Strat Traum Limb Recon (2006) 1:2–17

DOI 10.1007/s11751-006-0001-5
Trauma
REVIEW

K. Mader • D. Pennig

The treatment of severely comminuted intra-articular fractures

of the distal radius

Received: 29 September 2006 / Accepted: 30 October 2006 / Published online: 14 December 2006

Abstract Comminuted fractures of the distal end of the

Introduction
radius are caused by high-energy trauma and present as
shear and impacted fractures of the articular surface of the
distal radius with displacement of the fragments. The force More than 192 years have passed since Colles described
of the impact and the position of the hand and carpal bone a fracture of the distal end of the radius [1]. It is remark-
determine the pattern of articular fragmentation and their able that this common fracture remains one of the most
displacement and the amount and the extent of frequent challenging of the fractures treated by orthopaedic or
concommitant ligament and carpal bone injury. The result general surgeons. Comminuted fractures of the distal end
of the osseous lesion in comminuted fractures was termed of the radius are caused by high-energy trauma in young
“pilon radiale”, which emphasizes the amount of damage patients and by low-energy trauma in the elderly, and
to the distal radius and the difficulties to be expected in present as shear and impacted fractures of the articular
restoring the articular congruity. Besides this the addition- surface of the distal radius with displacement of the frag-
al injury, either strain of disruption of the ligaments and ments [2–10]. The force of the impact and the position of
the displacement of the carpus and/ or the triangular fibro- the hand and carpal bones determine the pattern and dis-
cartilage complex will equally influence the functional placement of articular fragmentation and the amount and
outcome. This review will expand on the relevant anatomy, extent of the frequent concomitant ligament and carpal
correct classification and diagnosis of the fracture, diag- bone injury [11–13]. The result of the osseous lesion in
nostic tools and operative treatment options. Current treat- comminuted fractures was termed “pilon radiale” [11],
ment concepts are analysed with regard to actual literature which emphasises the amount of damage to the distal
using the tools of evidence based medicine criteria. A new radius and the difficulties to be expected in restoring the
classification of severely comminuted distal radius frac- articular congruity. In addition, disruption of the liga-
tures is proposed using CT data of 250 complex intraartic- ments and the displacement of the carpus and/or the tri-
ular radius fractures. Finally a standardized treatment pro- angular fibrocartilage complex (TFCC), will equally
tocol using external fixation in combination with minimal influence the functional outcome [14]. This review will
invasive internal osteosynthesis is described. expand on the relevant anatomy, correct classification
and diagnosis of the fracture, diagnostic tools and opera-
Key words Distal radius fractures • External fixation • tive treatment options.
Plate osteosynthesis • Meta-analysis

Epidemiology

K. Mader () • D. Pennig The distal radius fracture was clinically diagnosed in
Department of Trauma and Orthopedic Surgery, Hand and
1814 by Colles, who described this entity in a journal
Reconstructive Surgery
St. Vinzenz Hospital published in Edinburgh [1]. The treatment, however, even
Merheimer Straße 221–223 today, remains controversial. One of the reasons for this
D-50733 Cologne, Germany controversy is the heterogenic patient population in
e-mail: [email protected] which the fracture occurs. In younger patients (those
K. Mader, D. Pennig: Comminuted intra-articular fractures of the distal radius 3

