JBJS | Treatment of Displaced Intra-Articular Fractures of the Distal End of the Radius with Plates*

The Journal of Bone & Joint Surgery, Volume 79, Issue 9

Articles | September 01, 1997

Treatment of Displaced Intra-Articular Fractures of the Distal End of the Radius with Plates*

F. FITOUSSI, M.D.†; W. Y. IP, F.R.C.S.(ED)‡; S. P. CHOW, M.S., F.R.C.S.(ED)‡, HONG KONG

Investigation performed at the Department of Orthopaedic Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong

The Journal of Bone & Joint Surgery. 1997; 79:1303-12

5 Recommendations (Recommend) | 3 Comments | Saved by 3 Users Save Case

text A A A

Abstract

Thirty-four displaced intra-articular fractures of the distal aspect of the radius in thirty-four patients were treated with open reduction and internal fixation with plates and screws. Although there was a high rate of complications (nine [26 per cent] of thirty-four fractures), twenty-eight patients (82 per cent) had a good or excellent result according to the system of Gartland and Werley and twenty patients (59 per cent) had a good or excellent result according to the modified system of Green and O'Brien at the most recent evaluation. Immediately postoperatively, the articular surface of the distal aspect of the radius was restored to a mean of 2 degrees of volar tilt and 20 degrees of radial angulation and radial length was improved by a mean of ten millimeters compared with the preoperative length. The articular surface was restored to congruity or to at most one millimeter of step-off in twenty-six patients (76 per cent). By the time of the most recent evaluation, the initial postoperative alignment had changed markedly in three patients (9 per cent) and degenerative osteoarthrosis (grade II or III) had developed in six patients (18 per cent). We considered that the initial postoperative alignment had changed markedly when the articular surface was displaced by two millimeters or more, when the extra-articular alignment had changed by more than 10 degrees of radial tilt, or when there was more than five millimeters of radial shortening. The potential for restoration of normal alignment and the stability of the fixation are the main advantages of internal fixation with plates. Restoration of congruity to the joint was the major difficulty in this group of patients.

Figures in this Article

Introduction

Introduction | Materials and Methods | Results | Discussion | References

Fractures of the distal aspect of the radius continue to pose a therapeutic challenge. Some of these fractures are caused by severe high-energy trauma, resulting in intra-articular involvement and comminution. Treatment of such injuries is difficult. These fractures often are unstable, are difficult to reduce anatomically, and are associated with a high prevalence of complications^{2,4,6,8,11,12,14,15,17,18}. Knirk and Jupiter¹⁸ reported a 65 per cent prevalence (twenty-eight patients) of post-traumatic osteoarthrosis after intra-articular fracture of the distal aspect of the radius in forty-three young adults and demonstrated a strong correlation between residual articular incongruity and osteoarthrosis. It is also known that extra-articular malalignment can lead to decreased grip strength and endurance²⁹ as well as limited motion and carpal instability^4,22,26,30. Restoration of normal alignment and articular congruity after a displaced fracture can be difficult, but it is essential for a good functional result^18,24,28. The results of closed reduction, percutaneous pin fixation, pins and plaster, and internal and external fixation^{1-3,5,6,8-10,12,16,19,20,25} have been variable and have been determined largely by the pattern of the fracture²¹.

In 1987, we initiated a treatment strategy of open reduction and internal fixation with plates and screws for unstable, displaced intra-articular fractures of the distal aspect of the radius. We have managed thirty-four consecutive patients in this manner with palmar compression plates and screws or dorsal compression plates and screws, or both. We describe our experience and the results at regular intervals for as long as two years postoperatively.

*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

†10, Boulevard de l'Est, 93340 Le Raincy, France. E-mail address: ffitouss@pratique.fr. Please address requests for reprints to Dr. Fitoussi.

‡Department of Orthopaedic Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong.

*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

†10, Boulevard de l'Est, 93340 Le Raincy, France. E-mail address: ffitouss@pratique.fr. Please address requests for reprints to Dr. Fitoussi.

‡Department of Orthopaedic Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong.

View Larger

TABLE I CLINICAL DATA ON THE PATIENTS

*The fractures were also classified according to the Frykman¹⁴ system: nineteen fractures were type VIII, nine were type VII, five were type IV, and one was type III.†The ulnar and radial deviation for Cases 3 and 13 were measured at one year but not at the most recent evaluation.*Compared with the hand on the uninjured side and multiplied by an appropriate ratio (115 per cent) for the dominant limb⁷.

													Result
				Type of Fixation Plate		Range of Motion at Most Recent Follow-up Evaluation (Degrees)						Postop. Grid Strength‡	Modified System of Green and O'Brien¹³	System of Gartland and Werley¹⁵

	Gender,	AO	Bone-		Palmar	Dorsi-	Supi-	Pro-	Ulnar	Radial
Case	Age	Type²⁷*	Grafting	Complication	Flexion	flexion	nation	nation	Deviation†	Deviation†
	(Yrs.)											(Per cent)
1	M, 37	C3	No	Palmar	Median neuropathy	50	62	110	45	28	10	73	Fair	Good
2	M, 58	C1	No	Palmar	Median neuropathy	56	55	130	60	15	15	78	Good	Excellent
3	M, 41	C2	Yes	Dorsal	Infection around Kirschner wire	50	40	80	40	—	—	40	Poor	Fair
4	M, 40	C2	No	Dorsal	Shoulder-hand syndrome	38	35	95	75	20	15	71	Fair	Good
5	M, 23	C1	No	Dorsal		85	72	110	60	40	20	91	Excellent	Excellent
6	M, 57	C3	Yes	Double		50	46	95	65	21	20	75	Good	Excellent
7	M, 51	C3	Yes	Dorsal		58	68	95	64	40	8	71	Fair	Good
8	M, 32	C3	No	Double		41	56	93	75	13	12	55	Fair	Good
9	M, 33	C3	No	Dorsal		48	50	100	65	25	10	84	Fair	Good
10	M, 33	C1	No	Palmar		67	67	104	50	17	26	60	Good	Excellent
11	M, 33	C2	Yes	Palmar		90	60	120	45	30	21	85	Excellent	Excellent
12	M, 34	C3	Yes	Double		65	55	86	56	19	10	72	Excellent	Excellent
13	M, 39	C3	No	Double	Rupture of extensor pollicis longus	55	45	100	63	—	—	84	Good	Excellent
14	M, 50	C2	Yes	Palmar		35	42	95	55	27	15	44	Fair	Good
15	M, 50	C3	Yes	Dorsal		27	40	85	80	24	15	43	Fair	Fair
16	M, 16	C1	No	Dorsal		72	65	103	95	20	22	98	Excellent	Excellent
17	M, 39	C3	Yes	Double		65	56	95	73	35	13	67	Good	Excellent
18	M, 40	C3	Yes	Double		42	70	85	73	23	13	94	Good	Excellent
19	M, 43	C3	Yes	Palmar		65	40	75	74	14	5	67	Fair	Fair
20	M, 42	C3	No	Dorsal		15	28	25	56	20	0	43	Poor	Fair
21	M, 48	C2	Yes	Palmar		64	46	84	62	22	17	75	Good	Excellent
22	M, 44	C3	Yes	Double		54	42	90	88	22	16	83	Good	Fair
23	M, 31	C2	No	Dorsal		78	65	90	90	38	25	83	Excellent	Excellent
24	M, 46	C3	Yes	Double	Displaced plate, median neuropathy	40	50	40	78	25	10	92	Fair	Fair
25	M, 51	C2	No	Dorsal		45	48	85	80	40	18	123	Excellent	Excellent
26	M, 29	C2	No	Dorsal		45	70	90	70	33	10	77	Good	Good
27	M, 44	C2	No	Dorsal	Shoulder-hand syndrome	53	55	85	80	30	16	72	Fair	Excellent
28	M, 52	C3	Yes	Double		25	28	67	50	18	10	76	Fair	Good
29	F, 52	C2	Yes	Double		55	55	92	85	45	17	64	Good	Excellent
30	M, 42	C2	Yes	Palmar		52	55	72	75	33	18	108	Excellent	Excellent
31	F, 58	C2	Yes	Double		43	40	70	70	22	10	60	Fair	Good
32	F, 60	C2	No	Double	Median neuropathy	49	55	86	70	21	8	75	Good	Good
33	F, 43	C3	Yes	Dorsal		56	66	80	84	45	8	100	Excellent	Excellent
34	M, 43	C3	No	Palmar		40	35	78	65	20	20	87	Good	Good
Mean	42					52	52	88	68	26	14	76

