3

Distal Radius Fractures: Strategic Alternatives

to Volar Plate Fixation
Christopher J. Dy, MD MSPH
Scott W. Wolfe, MD
Jesse B. Jupiter, MD
Philip E. Blazar, MD
David S. Ruch, MD
Douglas P. Hanel, MD

Fractures of the distal radius are

Abstract
Volar locking plates have provided surgeons with enhanced capability to reliably common, and the incidence of these
repair both simple and complex fractures and avoid the hardware-related compli- injuries continues to increase.1 A
cations associated with dorsal plating. However, there have been an increasing broad range of individuals are affected,
number of published reports on the frequency and types of complications and fail- from young patients with high-energy
ures associated with volar locked plating of distal radius fractures. An informed, injuries to elderly patients with osteo-
critical assessment of distal radius fracture characteristics will allow surgeons to se- porotic fragility fractures. Treatment
lect an individualized treatment strategy that maximizes the likelihood of a suc- strategies have evolved along with an
cessful outcome. Knowledge of the anatomy, patterns, and characteristics of the di- understanding of these injuries, with
verse types of distal radius fractures and the complications and failures associated recent epidemiologic studies indicat-
with volar locked plating will be helpful to orthopaedic surgeons who treat patients ing the growing use of internal fixa-
with these injuries. tion.2,3 Volar locking plates have
provided surgeons with enhanced ca-
Instr Course Lect 2014;63:27-37. pability to reliably repair both simple
and complex fractures while avoiding
the hardware-related complications as-
sociated with dorsal plating.4 How-
ever, there is a growing body of litera-
Dr. Dy or an immediate family member serves as a board member, owner, officer, or committee member of the ture reporting the frequency and types
Accreditation Council for Graduate Medical Education. Dr. Wolfe or an immediate family member has received of complications and failures associ-
royalties from Extremity Medical; is a member of a speakers’ bureau or has made paid presentations on behalf of
TriMed; serves as a paid consultant to or is an employee of Extremity Medical; has received research or institu- ated with distal radius fracture fixation
tional support from Integra AxoGen; and serves as a board member, owner, officer, or committee member of the with volar locking plates.5 An assess-
New York Society for Surgery of the Hand. Dr. Jupiter or an immediate family member serves as a paid consul-
tant to or is an employee of OHK; serves as an unpaid consultant to Synthes TriMed; has received research or in-
ment of fracture characteristics will
stitutional support from the AO Foundation; has stock or stock options held in OHK; and is a member of a allow the surgeon to select an individ-
speakers’ bureau or has made paid presentations on behalf of the AAHS Board Curriculum Committee. Dr. Bla- ualized treatment strategy that maxi-
zar or an immediate family member serves as a paid consultant to or is an employee of Auxillium Pharmaceuti-
cals and has received research or institutional support from Auxillium Pharmaceuticals. Dr. Ruch or an imme- mizes the chances of success.
diate family member has received research or institutional support from Synthes and serves as a board member,
owner, officer, or committee member of the American Society for Surgery of the Hand. Dr. Hanel or an imme-
diate family member serves as a paid consultant to or is an employee of Aptis Medical.