under 40 years of age) considerable forces are necessary patients studied surgical interventions. Twenty-one of
to cause this fracture, which is defined as being localised these compared surgical intervention with conservative
within 3 cm of the distal end of the radius [2, 3]. There is treatment, always plaster cast immobilisation for about 6
a sharp increase in incidence above the age of 30 years, weeks. Three trials had more than 2 intervention groups
which apparently is associated with post-menopausal and and featured in 3 or 4 comparisons.
age-related osteopenia. In the USA and Northern Europe In summary, they found that a wide range of interven-
this fracture is the most common one in women under 75 tions had been used to treat distal radius fractures and
years old [15]. Studies looking at radial bone density there was insufficient robust evidence from randomised
failed to demonstrate significant reductions in bone den- and quasi-randomised clinical trials for most of the inter-
sity when radius fracture patients were compared with ventions used.
age-matched control subjects [16]. Sparado et al. could There was evidence that some surgical methods sho-
show that both the cortical and the trabecular bone con- wed better anatomical outcomes but there were insufficient
tribute to the overall strength of the osteopenic distal data on other outcomes to determine whether surgical
radius. In effect, both the cortical comminution and the intervention in most fracture types would produce consis-
metaphyseal cancellous bone defect may contribute to the tently better long-term outcomes.
inherent instability of a distal radius fracture [17]. Thus their findings reflect the limited scope, quantity
Looking at the epidemiology of distal radius fractures, and usually uncertain validity of the available evidence
the Reykjavik, Iceland, study showed that 249 fractures in from the trials available. Heterogeneity and incomplete
patients over 15 years of age occurred within a total at-risk data either hindered or prohibited pooling of results from
population of 100,154 [18]. The incidence pattern here is comparable trials and thus the potential of meta-analysis to
similar to those reported in other Nordic studies. The study enhance the precision of the results from small trials.
analysed the distribution of distal radius fractures with There was considerable variation in trial design, such as
regard to the social environment. With more than a half of patient characteristics, the type and application of inter-
the radius fracture patients being employed, the economic ventions, the overall care programmes and so on. For
implications became evident [3, 19]. example, there were 9 different external fixators as well as
pins and plaster being compared with plaster cast immobil-
isation in the group of 13 trials that compared external fix-
ation with conservative treatment. This sort of variation,
Evidence-based medicine and meta-analyses, ran- with insufficient information on trial characteristics and
domised trials incomplete and inadequate outcome assessment invalidat-
ed the interpretation of the results, and their clinical appli-
Systematic analysis and the aim of introducing evidence- cability [27]. Finally, information on resource use and
based medicine criteria in the diagnosis and treatment of costs was rarely available and, where provided, was mini-
distal radius fracture are connected to Helen Handoll and mal [28].
Raj Madhok at the Public Health Research Unit, Having understood that the overall failure to produce a
University of Hull, UK. They have completed a portfolio systematic evaluation of the treatment of distal radius frac-
of systematic reviews (published in The Cochrane tures is mainly due to our own methodological incompe-
Library) of the evidence from relevant randomised con- tence as orthopaedic investigators, we should reconsider
trolled trials (RCTs). Their five reviews, which examine the evidence in the treatment of the subgroup of commin-
conservative and surgical treatments, anaesthesia and uted distal radius fractures. Here special attention should
rehabilitation, cover all of the key interventions for the be paid to any evidence for superior outcome after plating
management of these fractures [20–25]. The reviews of these fractures with new armamentarium on the
include all published randomised or quasi-randomised orthopaedic market, especially for angle-stable implants.
clinical trials comparing various conservative and/or sur- In 2002, Handoll and Madhok found 44 randomised tri-
gical interventions. Seventy-five trials, involving 6565 als that did not provide robust evidence for most of the
mainly female and older patients, were included. These decisions necessary in the management of these fractures
were mainly single-centre trials performed in 20 coun- [28]. Although, in particular, there was some evidence to
tries with only one international trial. Overall, the 75 tri- support the use of external fixation or percutaneous pin-
als were only of poor to moderate quality as rated by the ning, their precise role and methods are not established. It
methodological checklist, using the three prime measures was also unclear whether surgical intervention in most
of internal validity, which are reported to affect the fracture types would produce consistently better long-term
results of trials [26]. outcomes [28].
Even more so, their results on surgical interventions in In 2004, Paksima et al. published a meta-analysis of
radius fractures, a subgroup of their analysis, show the sci- the literature on distal radius fractures, reviewing 615
entific standard in this medical field: 41 trials with 3193 articles [7]. Again, there was insufficient data to perform
4 K. Mader, D. Pennig: Comminuted intra-articular fractures of the distal radius

