Background: Distal radial fractures with extensive comminution
involving the metaphyseal-diaphyseal junction present a major treatment
dilemma. Of particular difficulty are those fractures involving the articular
surface. One approach is to apply a dorsal 3.5-mm plate extra-articularly from
the radius to the third metacarpal, stabilizing the diaphysis and maintaining
distraction across the radiocarpal joint.
Methods: Twenty-two patients treated with a distraction plate for a
comminuted distal radial fracture were included in the study. With use of
three limited incisions, a 3.5-mm ASIF plate was applied in distraction
dorsally from the radial diaphysis, bypassing the comminuted segment, to the
long-finger metacarpal, where it was fixed distally. The articular surface was
anatomically reduced and was secured with Kirschner wires or screws. Eleven of
the twenty-two fractures were treated with bone-grafting. The plate was
removed after fracture consolidation (at an average of 124 days), and wrist
motion was initiated. All patients were followed prospectively with use of
radiographs, physical examination, and DASH (Disabilities of the Arm, Shoulder
and Hand) scores.
Results: All fractures united by an average of 110 days. Radiographs
showed an average palmar tilt of 4.6° and an average ulnar variance of
neutral (0°), whereas loss of radial length averaged 2 mm. Flexion and
extension averaged 57° and 65°, respectively, and pronation and
supination averaged 77° and 76°, respectively. The average DASH scores
were 34 points at six months, 15 points at one year, and 11.5 points at the
time of final follow-up (at an average of 24.8 months). According to the
Gartland-Werley rating system, fourteen patients had an excellent result, six
had a good result, and two had a fair result. Grip strength and the range of
motion of the wrist at one year correlated inversely with the proximal extent
of fracture comminution into the diaphysis. The duration of plate
immobilization did not correlate with the range of motion of the wrist or with
the DASH score at one year.
Conclusions: The use of a distraction plate combined with reduction
of the articular surface and bone-grafting when needed can be an effective
technique for treatment of fractures of the distal end of the radius with
extensive metaphyseal and diaphyseal comminution. A functional range of motion
with minimal disability can be achieved despite a prolonged period of fixation
with a distraction plate across the wrist joint.
Level of Evidence: Therapeutic Level IV. See Instructions
to Authors for a complete description of levels of evidence.