© 2014 AAOS Instructional Course Lectures, Volume 63 27

Trauma

operative planning, careful attention

Table 1
should be paid to fractures that are
Complications of Volar Plate Fixation particularly prone to radiocarpal insta-
Number bility (such as articular shearing frac-
Study (Year) of Patients Reported Complications tures),13 loss of fixation (such as lunate
Extensor tendon-related facet fractures), and fractures that may
Arora et al20 (2007) 141 2 EPL ruptures require direct articular visualization
4 extensor tenosynovitis and reconstruction (such as extensively
Rampoldi and Marsico22 (2007) 90 3 extensor tendon irritations or impacted articular fractures). Each of
ruptures
these fracture characteristics should
Soong et al23 (2011) 321 1 extensor tendon irritation
alert the surgeon that adequate frac-
Flexor tendon-related
ture fixation may not be possible using
Arora et al20 (2007) 141 2 FPL ruptures
9 flexor tendon irritations only volar plating; however, the frac-
Rampoldi and Marsico22 (2007) 90 2 flexor tendon irritations ture can be successfully managed if
Soong et al23 (2011) 321 13 flexor tendon irritations these characteristics are recognized
Loss of volar tilt preoperatively or intraoperatively.14,15
Rozental and Blazar21 (2006) 41 2 cases
Loss of lunate facet fixation
Complications Associated
Rozental and Blazar21 (2006) 41 2 cases
With Volar Locking Plates
Rampoldi and Marsico22 (2007) 90 1 case
Since their introduction, volar locking
Harness et al37 (2004) NA (case report 7 cases
plates have been reliably used to treat
series) displaced distal radius fractures.16,17
EPL = extensor pollicis longus, FPL = flexor pollicis longus, NA = not available.
The fixed-angle construct minimizes
the load transmitted to the often-
comminuted metaphysis while de-
Anatomic and Biomechanical bearing surface of the radiocarpal creasing the risks of screw loosening
Considerations joint.9 Reducing the articular surface and loss of reduction.18 Successful re-
Current approaches to the management of the sigmoid notch provides congru- ports of fixation with volar plating
of distal radius fractures are based on the ity to the distal radioulnar joint were contemporaneous with the in-
principle that restoration of normal (DRUJ) and tensions its soft-tissue at- creasing frequency of hardware-related
anatomy will facilitate an expeditious re- tachments.10,11 Restoring the volar lu- complications from dorsal plating,
turn to function.6,7 Careful consider- nate facet provides radiocarpal stability leading to the rapid adoption of volar
ation of the anatomy and biomechan- via a bony buttress (the teardrop or plating to fix dorsally angulated frac-
ics of the injury will help the surgeon critical corner) and the ligamentous tures.4,19
choose a treatment strategy to restore support of the short radiolunate liga- Although volar plates are increas-
the normal stability and load-bearing ment.12 Restoring the integrity of the ingly used to manage many injury pat-
characteristics of the wrist. medial (or ulnar) column, composed terns, complications are associated
The three-column theory of the dis- of the distal ulna and triangular fibro- with these implants. These complica-
tal radius and ulna is particularly help- cartilage complex (TFCC), allows it to tions can be divided into two main cat-
ful in understanding the biomechani- serve as a fulcrum for rotating the ra- egories: tendon-related and loss of fixa-
cal rationale for treating distal radius dius and share in load transmission tion (Table 1). Other complications,
fractures.8,9 The lateral (radial) col- from the carpus.9 including complex regional pain syn-
umn, composed of the radial styloid The optimal management of a dis- drome and neurologic injury, occur
and the scaphoid fossa, provides radio- tal radius fracture will ensure restora- less frequently and are less directly re-
carpal stability through the styloid’s os- tion of each column. The radial and lated to the hardware.5,20,21
seous buttress and the origin of the intermediate columns are anatomically
palmar radiocarpal ligaments. Restor- reduced and rigidly fixed, and the me- Tendon-Related Complications
ing the intermediate column, com- dial column is stabilized as necessary Extensor Tendons
posed of the lunate fossa and sigmoid through bony fixation, TFCC repair, Although avoidance of extensor ten-
notch, reestablishes the primary load- and/or immobilization.8 During pre- don irritation was seen as a key advan-

28 © 2014 AAOS Instructional Course Lectures, Volume 63

Distal Radius Fractures: Strategic Alternatives to Volar Plate Fixation Chapter 3