a scientific meta-analysis because of the poor quality of open reduction and internal fixation, provided that the
the studies and lack of a uniform method of outcome intra-articular step and gap deformity were minimised.
assessment. However, the data from the comparative tri- Grewal et al. in 2005 compared, in a randomised study,
als showed that external fixation was favoured over open reduction and internal fixation with dorsal plating
closed reduction and casting. Additionally, comparing the (Pi Plate; Synthes, Paoli, PA) versus mini open reduction
results of the case series showed that external fixation with percutaneous K-wire and external fixation [42]. At
was superior to internal fixation [8]. midterm analysis the dorsal plate group showed a signif-
In 2005, Margaliot et al. performed a meta-analysis icantly higher complication rate compared with the exter-
on outcome after plate fixation versus external fixation in nal fixator group; therefore enrolment in the study was
unstable distal radius fractures [29]. The outcomes of terminated. The dorsal plate group also showed statisti-
internal and external fixation were compared using con- cally significantly higher levels of pain, weaker grip
tinuous measures of grip strength, wrist range of motion strength, and longer surgical and tourniquet times. Based
and radiographic alignment, and categoric measures of on these results they refused to recommend the use of
pain, physician-rated outcome scales and complication dorsal plates in treating complex intra-articular fractures
rates. Outcomes were pooled by random-effects; meta- of the distal radius.
analysis and meta-regression analysis were used to con-
trol for patient age, presence of intra-articular fracture,
duration of follow-up period and date of publication.
Sensitivity analyses were used to test the stability of the Classification systems
meta-analysis results under different assumptions. They
could include 46 articles in the review with 28 (917 A number of authors have proposed systems for the classi-
patients) external fixation studies and 18 (603 patients) fication of fractures of the distal radius, the most known
internal fixation studies. Meta-analysis did not detect and used being the AO [43], Fernandez [44], Frykman [45],
clinically or statistically significant differences in pooled Mayo [46] and Melone [6] classifications. Many of these
grip strength, wrist range of motion, radiographic align- systems combine intra-articular and extra-articular frac-
ment, pain and physician-rated outcomes between the 2 tures; however recent studies have not revealed substantial
treatment arms. There were higher rates of infection, interobserver agreement among fracture types determined
hardware failure and neuritis with external fixation and by the use of the AO, Frykman, Mayo and Melone classifi-
higher rates of tendon complications and early hardware cations [47]. Significant agreement (p<0.05) among sur-
removal with internal fixation. Considerable heterogene- geon classifications using the AO system was achieved only
ity was present in all studies and adversely affected the after the classification was reduced substantially, and freed
precision of the meta-analysis. They concluded that the from all subgroups, to the three major fracture types (A,
current literature offers no evidence to support the use of extra-articular; B, intra-articular with part of metaphysis
internal fixation over external fixation for unstable distal intact and C, intra-articular fractures with complete disrup-
radius fractures [29]. tion of the metaphysis) [47].
Looking at the systematic analysis of the “new” internal
plating systems, we should draw an even more pessimistic
view. Although there are publications of biomechanical
testing of different plate systems [30–34] and non-ran- AO classification
domised case series and so-called expert opinions of using
these implants [4, 35–40], in September 2006 there are no The AO classification system, which comprises 27 cate-
scientific relevant studies available showing a superior out- gories, is the most detailed. It also is the most inclusive,
come using the criteria of Handoll and Madhok [27]. making it, in theory, useful for detailed anatomical cate-
In contrast, Kreder et al. in 2006 performed a ran- gorisation for trauma registries [43]. Although it is widely
domised controlled trial in a total of 179 adult patients used in the literature, it lacks any link between description
with displaced intra-articular fractures of the distal of the fracture and any clinical decision-making for frac-
radius, that were randomised to receive indirect percuta- ture treatment. Furthermore, Andersen et al. [47] and more
neous reduction and external fixation (n=88) or open recently Flikkila et al. [48], after inclusion of computed
reduction and internal fixation (n=91) [41]. There was no tomography (CT) scans in the diagnostic protocol, have
statistically significant difference in the radiological shown that interobserver reliability was poor when
restoration of anatomical features or the range of move- detailed classification was used. By reducing the cate-
ment between the groups. During the period of two years, gories to five, interobserver reliability was slightly im-
patients who underwent indirect reduction and percuta- proved, but was still poor. When only two (!) AO types
neous fixation had a more rapid return of function and a were used, the reliability was moderate using plain radi-
better functional outcome than those who underwent ographs and good to excellent with the addition of CT.
K. Mader, D. Pennig: Comminuted intra-articular fractures of the distal radius 5