Add to My JBJS

TABLE I CLINICAL DATA ON THE PATIENTS

													Result
				Type of Fixation Plate		Range of Motion at Most Recent Follow-up Evaluation (Degrees)						Postop. Grid Strength‡	Modified System of Green and O'Brien¹³	System of Gartland and Werley¹⁵

	Gender,	AO	Bone-		Palmar	Dorsi-	Supi-	Pro-	Ulnar	Radial
Case	Age	Type²⁷*	Grafting	Complication	Flexion	flexion	nation	nation	Deviation†	Deviation†
	(Yrs.)											(Per cent)
1	M, 37	C3	No	Palmar	Median neuropathy	50	62	110	45	28	10	73	Fair	Good
2	M, 58	C1	No	Palmar	Median neuropathy	56	55	130	60	15	15	78	Good	Excellent
3	M, 41	C2	Yes	Dorsal	Infection around Kirschner wire	50	40	80	40	—	—	40	Poor	Fair
4	M, 40	C2	No	Dorsal	Shoulder-hand syndrome	38	35	95	75	20	15	71	Fair	Good
5	M, 23	C1	No	Dorsal		85	72	110	60	40	20	91	Excellent	Excellent
6	M, 57	C3	Yes	Double		50	46	95	65	21	20	75	Good	Excellent
7	M, 51	C3	Yes	Dorsal		58	68	95	64	40	8	71	Fair	Good
8	M, 32	C3	No	Double		41	56	93	75	13	12	55	Fair	Good
9	M, 33	C3	No	Dorsal		48	50	100	65	25	10	84	Fair	Good
10	M, 33	C1	No	Palmar		67	67	104	50	17	26	60	Good	Excellent
11	M, 33	C2	Yes	Palmar		90	60	120	45	30	21	85	Excellent	Excellent
12	M, 34	C3	Yes	Double		65	55	86	56	19	10	72	Excellent	Excellent
13	M, 39	C3	No	Double	Rupture of extensor pollicis longus	55	45	100	63	—	—	84	Good	Excellent
14	M, 50	C2	Yes	Palmar		35	42	95	55	27	15	44	Fair	Good
15	M, 50	C3	Yes	Dorsal		27	40	85	80	24	15	43	Fair	Fair
16	M, 16	C1	No	Dorsal		72	65	103	95	20	22	98	Excellent	Excellent
17	M, 39	C3	Yes	Double		65	56	95	73	35	13	67	Good	Excellent
18	M, 40	C3	Yes	Double		42	70	85	73	23	13	94	Good	Excellent
19	M, 43	C3	Yes	Palmar		65	40	75	74	14	5	67	Fair	Fair
20	M, 42	C3	No	Dorsal		15	28	25	56	20	0	43	Poor	Fair
21	M, 48	C2	Yes	Palmar		64	46	84	62	22	17	75	Good	Excellent
22	M, 44	C3	Yes	Double		54	42	90	88	22	16	83	Good	Fair
23	M, 31	C2	No	Dorsal		78	65	90	90	38	25	83	Excellent	Excellent
24	M, 46	C3	Yes	Double	Displaced plate, median neuropathy	40	50	40	78	25	10	92	Fair	Fair
25	M, 51	C2	No	Dorsal		45	48	85	80	40	18	123	Excellent	Excellent
26	M, 29	C2	No	Dorsal		45	70	90	70	33	10	77	Good	Good
27	M, 44	C2	No	Dorsal	Shoulder-hand syndrome	53	55	85	80	30	16	72	Fair	Excellent
28	M, 52	C3	Yes	Double		25	28	67	50	18	10	76	Fair	Good
29	F, 52	C2	Yes	Double		55	55	92	85	45	17	64	Good	Excellent
30	M, 42	C2	Yes	Palmar		52	55	72	75	33	18	108	Excellent	Excellent
31	F, 58	C2	Yes	Double		43	40	70	70	22	10	60	Fair	Good
32	F, 60	C2	No	Double	Median neuropathy	49	55	86	70	21	8	75	Good	Good
33	F, 43	C3	Yes	Dorsal		56	66	80	84	45	8	100	Excellent	Excellent
34	M, 43	C3	No	Palmar		40	35	78	65	20	20	87	Good	Good
Mean	42					52	52	88	68	26	14	76

View Larger

TABLE II RADIOGRAPHIC DATA IMMEDIATELY POSTOPERATIVELY

Case	Radial Length	Radial Inclination	Tilt*	Radio-Ulnar Index†	Gap	Step-off
	(mm)	(Degrees)	(Degrees)	(mm)	(mm)	(mm)
1	11	20	10	0	1	1
2	3	12	-22	—	0	0
3	3	7	-4	1	3	2
4	7	9	14	-3	0	2
5	13	23	10	0	0	0
6	9	25	5	2	1	1
7	16	30	-18	1	1	1
8	2	13	6	2	3	2
9	11	20	-3	0	0	0
10	3	16	0	4	0	0
11	11	11	9	-4	0	1
12	9	22	7	-2	1	1
13	13	26	5	—	1	1
14	13	18	1	-2	2	1
15	6	20	5	1	0	0
16	14	20	9	0	0	0
17	9	15	0	0	0	0
18	12	23	0	—	2	2
19	4	15	-5	—	0	0
20	9	23	3	4	2	3
21	10	19	-17	-1	0	0
22	15	33	0	4	5	5
23	8	17	5	-1	0	0
24	19	36	20	4	0	0
25	13	20	11	-2	2	0
26	11	23	9	1	1	1
27	11	25	0	0	0	1
28	12	26	0	0	1	2
29	13	28	13	-1	0	0
30	11	20	-5	-1	1	1
31	3	5	-5	2	0	0
32	7	21	0	2	0	0
33	9	22	7	1	0	0
34	12	15	5	-2	2	2
Mean	10	20	2	0	1	1

Add to My JBJS

TABLE II RADIOGRAPHIC DATA IMMEDIATELY POSTOPERATIVELY

Case	Radial Length	Radial Inclination	Tilt*	Radio-Ulnar Index†	Gap	Step-off
	(mm)	(Degrees)	(Degrees)	(mm)	(mm)	(mm)
1	11	20	10	0	1	1
2	3	12	-22	—	0	0
3	3	7	-4	1	3	2
4	7	9	14	-3	0	2
5	13	23	10	0	0	0
6	9	25	5	2	1	1
7	16	30	-18	1	1	1
8	2	13	6	2	3	2
9	11	20	-3	0	0	0
10	3	16	0	4	0	0
11	11	11	9	-4	0	1
12	9	22	7	-2	1	1
13	13	26	5	—	1	1
14	13	18	1	-2	2	1
15	6	20	5	1	0	0
16	14	20	9	0	0	0
17	9	15	0	0	0	0
18	12	23	0	—	2	2
19	4	15	-5	—	0	0
20	9	23	3	4	2	3
21	10	19	-17	-1	0	0
22	15	33	0	4	5	5
23	8	17	5	-1	0	0
24	19	36	20	4	0	0
25	13	20	11	-2	2	0
26	11	23	9	1	1	1
27	11	25	0	0	0	1
28	12	26	0	0	1	2
29	13	28	13	-1	0	0
30	11	20	-5	-1	1	1
31	3	5	-5	2	0	0
32	7	21	0	2	0	0
33	9	22	7	1	0	0
34	12	15	5	-2	2	2
Mean	10	20	2	0	1	1

View Larger

TABLE III RADIOGRAPHIC DATA AT THE MOST RECENT FOLLOW-UP EXAMINATION

*A positive number indicates volar tilt, and a negative number indicates dorsal tilt.†The position of the wrist and forearm on the radiographs prevented precise measurement of the radio-ulnar index in some patients.‡The position of the wrist and forearm on the radiographs prevented precise measurements for this patient.