tage of volar locking plate fixation for sured amount, particularly in the set- postoperative flexor tendon rupture26
dorsally displaced fractures, damage to ting of dorsal comminution. Alterna- (Figure 2, A). Distal plate placement
the extensor tendons still occurs from tively, if the fracture necessitates does not allow the hardware to be fully
drill tips, prominent screws, and dis- bicortical fixation, full-length smooth covered by the pronator quadratus
placed bony fragments (Figure 1). pegs are preferred. This practice is sub- (Figure 2, B). Arora et al20 reported
Arora et al20 reported 2 ruptures of the stantiated by a biomechanical study by 2 flexor pollicis longus ruptures and
extensor pollicis longus and 4 patients Wall et al24 that reported no difference 9 cases of flexor tendon tenosynovitis
with extensor tenosynovitis in a series in axial or sagittal stiffness force among in their study of 141 patients with un-
of 141 consecutive patients with dor- full-length bicortical screws, unicorti- stable distal radius fractures treated
sally displaced distal radius fractures cal screws (full length, 75% length, with a fixed-angle plate. Two cases of
treated with a volar locking plate. In a and 50% length), and unicortical pegs
study of 90 patients with distal radius in an osteoporotic distal radius model.
fractures treated with volar plate fixa-
tion, Rampoldi and Marisco22 re- Flexor Tendons
ported 3 extensor tendon irritations or The placement of hardware within the
ruptures.22 In the largest series of pa- volar concavity of the distal radius
tients followed for complications after minimizes the risk of flexor tendon ir-
volar plating, Soong et al23 reported ritation. This innate advantage is pres-
that 1 of 321 patients had plate-related ent only if the plate is positioned prox-
extensor tendon irritation. imal to the transverse ridge at the distal
Despite its relative rarity, this chap- extent of the pronator fossa (the so-
ter’s authors attempt to prevent intra- called watershed line).25 Placing the
operative extensor tendon damage and plate distal to the ridge allows greater Figure 1 CT scan showing the
postoperative extensor tendon irrita- capability in securing distal subchon- risk of injury to extensor tendons
tion by drilling only the volar cortex dral fragments but leaves the plate and (arrow) from prominent locking
and inserting unicortical locked screws screw heads in close proximity to the screws. (Courtesy of Philip E. Bla-
zar, MD, Boston, MA.)
that are slightly shorter than the mea- flexor tendons and at increased risk for

Figure 2 Distal placement of a volar locking plate puts the hardware in close proximity to the flexor tendons. A, In
this illustration, the position of the volar plate is too distal, placing the flexor tendons at increased risk for irritation from
the hardware. B, Illustration showing the appropriate position of the volar plate within the concavity of the distal radius.
(Reproduced with permission from Wolfe SW: Distal radius fractures, in Wolfe SW, Hotchkiss RN, Pederson WC, Kozin
SH, eds: Green’s Operative Hand Surgery, ed 6. Philadelphia, PA, Elsevier, 2010, pp 561-638.) C, Distal placement of a
volar locking plate does not allow the hardware to be fully covered by closure of the pronator quadratus. (Courtesy of
Philip E. Blazar, MD, Boston, MA.)