They concluded that the use of CT combined with plain face of the radius into the scaphoid and lunate facets. The
radiographs brings interobserver reliability to a good level so-called TFCC extends from the rim of the sigmoid
in assessment of the presence or absence of articular notch of the radius to the ulnar styloid process. The only
involvement, but is otherwise of minor value in improving tendon that inserts onto the distal aspect the radius is that
the interobserver reliability of the AO system of classifica- of the brachioradialis. All other tendons of the wrist pass
tion of fractures of the distal radius [48]. Therefore the AO across the distal aspect of the radius to insert onto the
classification system is not suitable for reliable classifica- carpal bones or the bases of the metacarpals, or form the
tion of intra-articular fractures of the distal radius. extensors or flexors of the fingers. Delicate extrinsic and
intrinsic ligaments maintain the carpal bones in a smooth
articular unit. Because of the different areas of bone thi-
ckness and density, the fracture pattern tends to propa-
Frykman classification gate between the scaphoid and lunate facets. The degree,
direction and extent of the applied load in addition to the
This classification focuses on the intra-articular extension actual position of the wrist and hand causes additional
of the fracture and the involvement of the ulnar styloid coronal or sagittal splits within the lunate and/or sca-
process, implying that this involvement contributes to the phoid facet. The palmar thickening of the distal radius
seriousness of the fracture [48]. As one of the earliest sys- with its capsular attachment forms the palmar lip, and
tems for the classification of distal radius fractures, it drew more proximally the pronator quadratus muscle ensheat-
attention to the distal radioulnar joint (DRUJ), which is hs the palmar aspect of the distal radius.
important. The Frykman classification can be used to iden- While implants for internal fixation can be applied
tify and separate extra- and intra-articular fractures, but, as safely on the palmar aspect of the distal radius, both the
there is no differentiation between displaced and non-dis- radial and dorsal aspect are densely covered with tendons
placed fractures, this system is also of minor use in the adjacent to the joint capsule, which leaves these areas
classification of intra-articular radius fractures. more vulnerable to tendon adhesions or tendon injury
when implants are used in these areas.

Melone classification
Diagnostic tools
This classification was the first to provide an accurate
description of the way in which the fracture propagates Conventional X-ray
through the articular surface of the radius and as early as
1993 showed the importance of the palmar and dorsal Standard posterior-anterior, lateral and oblique radi-
ulnar-sided key fragment [6]. The original paper by Me- ographs of the wrist show the extent and direction of the
lone was based on only 14 patients, but the analysis of the initial displacement. They should be followed by repeat
fracture pattern and fracture biomechanics is still extraor- radiographs after reduction and cast application in order to
dinary. We strongly recommend this paper for an under- identify residual deformity and the degree of intra-articu-
standing of the pathology of comminuted intra-articular lar comminution. Special attention is paid to the capitate-
distal radius fractures. The Melone classification has lunate axis relative to the radius, identifying dorsal or pal-
gained more reliability and precision with the inclusion of mar carpal dislocation. Incongruencies in the proximal
CT scanning in the diagnostic armamentarium and is the- carpal bones, can reveal intracarpal fracture dislocations or
refore commended as the classification system of choice intercarpal dissociation, most commonly scapholunate
for intra-articular fractures. [49]. Of utmost importance is the evaluation of the DRUJ.
Incongruency disruption or subluxation of the DRUJ can
be readily seen on conventional X-rays and will influence
both treatment protocol and final outcome. Because frac-
Relevant anatomy tures of the distal radius and ulna and related ligamentous
or bone injuries to the wrist can be occult, precise evalua-
The articular surface of the distal aspect of the radius tilts tion of the soft tissues of the distal forearm and wrist can
20° in the anteroposterior plane (radial angle) and 4°–10° be key for correct diagnosis, and a systematic approach to
in the lateral plane (palmar angle). The dorsal cortical the soft tissues is useful. Two fat planes on the lateral view
surface of the radius thickens to form Lister’s tubercle and five fat planes on the posterior anterior view are use-
with further osseous prominences to support the exten- ful for analysis, the most important being the deep fat pad
sors of the wrist. A central ridge divides the articular sur- of the pronator quadratus muscle [50].
6 K. Mader, D. Pennig: Comminuted intra-articular fractures of the distal radius