Case	Radial Length	Radial Inclination	Tilt*	Radio-Ulnar Index†	Loss of Reduction	Grade of Osteoarthrosis¹⁸
	(mm)	(Degrees)	(Degrees)	(mm)
1	10	23	0	0	No	0
2	3	12	-23	-1	No	0
3	3	5	-3	1	No	III
4‡	—	—	—	—	No	0
5	12	22	10	0	No	0
6	10	25	5	2	No	0
7	11	20	-9	2	No	I
8	2	15	5	3	No	II
9	9	25	19	3	Yes	0
10	0	10	-12	5	Yes	0
11	13	12	8	-3	No	0
12	10	22	6	-2	No	0
13	15	26	7	0	No	0
14	12	18	0	-2	No	0
15	6	20	5	1	No	0
16	13	20	9	0	No	0
17	8	14	3	—	No	0
18	10	18	0	—	No	II
19	5	16	-4	—	No	0
20	7	25	0	5	No	III
21	12	21	-15	-1	No	0
22	6	21	20	8	Yes	II
23	10	19	4	-1	No	0
24	16	37	20	4	No	0
25	9	18	10	0	No	0
26	13	23	9	1	No	0
27	10	29	3	2	No	0
28	12	28	0	1	No	I
29	14	30	15	-1	No	0
30	12	23	0	-1	No	0
31	4	10	-5	2	No	0
32	9	24	0	2	No	0
33‡	—	—	—	—	No	0
34	11	15	5	-2	No	II
Mean	9	20	3	1

Add to My JBJS

TABLE III RADIOGRAPHIC DATA AT THE MOST RECENT FOLLOW-UP EXAMINATION

Case	Radial Length	Radial Inclination	Tilt*	Radio-Ulnar Index†	Loss of Reduction	Grade of Osteoarthrosis¹⁸
	(mm)	(Degrees)	(Degrees)	(mm)
1	10	23	0	0	No	0
2	3	12	-23	-1	No	0
3	3	5	-3	1	No	III
4‡	—	—	—	—	No	0
5	12	22	10	0	No	0
6	10	25	5	2	No	0
7	11	20	-9	2	No	I
8	2	15	5	3	No	II
9	9	25	19	3	Yes	0
10	0	10	-12	5	Yes	0
11	13	12	8	-3	No	0
12	10	22	6	-2	No	0
13	15	26	7	0	No	0
14	12	18	0	-2	No	0
15	6	20	5	1	No	0
16	13	20	9	0	No	0
17	8	14	3	—	No	0
18	10	18	0	—	No	II
19	5	16	-4	—	No	0
20	7	25	0	5	No	III
21	12	21	-15	-1	No	0
22	6	21	20	8	Yes	II
23	10	19	4	-1	No	0
24	16	37	20	4	No	0
25	9	18	10	0	No	0
26	13	23	9	1	No	0
27	10	29	3	2	No	0
28	12	28	0	1	No	I
29	14	30	15	-1	No	0
30	12	23	0	-1	No	0
31	4	10	-5	2	No	0
32	9	24	0	2	No	0
33‡	—	—	—	—	No	0
34	11	15	5	-2	No	II
Mean	9	20	3	1

View Large | Download Slide(.ppt)
Add to My JBJS

FIG1-A:: Figs. 1-A through 1-F: Case 6, a fifty-seven-year-old man who sustained an AO type-C3 fracture²⁷ of the left wrist in a fall from a height. Figs. 1-A and 1-B: Anteroposterior and lateral radiographs made at the time of the injury.

View Large | Download Slide(.ppt)
Add to My JBJS

FIG1-B:: Fig. 1-B: Anteroposterior and lateral radiographs made at the time of the injury.

View Large | Download Slide(.ppt)
Add to My JBJS

FIG1-C:: Fig. 1-C Anteroposterior and lateral radiographs made after unsatisfactory closed reduction and application of a cast.

View Large | Download Slide(.ppt)
Add to My JBJS

FIG1-D:: Fig. 1-D Anteroposterior and lateral radiographs made after unsatisfactory closed reduction and application of a cast.

View Large | Download Slide(.ppt)
Add to My JBJS

FIG1-E:: Fig. 1-E Anteroposterior and lateral radiographs made after application of two plates, showing satisfactory articular congruity and extra-articular alignment.

View Large | Download Slide(.ppt)
Add to My JBJS

FIG1-F:: Fig. 1-F Anteroposterior and lateral radiographs made after application of two plates, showing satisfactory articular congruity and extra-articular alignment.

View Large | Download Slide(.ppt)
Add to My JBJS

FIG2-A:: Figs. 2-A through 2-F: Case 11, a thirty-three-year-old man who had a Frykman type-IV fracture¹⁴ of the left wrist. Figs. 2-A and 2-B: Anteroposterior and lateral radiographs made at the time of the injury.

View Large | Download Slide(.ppt)
Add to My JBJS

FIG2-B:: Fig. 2-B: Anteroposterior and lateral radiographs made at the time of the injury.

View Large | Download Slide(.ppt)
Add to My JBJS

FIG2-C:: Figs. 2-C and 2-D: Anteroposterior and lateral radiographs showing an unsatisfactory closed reduction with an intra-articular step-off of two millimeters.

View Large | Download Slide(.ppt)
Add to My JBJS

FIG2-D:: Fig. 2-D: Anteroposterior and lateral radiographs showing an unsatisfactory closed reduction with an intra-articular step-off of two millimeters.

View Large | Download Slide(.ppt)
Add to My JBJS

FIG2-E:: Figs. 2-E and 2-F: Anteroposterior and lateral radiographs, made after open reduction and internal fixation, showing diastasis of the scapholunate joint and volar instability of the intercalated segment. The scapholunate angle was 30 degrees, the radiolunate angle was -40 degrees, and the capitolunate angle was 38 degrees.

View Large | Download Slide(.ppt)
Add to My JBJS

FIG2-F:: Fig. 2-F: Anteroposterior and lateral radiographs, made after open reduction and internal fixation, showing diastasis of the scapholunate joint and volar instability of the intercalated segment. The scapholunate angle was 30 degrees, the radiolunate angle was -40 degrees, and the capitolunate angle was 38 degrees.