© 2014 AAOS Instructional Course Lectures, Volume 63 29

Trauma

flexor tendon irritation in 90 patients Loss of Fixation What Cannot Be Fixed

were reported by Rampoldi and Mar- in the Lunate Facet With a Volar Plate?
sico,22 and 13 cases of plate-related The importance of the volar lunate Dorsal Ulnar Fragment
flexor tendon irritation were reported facet as the cornerstone of stability for The displaced dorsal ulnar fragment is
in 321 patients by Soong et al.23 Given the radiocarpal joint and the DRUJ particularly challenging to control
that delayed flexor tendon rupture has was reported by Melone.10 The effects with a volar implant. Although not all
been reported up to 5 years after volar of this fragment on radiocarpal insta- dorsal ulnar fragments require stabili-
plating,27 there should be a low thresh- bility have been emphasized, and zation, it is important to recognize that
old of consideration for hardware re- awareness of its importance for DRUJ this fragment comprises a portion of
moval if there is concern about flexor stability is increasing.32-35 The volar both the radiolunate and radioulnar
tendon irritation. Ultrasound or MRI aspect of the lunate facet contains a ra- articular surfaces, and displacement of
can be useful in identifying synovitis diographic prominence (teardrop) that larger fragments can lead to instability
or attritional changes in at-risk flexor provides stability against volar sublux- of either joint. The inability to secure
tendons. Retained drilling guides from ation by serving as a bony buttress at the dorsal ulnar fragment, depending
screw insertion and loosening of im- the origin of the short radiolunate liga- on its size, can prevent the mainte-
properly engaged locking screws have ment.12,36 Loss of fixation of the volar nance of adequate sagittal radiocarpal
been reported as mechanisms for flexor lunate facet has been widely recog- alignment and predispose the fracture
tendon irritation after volar plat- nized as a mechanism of failure after to dorsal collapse. Although dorsal
ing.20,28 volar plating.21,22,37 Because the tear- comminution and articular impaction
drop is less than 5 mm wide and has a can be addressed using an extended
relatively steep volar slope, it is diffi- flexor carpi radialis approach,42 this
Loss of Fixation After cult for the ulnar limb of volar locking technique relies on indirect articular
Volar Plating plates to provide adequate stabiliza- reduction and gaining adequate indi-
Loss of Volar Tilt tion.37,38 This chapter’s authors be- rect purchase of the dorsal fragments
The restoration of radiocarpal align- lieve that at least two points of fixation with volarly to dorsally placed screws.
ment in the sagittal plane substantially are needed within this critical corner of A dorsal approach provides the sur-
influences functional outcomes and the intermediate column. The newest geon with the advantage of visualizing
grip strength after distal radius fracture volar locking plates feature two distal and directly reducing the articular sur-
treatment.29 After achieving intraoper- rows of multiaxial locking screws, pro- face, often through a limited and tar-
ative reduction of anatomic sagittal viding the potential to achieve addi- geted approach. The application of a
tilt, the volar fixed-angle construct can tional screw purchase within the volar dorsally based implant also provides a
be used to secure reduction without lunate facet.39 However, it is unlikely buttress against dorsal fragment dis-
applying an implant to the dorsal sur- that the additional proximal row of placement, which decreases the risk of
face. However, long-term clinical suc- screws provides sufficient distal cap- secondary collapse.
cess has been correlated with mainte- ture for this small fragment, and distal As previously mentioned, the fre-
nance of sagittal collinearity of the placement of the entire plate comes at quency of hardware-related irritation
radius and the carpus.29 The biome- the expense of potential flexor tendon of the extensor tendons was a major
chanical stability of the construct is irritation. Given this risk, alternate limitation of conventional dorsally ap-
contingent on the distance of the distal methods of fixation are often preferred plied implants. This prompted the de-
screws from subchondral bone, with to secure the volar lunate facet frag- velopment of low-profile dorsal plates;
the highest resistance to metaphyseal ment. Plating of the intermediate col- however, these plates had inherently
settling seen with screws inserted as umn can be accomplished through a less material strength. In recognizing
close to subchondral bone as possi- volar-ulnar incision using a buttress the need to strategically apply these
ble.30 Because fractures with extensive pin, a mini plate-and-screw construct, smaller plates, Rikli and Regazzoni8
dorsal comminution are believed to be or a tension banding tech- introduced the concept of multicol-
at greatest risk for loss of volar tilt, nique.14,34,40,41 These fixation tech- umn fixation. They achieved stable fix-
multiple fluoroscopic views should be niques can be used as part of a multi- ation and promising clinical results us-
used to maximize subchondral screw column internal fixation approach or ing 2.0-mm plates positioned on the
purchase distal to the zone of commi- an approach augmented by external lateral and intermediate columns at
nution.21,31 fixation.8,34 50° to 70° from each other.8,43 Biome-

30 © 2014 AAOS Instructional Course Lectures, Volume 63

Distal Radius Fractures: Strategic Alternatives to Volar Plate Fixation Chapter 3