CT scan tion. Interobserver agreement increased when three-di-

mensional CT was used to determine the exact number of
In all cases with fracture comminution, displacement or articular fracture fragments. Although they stated that
complex intra-articular extension of the fracture, conven- three-dimensional CT improves both the reliability and the
tional radiography is insufficient and CT is warranted. In accuracy of radiographic characterisation of articular frac-
our unit, a standard CT examination is performed on all tures of the distal radius and influences treatment deci-
intra-articular fractures of the distal radius. After marking sions, we find that we obtained sufficient information from
the region of interest (usually extending from the radial transverse section and the addition of sagittal and frontal
metaphysis to the distal carpal row) the CT scan is per- reconstruction allows us to make a CT-based classification
formed with 1-mm sections and a table propagation of of intra-articular fractures of the distal radius and to form
1 mm, giving the highest possible resolution. These sec- our treatment plan.
tions are strictly transverse and will allow for two-dimen-
sional reconstruction in the frontal and sagittal planes. The
images are displayed in the bone-sensitive window. The
transverse plane reconstruction is used to evaluate the dis- Classification based on CT data and operative strategy
tal radioulnar joint and carpal bones and the pattern of
articular fragmentation. The coronal or frontal plane pro- In a prospective evaluation 250 severely comminuted dis-
vides an image similar to the standard PA radiograph and tal radius fractures were treated according to a prospective
will provide better bone detail and intra-articular step-off protocol. In all cases a CT scan was performed with the
or gap. The sagittal plane will give a clear view of dorsal parameters outlined in the previous paragraph. Analysis of
or palmar dislocation of the carpus and any separation of the CT scans led to five distinct fracture types, which can
the dorsal or palmar articular rim of the radius. An addi- be used for a CT-based classification of comminuted intra-
tional oblique sagittal plane in the long axis of the articular fractures of the distal radius.
scaphoid is performed to better assess the scaphoid. In The following fracture types were identified:
subtle cases of radioulnar subluxation a comparison of
transverse CT images of both wrists in neutral, pro- and
supination is an excellent way of evaluating distal radioul- (1) Intra-articular fracture with displaced dorsal fragment
nar joint incongruency. With this diagnostic tool, an accu- (Fig. 1)
rate Melone classification is possible and secondly a defi-
nite operative approach can be planned. In addition, a CT- In addition to intra-articular fragmentation there is a dis-
based classification and treatment plan can be developed. placed and rotated dorso-ulnar fragment, which causes
The benefit of using CT scans in addition to plain radi- incongruency of the dorsal part of the DRUJ. This frag-
ography for the evaluation of small (<5 mm) intra-articu- ment should be reduced via a limited dorsal approach and
lar displacements of distal radius fracture fragments was fixation should be performed either with a single screw or
shown first by Cole et al. in 1997 [51]. They concluded a small dorsal straight plate.
from their study that CT scanning data, using the arc
method of measurement, were more reliable for quantify- (2) Dorsal split with dorsal dislocation (Fig. 2)
ing articular surface incongruities of the distal radius than
plain radiography measurements were. This fracture type is defined by a transverse dorsal split
Katz et al. showed that the addition of CT results in with dorsal dislocation of the fragment(s) and the carpus.
changes in the evaluation and treatment of intra-articular These fractures are actually fractures of the dorsal articu-
distal radius fractures [52]. CT scans improved the sensi- lar margin with dorsal radiocarpal subluxation and are
tivity of measurement of articular surface separation and therefore unstable [4]. Most of the bony ridges are very
the accuracy of detection of comminution and DRUJ small and therefore difficult to refix with implants such as
involvement, and altered the proposed treatment plans in screws or plates and indirect techniques of reduction of the
observers. A very recent study by Harness et al. evaluated fragment and the carpus (by ligamentotaxis with an exter-
the hypothesis that three-dimensional CT images would nal fixator) will reduce the fracture. After reduction those
further increase the reliability and accuracy of radiograph- fragments will be fixed indirectly with the means of screws
ic characterisation of distal radial fractures [53]. They through palmar plates.
showed that three-dimensional CT improved the intraob-
server agreement, but not the interobserver agreement, (3) Palmar split with palmar dislocation (Fig. 3)
regarding the presence of coronal plane fracture lines and
central articular fragment depression. Three-dimensional These fractures are caused by an opposite (palmar) dis-
CT improved both the intraobserver and the interobserver placement of the carpus disrupting a small palmar margin
agreement regarding the presence of articular comminu- of the articular surface and are equally unstable. Here
K. Mader, D. Pennig: Comminuted intra-articular fractures of the distal radius 7