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

Two hundred and ninety-five displaced fractures of the distal aspect of the radius where treated at Queen Mary Hospital between October 1987 and August 1994. Closed reduction was attempted after admission to the hospital and was considered to be satisfactory if there was less than 10 degrees of dorsal angulation, 0 to 20 degrees of radial inclination, less than 20 degrees of volar tilt, less than two millimeters of intra-articular incongruity, and less than two millimeters of radial shortening compared with the measurements on the uninjured side. Sixty of the 295 patients were managed operatively because the attempt at closed reduction had failed or because of secondary displacement. The timing of the operative treatment ranged from the day of the injury to twenty-seven days after the closed reduction. Of these sixty patients, twenty-six had an extra-articular fracture treated with pins and plaster, percutaneous fixation with Kirschner wire, or a plate and screws. Thirty-four patients had a displaced intra-articular fracture treated with open reduction and internal fixation with one plate or two and screws. The latter group is the focus of this study.

The mean age of the patients at the time of the injury was forty-two years (range, sixteen to sixty years). The mechanism of injury was a fall on level ground for nine patients, a fall from a height for eighteen, a motor-vehicle accident for four, a sporting accident for two, and a crush injury for one. Three patients had a concomitant ipsilateral injury: two had a fracture of the scaphoid, and one had a fracture of a distal phalanx. One fracture was open. The dominant hand was involved in fourteen patients. A median neuropathy was noted at the time of the initial examination in four patients, three of whom had a release of the transverse carpal ligament at the time of the open reduction. In the fourth patient, the symptoms of median neuropathy resolved after closed reduction and immobilization of the fracture. This patient subsequently had open reduction and internal fixation because of secondary displacement.

The fractures were classified with the AO²⁷ and Frykman¹⁴ systems on the basis of the findings on lateral and anteroposterior radiographs (Table I). The AO classification is based on the presence or absence of intra-articular involvement of the distal aspect of the radius, the number and location of intra-articular fragments, and the presence or absence of metaphyseal involvement. The Frykman classification is based on the presence or absence of intra-articular involvement of either the radiocarpal or the distal radio-ulnar joint. Seventeen fractures were AO type C3 (Figs. 1-A and 1-B), thirteen were type C2, and four were type C1. Nineteen of the fractures were classified as Frykman type VIII; nine, as type VII; five, as type IV; and one, as type III. Computerized tomography scans and tomograms were not used in this study.

Treatment

A dorsal plate only was used in thirteen patients who had dorsal displacement of the fracture, and a palmar plate only was used in nine patients who had palmar displacement (Figs. 2-A, 2-B, 2-C, 2-D, 2-E, and 2-F). Twelve patients were managed with both a palmar and a dorsal plate because of a comminuted fracture or because a single plate was inadequate to maintain reduction or to restore the articular surface (Figs. 1-A, 1-B, 1-C, 1-D, 1-E and 1-F). Any so-called die-punch fragments²⁸ (central depression of the articular surface of the lunate fossa) with the attached inferior aspect of the dorsal radio-ulnar ligament were fixed with screws; Kirschner wire; or, in five patients, a mattress suture attached to one of the holes of the T-plate.

Cancellous bone graft was used in eighteen patients to reconstruct osseous defects in the distal metaphyseal region of the radius after reduction (Table I). Supplementary Kirschner wires were used in addition to the plates and screws in fourteen patients.

A splint was used to support the wrist and forearm for three to four weeks after the operation, and a passive range-of-motion program for the wrist was started after this period. An active range-of-motion program was started one to two weeks after the splint was removed.

Clinical Evaluation

A functional evaluation was performed ten weeks, six months, one year, and two years after the injury. Pain, swelling, grip and pinch strength, sensibility, and the range of motion of the wrist and forearm were evaluated at each assessment. The range of motion of the injured limb was expressed as a percentage of that of the uninjured limb. The grip strength of the hand on the side of the injury, as measured with a Jamar adjustable dynamometer (Asimow Engineering, Los Angeles, California), was compared with that of the contralateral hand, and the result was expressed as a corrected percentage after multiplying by an appropriate ratio (115 per cent) for the dominant limb⁷.

Radiographic Evaluation

Anteroposterior and lateral radiographs of the injured wrist were assessed after the definitive treatment and at the time of the most recent evaluation. Any loss of articular congruity, as demonstrated by an intra-articular step-off or gap, was measured. Radial inclination, radial length compared with that on the uninjured side, volar or dorsal tilt, and the radio-ulnar index were calculated. Radial length is defined as the distance between two lines perpendicular to the long axis of the radius: one through the distal tip of the radial styloid process and one through the most distal aspect of the articular surface of the ulna. The normal mean length is eleven to twelve millimeters²³. The radio-ulnar index, or ulnar variance, is defined on a posteroanterior radiograph, made with the wrist in a neutral position, as neutral, positive (plus), or negative (minus) depending on whether the distal articular surface of the ulna is at the same level as, distal to, or proximal to the distal articular surface of the radius²³. The scapholunate gap; the radiolunate, capitolunate, and scapholunate angles; and the carpal-height ratio were measured in order to assess radiographic evidence of carpal instability^13,23.

Osteoarthrosis of the radiocarpal joint was graded at the most recent evaluation according to the criteria of Knirk and Jupiter¹⁸. Grade 0 indicates no osteoarthrosis; grade I, slight narrowing of the joint space; grade II, marked narrowing of the joint space and the formation of osteophytes; and grade III, bone on bone and the formation of osteophytes and cysts.

The data were quantified with two scoring systems: the modified system of Green and O'Brien¹³, with which subjective and objective clinical data are used to determine a score, and the system of Gartland and Werley¹⁵, with which clinical and radiographic data are used. The result for each fracture was graded as excellent, good, fair, or poor with use of both scoring systems.

Statistical Analysis

There were two occasions on which to count occurrences of one characteristic at each level of another characteristic. Therefore, a chi-square analysis for non-parametric ordinal variables was used on observed contingency tables in order to find possible associations between variables. The level of significance was p = 0.05.

Results

Introduction | Materials and Methods | Results | Discussion | References

All thirty-four patients were evaluated ten weeks, six months, one year, and two years after the injury.

At the most recent follow-up evaluation, seventeen wrists (50 per cent) had an excellent result, eleven (32 per cent) had a good result, and six (18 per cent) had a fair result, according to the system of Gartland and Werley¹⁵. According to the modified system of Green and O'Brien¹³, eight wrists (24 per cent) had an excellent result, twelve (35 per cent) had a good result, twelve had a fair result, and two (6 per cent) had a poor result (Table I).

The mean range of motion at the most recent follow-up evaluation was 52 degrees (range, 15 to 90 degrees) of palmar flexion, 52 degrees (range, 28 to 72 degrees) of dorsiflexion, 26 degrees (range, 13 to 45 degrees) of ulnar deviation, 14 degrees (range, 0 to 26 degrees) of radial deviation, 88 degrees (range, 25 to 130 degrees) of supination, and 68 degrees (range, 40 to 95 degrees) of pronation (Table I). The ulnar and radial deviation for two patients (Cases 3 and 13) were measured at one year but were not measured at the latest follow-up examination. Ten patients had less than 45 degrees of dorsiflexion.

The mean grip strength on the injured side was 76 per cent (range, 40 to 123 per cent) of that on the uninjured side. Grip strength of less than 60 per cent was highly associated with radial shortening of more than ten millimeters²³ (p < 0.05).

The radial fractures healed at a mean of eight weeks (range, six to ten weeks). Twenty-nine patients (85 per cent) were able to return to their previous occupation.

Radiographic Results

On the immediate postoperative radiographs, the distal articular surface was reduced either to neutral or to less than 15 degrees of volar tilt (inclination of the distal radial articular surface in the sagittal plane on a true lateral radiograph) in twenty-five patients. One patient had more than 15 degrees of volar tilt. Eight patients had dorsal tilt. The entire group had a mean of 2 degrees (range, 22 degrees of dorsal tilt to 20 degrees of volar tilt) of volar tilt, 20 degrees (range, 5 to 36 degrees) of radial inclination, and ten millimeters (range, two to nineteen millimeters) of radial length (Table II).

