Article published online: 2021-12-13

Special Symposium: Volar Rim Distal Radius Fracture 219

Classification and Management of Failed

Fixation of the Volar Marginal Fragment in Distal
Radius Fractures
M. Carolina Orbay, MD1 Jorge L. Orbay, MD1

1 Miami Bone and Joint Institute, Miami, Florida Address for correspondence M. Carolina Orbay, MD, Miami Bone and
Joint Institute, 8905 SW 87th Avenue Suite 100, Miami, FL 33176
J Wrist Surg 2022;11:219–223. (e-mail: [email protected]).

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Abstract Greater understanding of specific fracture patterns following distal radius fractures has
arisen with the advent of volar plating. The volar marginal fragment (VMF) is a small
Keywords peripheral piece of bone which is critical to carpal stability. Failure to achieve good
► distal radius fractures fixation of the VMF can result in volar subluxation of the carpus and distal radioulnar
► hook plate joint instability. Due to its small, distal nature, this fragment can be easily missed and
► revision distal radius difficult to fix. Loss of reduction of the VMF following operative fixation presents
► volar lunate facet specific challenges and surgical considerations dictated by patient characteristics and
► volar marginal timing. Our goal of this review is to present a classification system for these failed VMFs
fragment which can help guide surgical treatment as well as expected outcomes.

The volar lunate facet is critical to carpal stability, particu- the fracture. Many methods of fixation have been described
larly at 20 degrees of wrist extension, when the centroid of to stabilize this fragment in the acute setting.7,9 The best
contact pressures is shifted most palmarly.1 Recently, a results are obtained when the fragment is treated adequately
specific fracture fragment from this important bony buttress, at the initial occasion.11
the volar marginal fragment (VMF), has undergone signifi- Although not a common situation, the hand surgeon will
cant scientific investigation.2–5 The VMF, also referred to as likely be confronted with a VMF which has lost fixation. We
the volar ulnar corner, volar marginal rim, and “critical refer to these as failed VMFs. These can be addressed
corner,” is a small peripheral fragment which forms the successfully by using several available revision strategies.
attachment point of the short radiolunate and radioulnar These must be chosen to best match patient and fracture
ligaments.5 Loss of the VMF can result in volar subluxation of characteristics.
the carpus and distal radioulnar joint (DRUJ) instability.6 This
fracture fragment, when present, creates difficulties for
Classification of Failed Volar Marginal
upper extremity surgeons, as the fragment is often too small
Fragment Fractures
and distal for adequate fixation using a standard volar lock-
ing plate (VLP).3 The fracture fragment is not readily visible Since the introduction of VLP for the treatment of distal
in X-rays or intraoperatively without adequate distal expo- radius fractures over 20 years ago,8 we have had many
sure. Failure to recognize its presence can result in subse- occasions to learn from failed VMFs. After observing the
quent loss of reduction, bony resorption, and carpal spectrum of outcomes following treatment of this problem,
dislocation. These complications can present at any time we have identified trends based on chronicity and patient
after VLP.1 characteristics. In the first few weeks, we have observed the
A high index of suspicion and careful attention to radio- fragment can be successfully treated using standard meth-
graphs is necessary to identify this fragment in preoperative ods. These patients tend to have outcomes comparable to
imaging. Computer tomography (CT) can define the details of acutely treated VMFs. Once a VMF has been displaced for

received © 2021. Thieme. All rights reserved. DOI https://doi.org/

May 17, 2021 Thieme Medical Publishers, Inc., 10.1055/s-0041-1735885.
accepted 333 Seventh Avenue, 18th Floor, ISSN 2163-3916.
August 2, 2021 New York, NY 10001, USA
published online
December 13, 2021
220 Failed Fixation of VMF Orbay and Orbay

more than a few weeks, the fragment resorbs, making Type I (0–4 weeks): Expeditious Revision
revision surgery much more difficult. Outcomes during
this time are less favorable. Finally, in late cases, we have Fractures with a missed VMF can present with acute loss of
observed irreversible chondral damage, ultimately requiring fixation and volar carpal subluxation at the first postopera-
arthrodesis. Based on these findings, we propose a classifi- tive visit.6 In this acute setting, the aim of treatment is to
cation system that can help guide treatment, predict out- stabilize the fracture and carpus, as in a primary case. We use
comes, and set patient expectations. This system is based on the principles developed for the acute fractures.2,4,5,7 As
time from original operative intervention and whether the further delay will compromise the outcome, it is best to
VMF was originally identified and specifically addressed. proceed expeditiously with revision surgery once the con-
cerns have been identified. The surgeon should focus on
Type I: Acute Displacement of VMFs following Initial adequate exposure, stable fixation, and give strong consid-
ORIF (0–4 Weeks) eration to the use of a neutralization device such as a bridge
Acutely failed VMFs are identified within 4 weeks following plate.9
initial surgical intervention. Patients presenting in this man- Inadequate surgical exposure can result in failure to

