion of the
distal radius, as described by Watson and Castle,118
uses distal radial bone. A and B, The osteotomy is
made 1 cm proximal to the articular surface and
parallel with the articular surface, C, With a lamina
spreader, the distal fragment is elevated and
displaced to produce a biplanar osteotomy. An
Trapezoidal appropriate section of distal radial bone is then
graft site outlined on the dorsal aspect of the distal radius.
D and E, The bone graft is harvested, rotated 90
C degrees, packed into the biplanar osteotomy site,
and fixed with two Kirschner wires. (Copyright
Elizabeth Martin.)

D E

while the graft is wedged deeper into the osteotomy space. Figure 17.71. The palmar opening wedge osteotomy, graft-
The osteotomy and graft are secured with two crossed ing, and plating are then carried out as for a Colles’ defor-
0.0625-inch Kirschner wires to “cage” the corticocancellous mity, but in a reversed manner from the volar side. Care
graft, and the wrist is protected in a cast for 4 to 6 weeks. must be taken to not overcorrect the physiologic palmar tilt
This technique has the advantage of using a local graft, so it of 10 degrees when manipulating the distal fragment into
can be performed with the use of regional anesthesia. I dorsiflexion. Another common pitfall is to translate the entire
would, however, not recommend it for severe radial mal- distal radius fragment dorsally and, in so doing, fail to gain
union or when substantial length discrepancy is present. adequate correction. Temporary Kirschner wire fixation
through the radial styloid and a second wire placed volar to
Malunited Smith’s Fractures dorsal from the radial rim help stabilize the correction, which
The classic symptoms of volar malunion include decreased is verified with fluoroscopy. Application of a fixed-angle
wrist extension and supination because of the tendency for volar plate automatically derotates the pronation deformity
Smith’s fractures to heal with a pronation deformity. These of the distal fragment by virtue of the contoured surface of
malunions are exposed through a standard FCR incision, with the plate. Dorsiflexion of the distal fragment and derotation,
radial detachment of the pronator quadratus muscle and as well as lengthening, reorient the sigmoid notch of the
partial disinsertion of the FPL from the radial shaft. Two radius with respect to the ulnar head (see Figure 17.71).
Kirschner wires or a two-pin external fixator are inserted on Degenerative arthritis of the DRUJ may necessitate simulta-
the volar aspect to mark the angle of correction, as shown in neous distal ulnar excision or replacement in chronic cases.
631
PART
III
17 
Wrist

A B C

D E F

G H

I J
Figure 17.71  A and B, Malunited Smith’s fracture with palmar translation and a pronation deformity of the distal fragment
resulting in marked loss of supination (C and D). E and F, Intraoperative photograph and fluoroscopy demonstrating the use of a
two-pin external fixator to simultaneously gain length, rotation, and sagittal alignment of the distal fragment with an opening
wedge osteotomy. Preoperative degenerative disease of the distal radioulnar joint in this 70-year-old necessitated matched
excision of the distal ulna. G to J, Radiographic and clinical results at 3 months postoperatively demonstrating marked
improvement in rotation and wrist alignment.

Intra-articular Osteotomies sensitive sequences or concomitant wrist arthroscopy may

The role of osteotomy in correcting an intra-articular mal- play a useful role in evaluating the amount of cartilage
union of the radiocarpal joint after a distal radius fracture is damage and intra-articular incongruence. The presence of
limited by both chronology and the type of injury. The oste- areas bare of subchondral bone represents a formal contra-
otomy should be done as early as possible after fracture, and indication to osteotomy. I prefer to reserve such a procedure
the fracture plane can readily be identified upward of 8 to for malunited fractures that have a relatively simple intra-
12 weeks after injury.100 High-resolution CT with multiplanar articular component (Figure 17.72). Such fractures include
reformatting is particularly helpful in identifying the fracture malunited radial styloid fractures, volar or dorsal shearing
plane and planning the osteotomy. MRI with cartilage- (Barton’s) fractures, and dorsal die punch fractures. The
632
 If the patient’s main complaints are localized to the DRUJ PART
(pain associated with limitation of forearm rotation) and the III
angulation of the radial articular surface in the sagittal and
frontal planes is less than 10 degrees, a reconstructive pro-
17 
cedure at the distal radioulnar level is indicated, without a