Fig. 1 CT-based classification of

comminuted intra-articular frac-
tures of the distal radius. Type I:
intra-articular fracture with dis-
placed dorso-ulnar fragment

Fig. 2 Type II: dorsal split with dorsal dislocation

Fig. 3 Type III: palmar split with palmar dislocation

Fig. 4 Type IV: complex distal radius fractures with metaphyseal separation

Fig. 5 Type V: destruction of the articular surface

8 K. Mader, D. Pennig: Comminuted intra-articular fractures of the distal radius

reduction of the palmar is achieved via a palmar approach and palmar edges of the distal radius. The TFCC includes
and small buttress plating. Again the deforming forces and a central articular disc and the ulnocarpal ligament. The
palmar (sub)luxation of the carpus are counteracted by a articular disc bears a compressive load and acts like an
neutralising external fixator. ulnocarpal cushion, but gives no stability to the DRUJ
[54]. It is cartilaginous and avascular. The ulnocarpal liga-
(4) Complex distal radius fractures with metaphyseal sep- ment arises from the fovea of the ulnar head and inserts on
aration (Fig. 4) the palmar surface of the triquetrum. It may partly con-
tribute to the stability of the DRUJ [55, 56]. It is generally
These fractures are defined by complete additional dorsal accepted that, in addition to the TFCC, stability is achie-
or palmar disruption of the metaphysis with severe com- ved by various degrees of contribution from the extensor
minution. They often show a total disruption of the DRUJ carpi ulnaris tendon, the pronator quadratus muscle and
and gross displacement. the radioulnar interosseous membrane [55–61].
It has been increasingly accepted that fractures of the
(5) Destruction of the articular surface (Fig. 5) distal radius in patients below the usual age for osteoporosis
are associated with tears of the TFCC [12, 54]. These liga-
On this CT evaluation there is destruction of the very dis- ment tears have been found on wrist arthroscopy and occur
tal aspect of the distal radius, with involvement of the with or without fractures of the ulnar styloid. This implies
greater part of the articular surface. These fractures are the that distal radial fractures in younger patients are frequently
most difficult ones to treat, because major parts of the complicated by injuries that cannot be seen on radiographs.
articular surface are destroyed and displaced. A combina- Some authors advocate including supplementary arthrosco-
tion of reconstruction of the articular surface and minimal py into the operative regimen [10, 12, 54].
distraction of the carpus is necessary to unload the articu- Cole et al., in a recent biomechanical cadaveric study,
lar cartilage during bone healing. examined the effects of the volar and dorsal lips of the sig-
moid notch and the volar and dorsal aspects of the TFCC
The analysis of 250 complex distal radius fractures on DRUJ stability [62]. Sequential fractures of the distal
reveals the pattern of location and distribution of the frag- radius and sectioning of the TFCC were performed fol-
ments relative to the joint line. It was interesting to note lowed by measurements of ulnar translation with the fore-
that most of the fracture lines were distal to the so-called arm in pronation, neutral and supination. A dorsal lunate
“watershed line” (a line at the metaphyseal articular junc- facet fracture created instability in pronation. Lunate facet
tion bordered by the bulky palmar lip), which is the line fractures alone did not create instability in other forearm
that should not be crossed with the use of modern palmar positions. Sectioning of the volar TFCC after loss of the
implants. More than 60% of the fracture lines originated dorsal TFCC by a dorsal lunate facet fracture caused
distal to this watershed line. Therefore to treat the majority DRUJ instability with the forearm in neutral position.
of these fractures implants must be placed distal to this wa- Sectioning of the dorsal TFCC after loss of the volar TFCC
tershed line and therefore have a very low profile design in due to a volar lunate facet fracture created instability in
order not to impede the palmar tendons. neutral and pronated positions [62]. These findings show
clearly the importance of identifying the dorsal or palmar
ligament-bearing fragments during surgery and reattaching
them with fragment-specific internal fixation.
Concomitant injury to the distal radioulnar joint In 2002 May et al. showed that distal radius fractures
complicated by DRUJ instability were accompanied by an
Lindau and Aspenberg performed a detailed analysis of the ulnar styloid fracture [63]. A fracture at the ulnar styloid’s
literature in 2002 and showed, that evidenced-based infor- base and significant displacement of an ulnar styloid frac-
mation on injury to the DRUJ combined with a distal ture were found to increase the risk of DRUJ instability. At
radius fracture is actually absent [54]. They searched The the end of the surgical procedure the position and stability
Cochrane Library and Medline regarding the radioulnar of the ulnar styloid fracture should be visualised and doc-
joint in distal radial fractures and found no randomised or umented. While a perfectly reduced and stable ulnar sty-
controlled studies. Their excellent review presents the loid fragment can be left for fibrous healing, an unstable
descriptive literature by summarising accepted views and and or dislocated ulnar styloid fragment is reduced and
controversies. There is only weak (evidence-based) sup- fixed via a limited ulnar-sided approach. The supplemen-
port for the commonly accepted treatments. tary use of an ulnar outrigger to prevent rotation of the
The major stabilisers of the DRUJ are the ulnoradial forearm during healing is associated with a better out-
ligaments, which represent the transverse, peripheral part come, especially forearm rotation [64].
of the TFCC. The ligaments pass from the fovea of the Hirahara et al. showed, in a biomechanical study in 9
ulnar head and the base of the ulnar styloid to the dorsal fresh cadaver limbs, in a malunion model of the distal
K. Mader, D. Pennig: Comminuted intra-articular fractures of the distal radius 9