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ner are often young, with good bone quality, and most often identify the fragment or inadequate fixation; we think it is
experience a failed VMF due to failure to appropriately important to ensure that the exposure is good, such as that
address the fragment in the initial surgery. Postoperative achieved with an extended flexor carpi radialis (FCR) ap-
imaging will reveal the displaced fragment and volar sub- proach. Therefore, distal release of the FCR to the level of the
luxation of the carpus (►Fig. 1). trapezium allows retraction of the median nerve and flexor
tendons in an ulnar direction. This allows full exposure of the
Type II: Subacute Identification of the Failed VMF (4 volar distal radius to the watershed line and allows visuali-
Weeks—4 Months) zation of the VMF, which may not have been accomplished
In the subacute cases, there is progressive subluxation and during the original procedure. Elevating the thick distal
subchondral collapse of the volar aspect of the radiolunate periosteum to the level of the watershed line permits access
articulation. These patients are often older patients with to and reduction of the unstable VMF.10
poor bone quality. Bony resorption makes fixation more Several methods have been described to stabilize a VMF
difficult, and standard internal fixation is unlikely to be that cannot be adequately addressed with the buttressing
effective. surface of a VLP: K-wires, small screws, tension bands, hook
plates, and hook plates extensions.2,4,5,7–9,11,12 The latter
Type III: Chronic Failed VMF Fixation (Greater than 4 option is a modular addition to a standard VLP, which allows
Months) the decision to stabilize the fragment to be made at the end of
In chronic cases, the lunate may be eroded and articulating the procedure.
with the VLP or screws. These can present irreversible An augmentation to the revision procedure is the dorsal
degenerative changes of the radiocarpal articulation and bridge plate, which works as a neutralization device. The
require a reconstructive or salvage procedure such as a VMF needs to be addressed separately from the volar side, as
partial or total wrist arthrodesis. described below. The dorsal bridge plate is an excellent tool
to align the joint and neutralize the forces applied to the VMF.
Management of Failed VMFs Based on Chronology and The dorsal bridge plate is applied distally to the second or
Fragment Viability third metacarpal and proximally to the radial shaft by small
The assessment and subsequent classification enable a better separate incisions (►Fig. 2). The bridge plate is most often
understanding of these complex revision cases. The classifi- left in situ for around 12 weeks to ensure adequate fracture
cation type helps define the principles of surgical manage- healing prior to removal. Return of motion is often incom-
ment (►Table 1). plete but sufficient for acceptable function.12

Table 1 Classification and treatment strategies for failed fixation of VMF

Failed VMF type Time frame Common patient characteristics Suggested procedures
Type I 0–4 weeks Young, good bone quality. VMF often Revision with adequate exposure and
not properly addressed during initial good fixation of VMF þ/ bridge plate
fixation
Type II 4 weeks–4 months Older, poor bone quality. Often VMF Metaphyseal bone grafting,
does not grossly displace but resorbs in restoration of articular surface, bridge
situ plating, or opening wedge osteotomy
Type III > 4 months Chronic, long-standing injury. Proximal row to radius fusion or total
Degenerative changes. Lunate erosion wrist fusion
by hardware

Abbreviation: VMF, volar marginal fragment.

Journal of Wrist Surgery Vol. 11 No. 3/2022 © 2021. Thieme. All rights reserved.
 Failed Fixation of VMF Orbay and Orbay 221

Type II (4 weeks–4 months): Reconstruction,

Bone Grafting, and Joint Unloading
Unfortunately, many patients do not present within the first
4 weeks following surgery and require more advanced
techniques to address the rapid resorption of the fragment.5
During the process of avascular necrosis and bone resorp-
tion, cancellous bone fails first, which ultimately results in
subchondral fracture and collapse.13 This progression can be
seen in the failed VMF. Therefore, a significant metaphyseal
defect is present underneath the fragment, although the
cartilage surface and subchondral plate may still be viable.
The areas of bone reabsorption require bone grafting to
support the collapsed joint surface. Bone grafting and fixa-