Wrist: Distal Radius Fractures

corrective radial osteotomy. However, if significant radial
deformity is clearly associated with identifiable DRUJ prob-
lems, radial osteotomy and the appropriate DRUJ procedure
are performed simultaneously.
For radial shortening and ulnocarpal impaction with
acceptable congruency of the sigmoid notch and ulna, as
demonstrated by CT, a shortening osteotomy of the ulna is
the procedure of choice. Ulnar shortening decompresses the
ulnar compartment of the wrist, re-establishes DRUJ congru-
ity, and tightens the TFCC, which exerts a stabilizing effect
on the distal ulna. An oblique osteotomy with resection of a
bony segment and rigid fixation with a compression plate is
recommended (see Chapter 16).18
If associated instability of the DRUJ is present, transosse-
Figure 17.72  Relatively simple articular malunion involving ous reattachment of the TFCC is performed simultaneously
articular depression of the scaphoid facet. with the radial osteotomy.54 If the dorsal and palmar radio-
ulnar ligaments are in continuity with an ulnar styloid frag-
ment, bony reattachment with a screw, ulnar pin plate, or
tension band is preferred.
choice of surgical approach is as indicated for the fracture If plain radiographs or CT demonstrate post-traumatic
scenario in the acute stage. Rigid fixation of the osteotomized incongruity or degenerative changes of the radioulnar joint,
fragment enables early rehabilitation of the radiocarpal and either a resection arthroplasty, an ulnar head prosthetic
radioulnar joints. replacement (Figure 17.73), or a Sauve-Kapandji arthrodesis
is required to alleviate pain. A partial ulnar head or “matched
Distal Radioulnar Joint Procedures ulna” resection119 with periosteal and capsular imbrication
The most common cause of residual wrist disability after preserves the ulnocarpal ligaments and the TFCC in continu-
fracture of the distal radius involves the ulnar side of the ity with the distal ulnar stump. Partial ulnar resection does
wrist. The three basic conditions responsible for pain associ- not alter the ulnar variance, and therefore additional ulnar
ated with limitation of forearm rotation are incongruency, shortening, either at the styloid level or at the ulnar shaft,
impaction, and instability of the joint. Less frequent (or con- may be required to prevent stylocarpal impingement. The
comitant) findings are painful nonunion of the ulnar styloid, disadvantages of the Darrach procedure, such as loss of grip
capsular contracture of the joint, and radioulnar impinge- strength, loss of ulnar support of the carpus, and instability
ment (after distal ulnar resections or Sauve-Kapandji proce- of the distal ulnar stump, are well described, but the two most
dures). Incongruency of the DRUJ may be due to (1) common causes of failure are due to excessive resection of
extra-articular deformity of the radius or ulna, which leads the distal ulna and failure to correct a concomitant distal
to an abnormal orientation of the joint surfaces (sigmoid radius malunion.
notch and ulnar head) in space; (2) disruption of the intra- Radioulnar impingement, or convergence and scalloping of
articular joint surface by a fracture line affecting the sigmoid the resected ulna on the radial metaphysis, can be treated with
notch or the ulnar head, or both; and (3) extra- and intra- an ulnar head prosthesis, and acceptable midterm results have
articular factors combined. Impaction, defined as abnormal been reported with this procedure.116 Table 17.4 is an algo-
contact of two bony surfaces, occurs at the ulnocarpal joint rithm for ulnar-sided disorders that may accompany fractures
as a result of post-traumatic radial shortening and is synony- and malunions of the distal radius. The Darrach procedure still
mous with ulnocarpal abutment. With continuing impaction has a place in the treatment of distal ulnar derangement or
of the ulnar head against the carpus, progressive traumatic osteoarthritis after a Colles’ fracture in elderly patients, or it
changes follow in a predictable sequence, including attenua- can be used as a salvage procedure for failed reconstructive
tion and tears of the TFCC; chondromalacia of the ulnar procedures of the radioulnar joint (see Chapter 16).
head, lunate, and triquetrum; attenuation and tears of the DRUJ arthrodesis with the creation of a proximal pseud-
triquetrolunate ligament; and finally, ulnocarpal degenera- arthrosis preserves both the ulnocarpal ligaments and the
tive change, heralded by cyst formation in the apposing bony support of the carpus. This operation is extremely
bones. Instability is the result of loss of ligament support useful in younger, active patients to improve forearm rota-
because of avulsion of the palmar and dorsal radioulnar liga- tion in those with fixed DRUJ subluxation after articular
ments from their foveal insertion. Additional lesions of sec- fractures of the distal radius and severe destruction of the
ondary joint stabilizers (capsular ligaments, sheath of the joint (Figure 17.74). I recommend primary stabilization of
extensor carpi ulnaris, interosseous membrane, pronator the remaining distal ulna with distally based tendon weaves
quadratus) or intra-articular bony disruption of the joint using slips of both the flexor carpi ulnaris and the extensor
surface may aggravate the degree of laxity. carpi ulnaris, as described by Lamey and Fernandez.73
633
PART
III
17 
Wrist