At the most recent evaluation, three patients had a change in volar tilt of more than 10 degrees or had more than five millimeters of radial shortening compared with the initial postoperative radiographic findings: one patient (Case 9) had progression of volar tilt to 19 degrees, one (Case 10) had progression of dorsal tilt to 12 degrees, and one (Case 22) had progression of volar tilt to 20 degrees as well as nine millimeters of radial shortening. The position of the wrist and forearm on the radiographs of two patients (Cases 4 and 33) prevented precise measurements of these variables. Over-all, there was a mean of 3 degrees (range, 23 degrees of dorsal tilt to 20 degrees of volar tilt) of volar tilt, 20 degrees (range, 5 to 37 degrees) of radial inclination, and nine millimeters (range, zero to sixteen millimeters) of radial length at the most recent follow-up examination (Table III).

The congruity of the distal articular surface of the radius was assessed on the anteroposterior radiographs, and was graded according to the congruity of its subchondral line. On the initial postoperative radiograph, twenty-six patients (76 per cent) had zero or one millimeter of step-off, seven (21 per cent) had two or three millimeters of step-off, and one (3 per cent) had more than three millimeters of step-off (Table II).

Eight patients had evidence of osteoarthrosis of the radiocarpal joint on the most recent radiographs (Table III). Seven of these eight patients had intra-articular incongruity of two millimeters or more. Five of the eight had a fair or poor result according to the modified system of Green and O'Brien¹³. There was an association between articular incongruity of more than two millimeters and osteoarthrosis (p < 0.05).

Complications

The over-all rate of complications was 26 per cent (nine complications in eight patients); some were related to the fracture and some, to the treatment. Median neuropathy developed soon after the injury in four patients (Cases 1, 2, 24, and 32): three had resolution of the symptoms after a carpal tunnel release at the time of the operative treatment, and one had resolution after the initial closed reduction. One patient (Case 13) had rupture of the extensor pollicis longus, which was attributed to mechanical injury from a dorsal plate. The patient was managed with tenorrhaphy and had a good result, according to the modified system of Green and O'Brien¹³, at the most recent evaluation. One patient (Case 24) had displacement of the dorsal articular osseous fragment of a very comminuted fracture that had been treated with two plates. The dorsal plate was replaced, and the most recent result was fair, according to both evaluation systems. One patient (Case 3) had an infection about a Kirschner wire, which was treated non-operatively with application of a dressing. Two patients (Cases 4 and 27) had shoulder-hand syndrome. One of them (Case 4) had limited motion of the fingers and wrist at two years, and the result was fair according to the modified system of Green and O'Brien; the other patient (Case 27) also had a fair result according to the modified system of Green and O'Brien, but he had better motion in palmar flexion and dorsiflexion.

Discussion

Introduction | Materials and Methods | Results | Discussion | References

The outcome of a distal radial fracture is largely determined by its type. The treatment and prognosis for a simple extra-articular fracture cannot be compared with those for a comminuted intra-articular fracture. Extra-articular or non-comminuted intra-articular fractures (AO type A, B, or C1) have generally been associated with good results^3,6,7,10,29. However, the prognosis is much less favorable for displaced comminuted intra-articular fractures such as Frykman type-VII injuries (intra-articular radiocarpal and radio-ulnar involvement without an ulnar fracture) or type-VIII injuries (intra-articular radiocarpal and radio-ulnar involvement with an ulnar fracture), or AO type-C2 injuries (an intra-articular Colles and Smith fracture with metaphyseal comminution) or type-C3 injuries (an intra-articular Colles and Smith fracture with metaphyseal and articular comminution)^5,18,19,25. In the present series, twenty-eight fractures (82 per cent) were classified as Frykman type VII or VIII, and thirty (88 per cent) were classified as AO type C2 or C3.

Scheck²⁸ presented the concept of the die-punch fragment and suggested that restoration of this fragment and other articular fragments was important. Knirk and Jupiter¹⁸ reported that twenty-two (92 per cent) of twenty-four patients who had had a fracture that had healed with two millimeters of articular step-off or more had some radiographic evidence of degenerative changes. According to the system of Gartland and Werley¹⁵, Knirk and Jupiter reported a good or excellent result in only twenty (57 per cent) of the thirty-five patients who had a Frykman type-VII or VIII fracture treated with closed reduction and immobilization in a plaster cast (fifteen fractures), closed reduction and percutaneous pins with immobilization in a plaster cast (fifteen fractures), open reduction and internal fixation (three fractures), or external fixation (two fractures). However, the three patients who had open reduction and internal fixation all had a good result. Melone^24,25 reported a good or excellent result for fifteen patients who had had treatment of a severely displaced articular fracture with open reduction and internal fixation. Axelrod and McMurtry¹ reported restoration of articular congruity in fifteen of seventeen patients who had been managed with open reduction and internal fixation with a posterior plate for a comminuted intra-articular fracture.

Displaced, comminuted, and intra-articular fractures are the most challenging to treat. Anatomical restoration of the articular surface, which is the goal of treatment, is necessary to minimize the risk of post-traumatic osteoarthrosis¹⁸. Anatomical radial length and volar tilt of the articular surface must also be maintained to prevent extra-articular malalignment²⁹. In general, even with comminuted fractures, accurate manipulation and fixation should be used to restore the anatomy of the radiocarpal and distal radio-ulnar joints. All of our patients who had a displaced intra-articular fracture initially had closed reduction. Patients who had an unstable fracture or an unsuccessful closed reduction had open reduction and internal fixation with one plate or two. A dorsal plate was applied if the fracture was displaced dorsally, and a palmar plate was applied if the fracture was displaced palmarly. A second plate was used if reduction could not be maintained or if the articular surface could not be restored with a single plate. The internal fixation technique that we used prevented clinically important displacement (a step-off of two millimeters or more) and loss of reduction in thirty-one patients in this series: the mean loss was 0.5 millimeter of radial length, 0.2 degree of radial inclination, and 0.7 millimeter of radio-ulnar index.

Eight patients in our series had intra-articular incongruity and a clinically important step-off (two to five millimeters)¹⁸; six of these patients had a gap of two to five millimeters. None of the eight patients had had restoration of articular congruity at the time of operative treatment. In the future, the value of arthroscopic evaluation of the radiocarpal joint to assess restoration of the articular surface at the time of reduction should be considered.

The rate of complications was high (26 per cent) after the operations in this series. Cooney et al.¹¹ reported a similarly high rate of complications (31 per cent) in a series of 565 distal radial fractures. We believe that a carpal tunnel release should be performed at the time of operative treatment if symptoms of neuropathy are noted initially and persist until the time of the operation. Moreover, we believe that the dorsal plate should be removed after healing to minimize the risks of extensor tenosynovitis or tendon rupture. In the present series, this plate typically was removed four to six months after the injury. Six patients (18 per cent) had notable osteoarthrotic changes¹⁸ (grade II or III). The maximum two years of follow-up in our series is quite short, and gradual deterioration may occur with time.

In our series, the mean recovery of 52 degrees of dorsiflexion, 52 degrees of palmar flexion, 88 degrees of supination, 68 degrees of pronation, 14 degrees of radial deviation, and 26 degrees of ulnar deviation compares favorably with the criteria of Gartland and Werley¹⁵ for satisfactory function. According to the demerit point system of Gartland and Werley, the rate of excellent or good results for the AO-type C2 and C3 fractures in our series was 80 per cent (twenty-four of thirty). Notably, there was not a striking difference with regard to range of motion of the wrist in the patients who were managed with the double-plate technique compared with those who were managed with one plate.