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tion of the fragment should be paired with a neutralization
procedure.
The load transmitted by the lunate to the distal radius is
preferentially applied at its volar aspect.14 Therefore, it is
useful to neutralize or redirect these forces, which result in
Fig. 1 Anteroposterior and lateral radiographs of a patient who
volar subluxation and VMF displacement. The use of a
presented 2 weeks following attempted fixation of a complex fracture
with a standard volar locked plate and Kirschner wires. Failure of neutralization device such as a bridge plate or an external
fixation is evident on the lateral radiograph (arrow) with a “tear drop fixator will unload the VMF. Both techniques can be used at
angle” greater than 70 degrees and the carpus subluxated. Subluxa- any time after the initial injury, as they do not require healing
tion is confirmed, as the center of the lunate is palmar to the volar of the other fracture planes. External fixators can be removed
radial cortex (longitudinal line).
in the clinic but are cumbersome and can present pin tract
problems.15 Bridge plates are better tolerated than external
fixators but require a second surgical procedure for
removal.8
Another method to unload the VMF after its reduction and
grafting is the volar opening wedge osteotomy. This proce-
dure redirects joint forces to the dorsal aspect of the lunate
fossa and facilitates stable reduction of the carpus.5 This is a
useful technique when other fracture planes have already
healed. We have observed these cases display a positive ulnar
variance and an excessive volar tilt. A volar opening wedge
osteotomy redirects the articular surface in a dorsal direction
to unload the VMF and stabilize the carpus while simulta-
neously lengthening the radius to correct ulnar variance and
additionally stabilize the DRUJ.5,16 This osteotomy usually
requires bone grafting. A sagittal saw is used to create a volar
osteotomy of the metaphyseal radius, leaving a dorsal hinge
to rotate around. The goal of the osteotomy is to achieve
neutral or slight dorsal tilt. Radial inclination and length can
be addressed simultaneously. The defect can then be filled
with bone graft17 (►Figs. 3 and 4).
Finally, techniques to fix and unload the VMF can be used
in combination depending on the severity of the situation
(►Fig. 5).

Type III (Greater than 4 Months): Irreversible

Chondral Damage Requiring a Salvage
Procedure
Joints that persist in a malaligned state for a protracted
period may result in degenerative arthritis. In the setting
Fig. 2 Anteroposterior and lateral radiographs of revision fixation of
the failed volar marginal fragment (VMF). The VMF was captured
of prolonged carpal subluxation, resulting in chondral de-
volarly using an extension hook plate. Dorsal bridge plate fixation struction, reconstructive options are limited, and salvage
neutralized the joint forces and maintained reduction of the carpus. operations are often necessary. Proximal row to radius (PRR)

Journal of Wrist Surgery Vol. 11 No. 3/2022 © 2021. Thieme. All rights reserved.
222 Failed Fixation of VMF Orbay and Orbay

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Fig. 3 Lateral radiograph taken 3 months after fixation of distal radius
fracture with volar marginal fragment. Resorption of the fracture
fragment has resulted in subchondral collapse, volar subluxation of
the carpus, and articulation of the lunate against the plate (circle). Fig. 5 Multiple combined techniques: volar tilt corrected to neutral
with a volar opening wedge osteotomy and supported with cortico-
cancellous autograft. An extension hook plate used to capture the
volar marginal fragment. A dorsal bridge plate used to unload the
articular surface and aid with radiocarpal reduction. The lunate was
temporarily pinned to the radius with Kirschner wires.

Fig. 4 Anteroposterior and lateral radiographs taken 5 months after

volar opening wedge osteotomy. Note the volar plate was bent to Fig. 6 Anteroposterior and lateral radiographs taken 6 months following
deliver neutral tilt. Autologous corticocancellous bone graft was used proximal row to radius fusion. The relationship between the scaphoid and
to support the volar rim and fill the bony void below the lunate facet. the lunate was preserved by not interrupting the scapholunate ligament
Patient maintained functional range of motion and had significant and initially preserving the interval between these two carpal bones. The
improvement of pain following intervention. Consideration should be radial and proximal chondral surfaces of the scaphoid and lunate are
given to subsequent plate removal. partially decorticated with a small burr following fixation and grafted with
autologous graft obtained from the distal radius.

fusion is a motion-preserving procedure that will maintain

functional motion despite the radiocarpal articulation.15 It is PRR fusion is performed through a standard dorsal ap-
often combined with excision of the distal pole of the proach to the carpus. The subluxated carpus is reduced.
scaphoid to increase resultant motion17 (►Fig. 6). A total Fixation of the scaphoid and lunate to the radius is performed
wrist arthrodesis is the salvage option for the most severe prior to decortication of the joint surfaces, as this is a simple
cases in which both proximal and distal wrist articulations method of preserving the relationship between the capitate,
are destroyed. scaphoid, and lunate. Fixation options include screws, plates

Journal of Wrist Surgery Vol. 11 No. 3/2022 © 2021. Thieme. All rights reserved.
 Failed Fixation of VMF Orbay and Orbay 223

or K wires. Once fixation is performed, the distal radius and 2 Benis S, Vanhove W, Hollevoet N. Volar plate fixation in intra-
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infrequent. Here, we have presented our proposed algorithm 6 Andermahr J, Lozano-Calderon S, Trafton T, Crisco JJ, Ring D. The
for the management of the failed VMF (►Table 1). Treatment volar extension of the lunate facet of the distal radius: a quanti-
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J.L.O. is a consultant for Skeletal Dynamics. J.L.O. is the first model to examine bone adaptation in humans: a pilot study. J
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Journal of Wrist Surgery Vol. 11 No. 3/2022 © 2021. Thieme. All rights reserved.