chanical studies supported the multi- ity.9,10,37 The challenges of securing Marginal Articular
column strategy, with superior stiffness the volar ulnar fragment with a volar Shear Fractures
compared with both augmented exter- locking plate mainly arise from the Marginal shearing fractures (Fernan-
nal fixation and conventional dorsal small size and sloping morphology of dez type II) are difficult to treat with
plates.44,45 Because of persistent im- the fragment.38 Given the contour of volar locking plates for many of the
plant irritation, a system of even lower- currently available volar locking plates, same reasons described for dorsal and
profile pin-plates and wireforms was it is difficult to achieve multiple points volar ulnar fragments13 (Figure 4).
developed.40,43,46 This fragment- of fixation within the volar ulnar frag- Dorsal shearing fractures (reverse Bar-
specific implant system allows the sur- ment. Moving the plate more distally ton fractures) are associated with ra-
geon greater versatility in selecting im- puts the flexor tendons at increased diocarpal subluxation or dislocation.
plants for challenging fracture risk for irritation, whereas using a mul- These fractures are relatively uncom-
patterns, such as those that include a tiaxial guide to obtain more distal and mon; are usually caused by high-
dorsal ulnar fragment. Using a pin- ulnar screw trajectories increases the energy mechanisms; and often have a
plate to secure the dorsal ulnar corner risk of screw placement within the ra- spectrum of associated volar injuries,
allows buttressing of the deformity diocarpal joint or the DRUJ. The including carpal ligament tears, articu-
while minimizing the risk of soft-tissue shortcomings of using volar locking lar impaction, and volar marginal
irritation. Multicolumn fixation with shearing.51 Because of the direction of
plate fixation in this situation have
fragment-specific implants has been the associated radiocarpal instability,
been recognized along with the need
used with good to excellent results and these injuries are often best ap-
for smaller implants that can be placed
no reported extensor tendon rup- proached from the dorsal side. Articu-
more distally.21,37 It has been reported
tures.40,47,48 lar impaction can be directly assessed
that Kirschner wires, tension-band
The specific utility of multicolumn from this approach, and bone grafting
wiring, and miniplates provide ade-
fixation for stabilizing the dorsal ulnar is often helpful to provide subchondral
quate fixation of the volar ulnar cor-
fragment is substantiated by biome- support. The fracture is then but-
chanical testing. During loads ex- ner.34,41 The volar buttress pin has
tressed with a dorsally based implant
pected in the rehabilitation phase, the been reported to provide rapid and se-
to minimize the risk of recurrent insta-
dorsal ulnar pin-plate provided a but- cure fixation of small critical corner
bility.51 Low-profile implants of vari-
tress effect against dorsal closure of the fragments.14,15,40 Provisional fixation ous sizes, ranging from 2.0-mm to
osteotomy that was not provided by of the fragment is performed with a 3.5-mm dorsal plates to fragment-
the volar locking plate.49 A biome- Kirschner wire, and sagittal radiocar- specific pin-plates or wireforms can be
chanical evaluation by Taylor et al50 pal alignment and stability are care- used (Figure 4). The surgeon chooses
demonstrated that a multicolumn ap- fully assessed. The buttress pin has two the implant based on the fracture char-
proach using a dorsal ulnar pin-plate prongs that provide fixed-angle sup- acteristics and the soft-tissue coverage
provided greater stiffness for the ulnar- port within the subchondral bone capability. Volar shearing fractures
sided fracture fragment than a volar (Figure 3). The proximal aspect of the (and the treatment of volar injuries as-
locking plate. When viewed in con- volar buttress pin implant is secured to sociated with dorsal marginal shearing
junction, these studies indicate that the intact diaphysis with 2.0-mm fractures) require an analogous ap-
multicolumn plating provides an ad- screws and washers. Although the im- proach. Larger fragments can be stabi-
vantage over volar locking plates in se- plant can be applied through the stan- lized with volar locking plates; how-
curing the intermediate column and dard volar approach, a limited ap- ever, marginal shear fragments
opposing dorsal fracture collapse. proach between the flexor tendons and typically require the use of low-profile,
the ulnar neurovascular bundle is help- distally positioned implants to buttress
Volar Ulnar Fragment ful when performing multicolumn fix- the articular surface.
As previously mentioned, the volar ul- ation with multiple incisions.14,15
nar fragment is regarded as the corner- Care must be taken to avoid traction Unstable Radial Styloid
stone of the radiocarpal joint and the on the median nerve and the palmar The radial styloid plays a critical role
DRUJ because it plays critical roles in cutaneous branch if applying an ulnar- in radiocarpal stability, providing both
maintaining sagittal alignment, trans- sided implant through a standard an osseous buttress and the ligamen-
mitting the load from the carpus, and Henry approach. tous origin of the stout palmar radio-
providing sigmoid notch congru- carpal ligaments.9 Reduction of the ra-

© 2014 AAOS Instructional Course Lectures, Volume 63 31

Trauma

Figure 3 A volar buttress pin can be used to secure the volar ulnar corner of the distal radius. A, Radiograph show-
ing volar subluxation of the carpus. Oblique view (B) and frontal view (C) of a volar buttress pin applied to secure the
volar-ulnar corner. AP (D) and lateral (E) intraoperative radiographs of multicolumn fixation, including a volar buttress pin.
(Reproduced with permission from Wolfe SW: Distal radius fractures, in Wolfe SW, Hotchkiss RN, Pederson WC, Kozin
SH, eds: Green’s Operative Hand Surgery, ed 6. Philadelphia, PA, Elsevier, 2010, pp 561-638.)