radius, that torque across the DRUJ was affected by the lesions were frequent and may explain poor outcomes after
degree of a simulated malunion of the distal radius. They seemingly well healed distal fractures of the radius.
concluded that reduction of distal radius fractures to with- This high frequency of associated intracarpal lesions
in 10° of dorsal angulation is needed to allow patients to was clinically confirmed by Schadel-Hopfner et al in an
maintain full forearm and wrist rotation [58]. arthroscopic study and by Laulan and Bismuth in a radi-
The main unsolved problem resulting from concomi- ographic analysis [67, 68]. Lutz et al. showed, in a well
tant injury to the DRUJ is posttraumatic DRUJ laxity, documented clinical series, that sagittal wrist motion of
which shows no correlation to radiographic changes at the carpal bones following intra-articular fractures of the dis-
time of fracture or at follow-up [54]. tal radius was reduced due to an increased intra-articular
As Lindau stated correctly in 2005, the current problem depth after operative treatment of intra-articular fractures
of the concomitant injury to the DRUJ is that neither the of the distal radius as a result of chondral lesions and per-
initial ligament injury nor the posttraumatic laxity is sisting pressure on the articular surface [13]. The benefits
detectable with radiographic methods, which creates of the use of external fixation in the treatment of complex
future challenges regarding diagnosis and treatment [65]. carpal lesions were shown by Fernandez and Mader [69].
We therefore have to critically analyse each fracture in
each patient and be aware of the complexity of the entire
injury to the wrist.
External fixation