Despite the complex nature of these injuries and the high rate of complications, the results at the most recent evaluation suggest that open reduction and internal fixation with one plate or two is effective treatment for displaced, unstable intra-articular fractures of the distal aspect of the radius.

References

Introduction | Materials and Methods | Results | Discussion | References

Axelrod, T. S., and McMurtry, R. Y.: Open reduction and internal fixation of comminuted, intraarticular fractures of the distal radius. J. Hand Surg.,15A: 1-11, 1990.15A1 1990

Bacorn, R. W., and Kurtzke, J. F.: Colles' fracture. A study of two thousand cases from the New York State Workmen's Compensation Board. J. Bone and Joint Surg.,35-A: 643-658, July 1953.35-A643 1953

Bassett, R. L.: Displaced intraarticular fractures of the distal radius. Clin. Orthop.,214: 148-152, 1987.214148 1987 [PubMed]

Bickerstaff, D. R., and Bell, M. J.: Carpal malalignment in Colles' fractures. J. Hand Surg.,14-B: 155-160, 1989.14-B155 1989

Bradway, J. K.; Amadio, P. C.; and Cooney, W. P.: Open reduction and internal fixation of displaced, comminuted intra-articular fractures of the distal end of the radius. J. Bone and Joint Surg.,71-A: 839-847, July 1989.71-A839 1989

Chapman, D. R.; Bennett, J. B.; Bryan, W. J.; and Tullos, H. S.: Complications of distal radial fractures: pins and plaster treatment. J. Hand Surg.,7: 509-512, 1982.7509 1982

Chow, S. P.; Fung, K. Y.; Lam, K.; and Ma, A.: Long-term results after Colles' fracture—a computerized statistical analysis study. J. Western Pacific Assn.,21: 37-46, 1984.2137 1984

Cole, J. M., and Obletz, B. E.: Comminuted fractures of the distal end of the radius treated by skeletal transfixion in plaster cast. An end-result study of thirty-three cases. J. Bone and Joint Surg.,48-A: 931-945, July 1966.48-A931 1966

Colles, A.: On the fracture of the carpal extremity of the radius. Edinburgh Med. and Surg. J.,10: 182-186, 1814.10182 1814

Cooney, W. P.: External fixation of distal radial fractures. Clin. Orthop.,180: 44-49, 1983.18044 1983 [PubMed]

Cooney, W. P., III; Dobyns, J. H.; and Linscheid, R. L.: Complications of Colles' fractures. J. Bone and Joint Surg.,62-A: 613-619, June 1980.62-A613 1980

Cooney, W. P., III; Linscheid, R. L.; and Dobyns, J. H.: External pin fixation for unstable Colles' fractures. J. Bone and Joint Surg.,61-A: 840-845, Sept. 1979.61-A840 1979

Cooney, W. P.; Bussey, R.; Dobyns, J. H.;; and Linscheid, R. L.: Difficult wrist fractures. Perilunate fracture-dislocations of the wrist. Clin. Orthop.,214: 136-147, 1987.214136 1987 [PubMed]

Frykman, G.: Fracture of the distal radius including sequelae—shoulder-hand-finger syndrome, disturbance in the distal radio-ulnar joint and impairment of nerve function. A clinical and experimental study. Acta Orthop. Scandinavica, Supplementum 108, 1967.

Gartland, J. J., and Werley, C. W.: Evaluation of healed Colles' fractures. J. Bone and Joint Surg.,33-A: 895-907, Oct. 1951.33-A895 1951

Grana, W. A., and Kopta, J. A.: The Roger Anderson device in the treatment of fractures of the distal end of the radius. J. Bone and Joint Surg.,61-A: 1234-1238, Dec. 1979.61-A1234 1979

Green, D. P.: Pins and plaster treatment of comminuted fractures of the distal end of the radius. J. Bone and Joint Surg.,57-A: 304-310, April 1975.57-A304 1975

Knirk, J. L., and Jupiter, J. B.: Intra-articular fractures of the distal end of the radius in young adults. J. Bone and Joint Surg.,68-A: 647-659, June 1986.68-A647 1986

Leibovic, S. J., and Geissler, W. B.: Treatment of complex intra-articular distal radius fractures. Orthop. Clin. North America,25: 685-706, 1994.25685 1994

Leung, K. S.; Shen, W. Y.; Tsang, H. K.; Chiu, K. H.; Leung, P. C.; and Hung, L. K.: An effective treatment of comminuted fractures of the distal radius. J. Hand Surg.,15A: 11-17, 1990.15A11 1990

Lidstrom, A.: Fracture of the distal end of the radius. A clinical and statistical study of end results. Acta Orthop. Scandinavica,Supplementum 41: 1959.Supplementum 41 1959

Linscheid, R. L.; Dobyns, J. H.; Beabout, J. W.; and Bryan, R. S.: Traumatic instability of the wrist. Diagnosis, classification, and pathomechanics. J. Bone and Joint Surg.,54-A: 1612-1632, Dec. 1972.54-A1612 1972

Mann, F. A.; Wilson, A. J.; and Gilula, L. A.: Radiographic evaluation of the wrist: what does the hand surgeon want to know?. Radiology,184: 15-24, 1992.18415 1992 [PubMed]

Melone, C. P., Jr.: Articular fractures of the distal radius. Orthop. Clin. North America,15: 217-236, 1984.15217 1984

Melone, C. P., Jr.: Open treatment for displaced articular fractures of the distal radius. Clin. Orthop.,202: 103-111, 1986.202103 1986 [PubMed]

Mudgal, C., and Hastings, H.: Scapho-lunate diastasis in fractures of the distal radius. Pathomechanics and treatment options. J. Hand Surg.,18-B: 725-729, 1993.18-B725 1993

Müller, M. E.; Nazarian, S.; and Koch, P.: Classification AO der Fracturen. Berlin, Springer, 1987.

Scheck, M.: Long-term follow-up of treatment of comminuted fractures of the distal end of the radius by transfixation with Kirschner wires and cast. J. Bone and Joint Surg.,44-A: 337-351, March 1962.44-A337 1962

Stewart, H. D.; Innes, A. R.; and Burke, F. D.: Factors affecting the outcome of Colles' fractures: an anatomical and functional study. Injury,16: 289-295, 1985.16289 1985 [PubMed]

Taleisnik, J., and Watson, H. K.: Midcarpal instability caused by malunited fractures of the distal radius. J. Hand Surg.,9A: 350-357, 1984.9A350 1984

Topics

View Large | Download Slide(.ppt)
Add to My JBJS

FIG1-B:: Fig. 1-B: Anteroposterior and lateral radiographs made at the time of the injury.

View Large | Download Slide(.ppt)
Add to My JBJS

FIG1-C:: Fig. 1-C Anteroposterior and lateral radiographs made after unsatisfactory closed reduction and application of a cast.

View Large | Download Slide(.ppt)
Add to My JBJS

FIG1-D:: Fig. 1-D Anteroposterior and lateral radiographs made after unsatisfactory closed reduction and application of a cast.

View Large | Download Slide(.ppt)
Add to My JBJS

FIG1-E:: Fig. 1-E Anteroposterior and lateral radiographs made after application of two plates, showing satisfactory articular congruity and extra-articular alignment.

View Large | Download Slide(.ppt)
Add to My JBJS

FIG1-F:: Fig. 1-F Anteroposterior and lateral radiographs made after application of two plates, showing satisfactory articular congruity and extra-articular alignment.

View Large | Download Slide(.ppt)
Add to My JBJS

FIG2-B:: Fig. 2-B: Anteroposterior and lateral radiographs made at the time of the injury.