dial styloid is essential to ensure tional coronal plane compression to central impaction of the articular sur-
appropriate restoration of radial inclina- close articular gaps and aids in sup- face. Because of the volar radiocarpal
tion and the length and congruity of the porting a comminuted articular sur- ligaments, the volar approach requires
radioscaphoid articulation. Two or more face (Figure 5). This plate can be used indirect visualization and reduction
points of fixation can usually be ob- in combination with a volar locking techniques. Alternatively, an extended
tained for large radial styloid fragments plate or intermediate column-specific, Henry approach allows visualization
within the radial-sided distal screws of low-profile implants.40,52,53 Mechani- but entails considerable periosteal
the volar locking plate. However, if an- cal studies support the addition of a ra- stripping.42 Using a targeted dorsal ap-
atomic reduction and solid fixation of dial column plate to enhance the sta- proach, the articular surface is directly
the radial styloid cannot be confidently bility of a volar locking plate for reduced and reconstructed. Bone graft
obtained because of comminution, small comminuted articular fractures.54 may be used to fill subchondral and
fragment size, or instability from shear- metaphyseal voids to aid in supporting
ing, the application of a 2.0-mm plate Central Impaction small impacted articular fragments. If
should be considered along the radial The dorsal approach provides a dis- the subchondral bone has sufficient in-
column.8,40 The plate provides addi- tinct advantage if there is substantial tegrity, a dorsal plate is applied for

32 © 2014 AAOS Instructional Course Lectures, Volume 63

Distal Radius Fractures: Strategic Alternatives to Volar Plate Fixation Chapter 3

Figure 5 Illustration (A) and ra-

diograph (B) of a radial styloid plate
used to stabilize an unstable radial
styloid fracture and to close an artic-
ular gap. (Panel 5A reproduced with
permission from Wolfe SW: Distal
radius fractures, in Wolfe SW, Hotch-
Figure 4 Preoperative (A) and lateral (B) radiographs of a dorsal marginal kiss RN, Pederson WC, Kozin SH,
shear fracture. C, Intraoperative lateral fluoroscopic view. The fracture was re- eds: Green’s Operative Hand Sur-
duced and secured with dorsal wireform implants. AP (D) and lateral (E) radio- gery, ed 6. Philadelphia, PA, Elsevier,
graphs taken 1 month postoperatively. 2010, pp 561-638. Panel 5B copy-
right Scott Wolfe, MD, New York,
NY.)
fracture fixation. If bone stock is se- gidity of the construct.57 Different
verely compromised from a high- plates and hardware positions have technique is useful in the polytrauma
energy injury, a spanning dorsal plate been reported, with the original de- setting (limited surgical time, bilateral
can be used in a bridging fashion to scription of a 3.5-mm plate applied fractures, and fractures with severe
neutralize the compressive forces on under the fourth dorsal compart- comminution or osteoporosis).56,59,61
the articular surface55,56 (Figure 6). ment.58 Hanel et al59 described the use Consolidation of the fracture typically
The plate, which essentially serves as of a 2.4- to 2.7-mm combiplate ap- occurs at a mean of 110 days; the dis-
an internally placed external fixator, is plied under the second dorsal com- traction plate can be removed shortly
placed along the dorsal wrist and be- partment. Three screws each are placed thereafter.56 The clinical results are
neath the extensor retinaculum. Fixa- on the distal and proximal sides using comparable to other fixation tech-
tion screws are placed far from the a combination of locking and cortical niques. The complication profile is
zone of injury, in the radial diaphysis screws.60 In addition to its use for cen- safe, with the need for staged plate re-
and the metacarpal, to increase the ri- trally impacted articular injuries, this moval being the major limitation.62

© 2014 AAOS Instructional Course Lectures, Volume 63 33

Trauma

ily fix the radius and the ulna in supi-

nation.