A B D
Figure 17.73  Forty-two-year-old with a chronically painful and unstable ulna after multiple procedures for distal radial malunion.
A, Radically shortened ulna. B, Stability of the distal radioulnar joint was restored with a custom ulnar head replacement.
C and D, Functional and pain-free supination and pronation 2 years postoperatively.

MANAGEMENT ALGORITHM FOR DISTAL RADIOULNAR JOINT DISORDERS AFTER DISTAL RADIUS FRACTURE

Disorder Management

DRUJ incongruity
  Extra-articular Reorient the sigmoid notch with a radial osteotomy
  Intra-articular (post-traumatic arthrosis) Depending on the severity of degenerative changes, age, dominance, and occupation,
resection arthroplasty, Sauve-Kapandji procedure, or prosthetic replacement
  Combined Radial osteotomy and DRUJ procedure as for an intra-articular disorder
DRUJ instability Reattachment of the triangular fibrocartilage complex (open/arthroscopic)
Proximal reinsertion of the ulnar styloid nonunion
Capsulodesis (ulnar sling procedure—Herbert)
Shortening osteotomy of the ulna
Other ligament reconstructions
Ulnocarpal abutment (impaction) Restore the radioulnar index or ulnar variance to normal
Ulna-shortening osteotomy
Wafer procedure (Feldon)
Radius-lengthening osteotomy
Combined radius-ulna osteotomies
Symptomatic (painful) nonunion of the ulnar Simple excision
styloid
Capsular retraction Capsulotomy
Pronatory contracture of the DRUJ Pronator quadratus release and palmar capsulotomy
Radioulnar impingement Ulnar head prosthesis
Note: If these conditions occur in association, two or more procedures may need to be combined. A classic example is a malunited Colles fracture and
degenerative changes in the DRUJ.
DRUJ, distal radioulnar joint.

Table 17.4  Management Algorithm for Distal Radioulnar Joint Disorders After Distal Radius Fracture

634
 PART
III
17 

Wrist: Distal Radius Fractures

A B C

D E F
Figure 17.74  Suave-Kapandji procedure. A, Twenty-eight-year-old emergency medical technician with a chronically unstable and
degenerative distal radioulnar joint after multiple procedures for a malunited distal both-bones fracture. B, Intraoperative
photograph of the flexor carpi ulnaris tendon woven through the proximal stump of the Sauve-Kapandji reconstruction. C and
D, Radiographs 4 years postoperatively. E and F, Pain-free functional rotation enabled return to all activities.

Distal Radioulnar Joint Contracture

Capsular contraction of the DRUJ may be responsible for ACKNOWLEDGMENTS
limitation of forearm rotation after distal radius fractures. I would like to acknowledge with sincere gratitude the shoul-
Having ruled out joint incongruity, subluxation, radioulnar ders of those giants who have written past editions of “Distal
synchondrosis, interosseous membrane contracture, or Radius Fractures,” including Diego Fernandez and Andy
derangement of the proximal radioulnar joint as other pos- Palmer. Their insightful perspectives, tricks, and techniques,
sible causes of limitation of forearm rotation, surgical release as well as several of the original figures, tables, and parts of
is helpful if the condition does not improve after a trial of text, have been an enormous asset to me in writing this
physiotherapy. chapter.
The volar aspect of the joint is exposed through a longitu-
dinal incision just ulnar to the flexor carpi ulnaris tendon.
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