View Large | Download Slide(.ppt)
Add to My JBJS

FIG2-C:: Figs. 2-C and 2-D: Anteroposterior and lateral radiographs showing an unsatisfactory closed reduction with an intra-articular step-off of two millimeters.

View Large | Download Slide(.ppt)
Add to My JBJS

FIG2-D:: Fig. 2-D: Anteroposterior and lateral radiographs showing an unsatisfactory closed reduction with an intra-articular step-off of two millimeters.

View Large | Download Slide(.ppt)
Add to My JBJS

View Larger

TABLE I CLINICAL DATA ON THE PATIENTS

													Result
				Type of Fixation Plate		Range of Motion at Most Recent Follow-up Evaluation (Degrees)						Postop. Grid Strength‡	Modified System of Green and O'Brien¹³	System of Gartland and Werley¹⁵

	Gender,	AO	Bone-		Palmar	Dorsi-	Supi-	Pro-	Ulnar	Radial
Case	Age	Type²⁷*	Grafting	Complication	Flexion	flexion	nation	nation	Deviation†	Deviation†
	(Yrs.)											(Per cent)
1	M, 37	C3	No	Palmar	Median neuropathy	50	62	110	45	28	10	73	Fair	Good
2	M, 58	C1	No	Palmar	Median neuropathy	56	55	130	60	15	15	78	Good	Excellent
3	M, 41	C2	Yes	Dorsal	Infection around Kirschner wire	50	40	80	40	—	—	40	Poor	Fair
4	M, 40	C2	No	Dorsal	Shoulder-hand syndrome	38	35	95	75	20	15	71	Fair	Good
5	M, 23	C1	No	Dorsal		85	72	110	60	40	20	91	Excellent	Excellent
6	M, 57	C3	Yes	Double		50	46	95	65	21	20	75	Good	Excellent
7	M, 51	C3	Yes	Dorsal		58	68	95	64	40	8	71	Fair	Good
8	M, 32	C3	No	Double		41	56	93	75	13	12	55	Fair	Good
9	M, 33	C3	No	Dorsal		48	50	100	65	25	10	84	Fair	Good
10	M, 33	C1	No	Palmar		67	67	104	50	17	26	60	Good	Excellent
11	M, 33	C2	Yes	Palmar		90	60	120	45	30	21	85	Excellent	Excellent
12	M, 34	C3	Yes	Double		65	55	86	56	19	10	72	Excellent	Excellent
13	M, 39	C3	No	Double	Rupture of extensor pollicis longus	55	45	100	63	—	—	84	Good	Excellent
14	M, 50	C2	Yes	Palmar		35	42	95	55	27	15	44	Fair	Good
15	M, 50	C3	Yes	Dorsal		27	40	85	80	24	15	43	Fair	Fair
16	M, 16	C1	No	Dorsal		72	65	103	95	20	22	98	Excellent	Excellent
17	M, 39	C3	Yes	Double		65	56	95	73	35	13	67	Good	Excellent
18	M, 40	C3	Yes	Double		42	70	85	73	23	13	94	Good	Excellent
19	M, 43	C3	Yes	Palmar		65	40	75	74	14	5	67	Fair	Fair
20	M, 42	C3	No	Dorsal		15	28	25	56	20	0	43	Poor	Fair
21	M, 48	C2	Yes	Palmar		64	46	84	62	22	17	75	Good	Excellent
22	M, 44	C3	Yes	Double		54	42	90	88	22	16	83	Good	Fair
23	M, 31	C2	No	Dorsal		78	65	90	90	38	25	83	Excellent	Excellent
24	M, 46	C3	Yes	Double	Displaced plate, median neuropathy	40	50	40	78	25	10	92	Fair	Fair
25	M, 51	C2	No	Dorsal		45	48	85	80	40	18	123	Excellent	Excellent
26	M, 29	C2	No	Dorsal		45	70	90	70	33	10	77	Good	Good
27	M, 44	C2	No	Dorsal	Shoulder-hand syndrome	53	55	85	80	30	16	72	Fair	Excellent
28	M, 52	C3	Yes	Double		25	28	67	50	18	10	76	Fair	Good
29	F, 52	C2	Yes	Double		55	55	92	85	45	17	64	Good	Excellent
30	M, 42	C2	Yes	Palmar		52	55	72	75	33	18	108	Excellent	Excellent
31	F, 58	C2	Yes	Double		43	40	70	70	22	10	60	Fair	Good
32	F, 60	C2	No	Double	Median neuropathy	49	55	86	70	21	8	75	Good	Good
33	F, 43	C3	Yes	Dorsal		56	66	80	84	45	8	100	Excellent	Excellent
34	M, 43	C3	No	Palmar		40	35	78	65	20	20	87	Good	Good
Mean	42					52	52	88	68	26	14	76

Add to My JBJS

TABLE I CLINICAL DATA ON THE PATIENTS

													Result
				Type of Fixation Plate		Range of Motion at Most Recent Follow-up Evaluation (Degrees)						Postop. Grid Strength‡	Modified System of Green and O'Brien¹³	System of Gartland and Werley¹⁵

	Gender,	AO	Bone-		Palmar	Dorsi-	Supi-	Pro-	Ulnar	Radial
Case	Age	Type²⁷*	Grafting	Complication	Flexion	flexion	nation	nation	Deviation†	Deviation†
	(Yrs.)											(Per cent)
1	M, 37	C3	No	Palmar	Median neuropathy	50	62	110	45	28	10	73	Fair	Good
2	M, 58	C1	No	Palmar	Median neuropathy	56	55	130	60	15	15	78	Good	Excellent
3	M, 41	C2	Yes	Dorsal	Infection around Kirschner wire	50	40	80	40	—	—	40	Poor	Fair
4	M, 40	C2	No	Dorsal	Shoulder-hand syndrome	38	35	95	75	20	15	71	Fair	Good
5	M, 23	C1	No	Dorsal		85	72	110	60	40	20	91	Excellent	Excellent
6	M, 57	C3	Yes	Double		50	46	95	65	21	20	75	Good	Excellent
7	M, 51	C3	Yes	Dorsal		58	68	95	64	40	8	71	Fair	Good
8	M, 32	C3	No	Double		41	56	93	75	13	12	55	Fair	Good
9	M, 33	C3	No	Dorsal		48	50	100	65	25	10	84	Fair	Good
10	M, 33	C1	No	Palmar		67	67	104	50	17	26	60	Good	Excellent
11	M, 33	C2	Yes	Palmar		90	60	120	45	30	21	85	Excellent	Excellent
12	M, 34	C3	Yes	Double		65	55	86	56	19	10	72	Excellent	Excellent
13	M, 39	C3	No	Double	Rupture of extensor pollicis longus	55	45	100	63	—	—	84	Good	Excellent
14	M, 50	C2	Yes	Palmar		35	42	95	55	27	15	44	Fair	Good
15	M, 50	C3	Yes	Dorsal		27	40	85	80	24	15	43	Fair	Fair
16	M, 16	C1	No	Dorsal		72	65	103	95	20	22	98	Excellent	Excellent
17	M, 39	C3	Yes	Double		65	56	95	73	35	13	67	Good	Excellent
18	M, 40	C3	Yes	Double		42	70	85	73	23	13	94	Good	Excellent
19	M, 43	C3	Yes	Palmar		65	40	75	74	14	5	67	Fair	Fair
20	M, 42	C3	No	Dorsal		15	28	25	56	20	0	43	Poor	Fair
21	M, 48	C2	Yes	Palmar		64	46	84	62	22	17	75	Good	Excellent
22	M, 44	C3	Yes	Double		54	42	90	88	22	16	83	Good	Fair
23	M, 31	C2	No	Dorsal		78	65	90	90	38	25	83	Excellent	Excellent
24	M, 46	C3	Yes	Double	Displaced plate, median neuropathy	40	50	40	78	25	10	92	Fair	Fair
25	M, 51	C2	No	Dorsal		45	48	85	80	40	18	123	Excellent	Excellent
26	M, 29	C2	No	Dorsal		45	70	90	70	33	10	77	Good	Good
27	M, 44	C2	No	Dorsal	Shoulder-hand syndrome	53	55	85	80	30	16	72	Fair	Excellent
28	M, 52	C3	Yes	Double		25	28	67	50	18	10	76	Fair	Good
29	F, 52	C2	Yes	Double		55	55	92	85	45	17	64	Good	Excellent
30	M, 42	C2	Yes	Palmar		52	55	72	75	33	18	108	Excellent	Excellent
31	F, 58	C2	Yes	Double		43	40	70	70	22	10	60	Fair	Good
32	F, 60	C2	No	Double	Median neuropathy	49	55	86	70	21	8	75	Good	Good
33	F, 43	C3	Yes	Dorsal		56	66	80	84	45	8	100	Excellent	Excellent
34	M, 43	C3	No	Palmar		40	35	78	65	20	20	87	Good	Good
Mean	42					52	52	88	68	26	14	76