Summary
Although most distal radius fractures
can be treated reliably with volar lock-
ing plates, each fracture should be
carefully assessed to ensure that alter-
native strategies are not needed. When
using volar locking plates, the risk of
tendon-related complications can be
minimized by drilling in a unicortical
fashion, inserting less than full-length
distal locking screws, and avoiding dis-
tal positioning of the plate. The im-
portance of the intermediate column,
specifically the volar and dorsal ulnar
fragments of the distal radius, cannot
be overemphasized. Inadequate fixa-
tion of these fragments can have ad-
verse implications on radiocarpal
alignment, radioulnar stability, and
functional outcome. Marginal shear-
ing fractures are difficult to secure with
volar locking plates. Multicolumn fixa-
tion techniques can be used to fix volar
and dorsal ulnar fragments and but-
Figure 6 AP (A) and lateral (B) radiographic views of a spanning plate
used to bridge a comminuted articular surface. Fixation points are placed far
tress marginal shearing fractures. Dor-
from the zone of injury. (Reproduced with permission from Ruch DS, Ginn TA, sal approaches can be useful in recon-
Yang CC, Smith BP, Rushing J, Hanel DP: Use of a distraction plate for distal structing impacted articular fractures,
radial fractures with metaphyseal and diaphyseal comminution. with dorsal plating or distraction plat-
J Bone Joint Surg Am 2005;87(5):945-954.) ing used for definitive fixation. The ul-
nar column needs to be assessed after
osteosynthesis of the distal radius is
DRUJ Instability for DRUJ instability.35 If the DRUJ is
complete, with stabilization if neces-
Volar plating alone cannot treat DRUJ unstable, forearm rotation should be
sary via styloid plating, TFCC repair,
instability. Stabilization of the interme- examined to find a position of stability
or supine immobilization. Adherence
diate column may help improve DRUJ for postoperative immobilization. Ten
to these principles will maximize the
stability in two ways: by (1) restoring to 14 days of above-elbow immobiliza-
opportunity for the restoration of nor-
articular congruency of the sigmoid tion is generally sufficient to achieve
mal anatomy and function after a dis-
notch to provide a seat for the distal adequate stability to begin active fore-
tal radius fracture.
ulna and (2) tensioning the TFCC and arm rotation exercises. If a stable posi-
the surrounding soft-tissue stabilizers of tion cannot be identified, TFCC repair
the DRUJ. In each instance, stability of and/or open reduction and internal References
the ulnar column should be assessed fixation of the basilar styloid or ulnar 1. Nellans KW, Kowalski E, Chung
immediately after the lateral and inter- head fracture should be performed us- KC: The epidemiology of distal
mediate columns have been stabilized. ing Kirschner wires or styloid-specific radius fractures. Hand Clin 2012;
Injury patterns with TFCC avulsions or plates. In the setting of persistent in- 28(2):113-125.
basilar styloid fractures or fractures with stability, dual 0.062-inch Kirschner 2. Koval KJ, Harrast JJ, Anglen JO,
proximal extension are at highest risk wire fixation can be used to temporar- Weinstein JN: Fractures of the

34 © 2014 AAOS Instructional Course Lectures, Volume 63

Distal Radius Fractures: Strategic Alternatives to Volar Plate Fixation Chapter 3

distal part of the radius: The evo- 13. Fernández DL: Fractures of the tions after locked volar plate fixa-
lution of practice over time. distal radius: Operative treatment. tion. J Hand Surg Am 2011;
Where’s the evidence? J Bone Joint Instr Course Lect 1993;42:73-88. 36(1):3-9.
Surg Am 2008;90(9):1855-1861. 14. Wolfe SW: Green’s Operative 24. Wall LB, Brodt MD, Silva MJ,
3. Chung KC, Shauver MJ, Birk- Hand Surgery, ed 6. Philadelphia, Boyer MI, Calfee RP: The effects
meyer JD: Trends in the United PA, Elsevier, 2010. of screw length on stability of
States in the treatment of distal simulated osteoporotic distal ra-
radial fractures in the elderly. 15. Lam JW, Wolfe SW: Distal radius dius fractures fixed with volar
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1868-1873. with a volar plate? The role of 2012;37(3):446-453.
4. Orbay JL, Fernandez DL: Volar fragment-specific fixation in mod-
ern fracture treatment. Oper Tech 25. Orbay J: Volar plate fixation of
fixation for dorsally displaced frac- distal radius fractures. Hand Clin
tures of the distal radius: A pre- Sports Med 2010;18(3):181-188.
2005;21(3):347-354.
liminary report. J Hand Surg Am 16. Gesensway D, Putnam MD,
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2006;445:91-99.

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