View Larger

TABLE II RADIOGRAPHIC DATA IMMEDIATELY POSTOPERATIVELY

Case	Radial Length	Radial Inclination	Tilt*	Radio-Ulnar Index†	Gap	Step-off
	(mm)	(Degrees)	(Degrees)	(mm)	(mm)	(mm)
1	11	20	10	0	1	1
2	3	12	-22	—	0	0
3	3	7	-4	1	3	2
4	7	9	14	-3	0	2
5	13	23	10	0	0	0
6	9	25	5	2	1	1
7	16	30	-18	1	1	1
8	2	13	6	2	3	2
9	11	20	-3	0	0	0
10	3	16	0	4	0	0
11	11	11	9	-4	0	1
12	9	22	7	-2	1	1
13	13	26	5	—	1	1
14	13	18	1	-2	2	1
15	6	20	5	1	0	0
16	14	20	9	0	0	0
17	9	15	0	0	0	0
18	12	23	0	—	2	2
19	4	15	-5	—	0	0
20	9	23	3	4	2	3
21	10	19	-17	-1	0	0
22	15	33	0	4	5	5
23	8	17	5	-1	0	0
24	19	36	20	4	0	0
25	13	20	11	-2	2	0
26	11	23	9	1	1	1
27	11	25	0	0	0	1
28	12	26	0	0	1	2
29	13	28	13	-1	0	0
30	11	20	-5	-1	1	1
31	3	5	-5	2	0	0
32	7	21	0	2	0	0
33	9	22	7	1	0	0
34	12	15	5	-2	2	2
Mean	10	20	2	0	1	1

Add to My JBJS

TABLE II RADIOGRAPHIC DATA IMMEDIATELY POSTOPERATIVELY

Case	Radial Length	Radial Inclination	Tilt*	Radio-Ulnar Index†	Gap	Step-off
	(mm)	(Degrees)	(Degrees)	(mm)	(mm)	(mm)
1	11	20	10	0	1	1
2	3	12	-22	—	0	0
3	3	7	-4	1	3	2
4	7	9	14	-3	0	2
5	13	23	10	0	0	0
6	9	25	5	2	1	1
7	16	30	-18	1	1	1
8	2	13	6	2	3	2
9	11	20	-3	0	0	0
10	3	16	0	4	0	0
11	11	11	9	-4	0	1
12	9	22	7	-2	1	1
13	13	26	5	—	1	1
14	13	18	1	-2	2	1
15	6	20	5	1	0	0
16	14	20	9	0	0	0
17	9	15	0	0	0	0
18	12	23	0	—	2	2
19	4	15	-5	—	0	0
20	9	23	3	4	2	3
21	10	19	-17	-1	0	0
22	15	33	0	4	5	5
23	8	17	5	-1	0	0
24	19	36	20	4	0	0
25	13	20	11	-2	2	0
26	11	23	9	1	1	1
27	11	25	0	0	0	1
28	12	26	0	0	1	2
29	13	28	13	-1	0	0
30	11	20	-5	-1	1	1
31	3	5	-5	2	0	0
32	7	21	0	2	0	0
33	9	22	7	1	0	0
34	12	15	5	-2	2	2
Mean	10	20	2	0	1	1

View Larger

TABLE III RADIOGRAPHIC DATA AT THE MOST RECENT FOLLOW-UP EXAMINATION

Case	Radial Length	Radial Inclination	Tilt*	Radio-Ulnar Index†	Loss of Reduction	Grade of Osteoarthrosis¹⁸
	(mm)	(Degrees)	(Degrees)	(mm)
1	10	23	0	0	No	0
2	3	12	-23	-1	No	0
3	3	5	-3	1	No	III
4‡	—	—	—	—	No	0
5	12	22	10	0	No	0
6	10	25	5	2	No	0
7	11	20	-9	2	No	I
8	2	15	5	3	No	II
9	9	25	19	3	Yes	0
10	0	10	-12	5	Yes	0
11	13	12	8	-3	No	0
12	10	22	6	-2	No	0
13	15	26	7	0	No	0
14	12	18	0	-2	No	0
15	6	20	5	1	No	0
16	13	20	9	0	No	0
17	8	14	3	—	No	0
18	10	18	0	—	No	II
19	5	16	-4	—	No	0
20	7	25	0	5	No	III
21	12	21	-15	-1	No	0
22	6	21	20	8	Yes	II
23	10	19	4	-1	No	0
24	16	37	20	4	No	0
25	9	18	10	0	No	0
26	13	23	9	1	No	0
27	10	29	3	2	No	0
28	12	28	0	1	No	I
29	14	30	15	-1	No	0
30	12	23	0	-1	No	0
31	4	10	-5	2	No	0
32	9	24	0	2	No	0
33‡	—	—	—	—	No	0
34	11	15	5	-2	No	II
Mean	9	20	3	1

Add to My JBJS

TABLE III RADIOGRAPHIC DATA AT THE MOST RECENT FOLLOW-UP EXAMINATION

Case	Radial Length	Radial Inclination	Tilt*	Radio-Ulnar Index†	Loss of Reduction	Grade of Osteoarthrosis¹⁸
	(mm)	(Degrees)	(Degrees)	(mm)
1	10	23	0	0	No	0
2	3	12	-23	-1	No	0
3	3	5	-3	1	No	III
4‡	—	—	—	—	No	0
5	12	22	10	0	No	0
6	10	25	5	2	No	0
7	11	20	-9	2	No	I
8	2	15	5	3	No	II
9	9	25	19	3	Yes	0
10	0	10	-12	5	Yes	0
11	13	12	8	-3	No	0
12	10	22	6	-2	No	0
13	15	26	7	0	No	0
14	12	18	0	-2	No	0
15	6	20	5	1	No	0
16	13	20	9	0	No	0
17	8	14	3	—	No	0
18	10	18	0	—	No	II
19	5	16	-4	—	No	0
20	7	25	0	5	No	III
21	12	21	-15	-1	No	0
22	6	21	20	8	Yes	II
23	10	19	4	-1	No	0
24	16	37	20	4	No	0
25	9	18	10	0	No	0
26	13	23	9	1	No	0
27	10	29	3	2	No	0
28	12	28	0	1	No	I
29	14	30	15	-1	No	0
30	12	23	0	-1	No	0
31	4	10	-5	2	No	0
32	9	24	0	2	No	0
33‡	—	—	—	—	No	0
34	11	15	5	-2	No	II
Mean	9	20	3	1