Comminuted fractures of the distal radius are, as previous-

Associated injury to carpal ligaments and carpal bones ly discussed, not a bony lesion, but a complex injury to the
carpal ligaments and the DRUJ. After anatomical recon-
In 2002 Pechlaner et al. performed an extensive cadaver struction of the articular surface, it is important to neutralise
experiment, in which his group attempted to simulate the the deforming palmar or dorsal forces on the carpus [9, 70].
pathomechanism of distal radius fractures and evaluated The external fixator is ideal for postoperative wound access,
the bony and soft tissue lesions [14]. With the help of a moderate unloading of the carpus and stabilisation of the
materials testing machine, 63 prepared cadaver arms were carpal ligaments by means of ligamentotaxis, and can be
hyperextended in the wrist joint until a radius fracture used for mobilisation of the wrist if an appropriate device is
occurred. The concomitant lesions were registered radio- employed [13, 71–74] (Fig. 6). In contrast to statements of
logically and by dissection. Additional cadaver arms were other authors, we believe that the external fixator is not suit-
deep-frozen and examined by means of computer tomog-
raphy and cryosection techniques. Through experimental
hyperextension it was possible to generate dorsal, central
and palmar types of fractures. The subsequent dissection
showed in 40 cases (63%) mostly multiple concomitant
lesions and in 23 cases (37%) none of these. Most fre-
quently (27 cases, i.e., 43%), they found a destabilisation
of the articular disk with or without a bony avulsion frag-
ment (fracture of the ulnar styloid). They also commonly
found ruptures of the interosseous ligaments between
scaphoid and lunate (20 cases, i.e., 32%) and lunate and
triquetrum (11 cases, i.e., 18%).
As early as 1997 Lindau et al. investigated intra-articu-
lar lesions in distal fractures of the radius in young adults
in the clinical setting [66]. They examined the frequency
of associated chondral and ligament lesions in distal frac-
tures of the radius in young adults (men 20–60 years,
women 20–50 years). By supplementary arthroscopy they
found chondral lesions in 16 patients (32%). All patients
but one were found to have a ligamentous injury in the
wrist. The most frequent ligament tear was the TFCC in 39
Fig. 6 Schematic drawing of a monolateral external fixator with
cases (78%), with a statistical correlation to ulnar styloid double ball joints after application to the radial aspect of the second
fractures. The scapholunate ligament was partially or total- metacarpal and diaphysis of the radius: the distal ball joint is cen-
ly torn in 27 cases (54%). No correlation was found tred between the capitate (C) and lunate bone (L) (intraoperatively
between specific fracture types and the pattern of ligament by identification with a bone elevator under image intensification,
injury. They concluded that chondral and ligamentous lower part of the image) to allow for mobilisation of the fixator
10 K. Mader, D. Pennig: Comminuted intra-articular fractures of the distal radius

Fig. 7 Intraoperative images during

application of fixator pins into the ba-
se of the second metacarpal. On the
left side the appropriate use of a screw
guide and a trocar is shown, and on
the right side predrilling with cooling
of the drill bit is demonstrated

Fig. 8 Intraoperative images during

application of fixator pins into the
diaphysis of the radius: the soft tis-
sues are retracted, the periosteal
sleeve is incised (left) and detached
from the underlying bone (right)

able for the reduction of the fragments in severely commin- Reduction technique (ligamentotaxis)
uted distal radius fractures, because the ligament-bearing
fragments are individually rotated and displaced in different
directions, and will not derotate during simple distraction of Gupta outlined the principle of ligamentotaxis in the treat-
the external frame [6, 13, 75–77]. Although a variety of ment of distal radius fractures in a prospective study in 204
external fixators are available, only a few have the versatil- consecutive patients using closed reduction and plaster
ity to align the carpus correctly with the wrist in a neutral immobilisation [86]. After comparing three different posi-
and functional position, allowing for the placement of an tions of the wrist in plaster (palmar flexion, neutral and
ulnar outrigger and can be mobilised after proper applica- dorsiflexion) he showed the lowest incidence of redisplace-
tion [78–83]. The external fixator is placed strictly in the ment, especially of dorsal tilt, and the best functional
lateral plane from the radial side, with open insertion of results with a dorsiflexed immobilisation of the wrist. He
threaded fixator pins into the proximal third of the second showed clearly that in palmar flexion the dorsal carpal lig-
metacarpal and the radial aspect of the distal third of the ament is taut, but cannot stabilise the fracture because of its
radial diaphysis (Figs. 7 and 8). Care is taken to avoid lack of attachment to the distal carpal row. The deforming
injury to the dorsal cutaneous branch of the radial nerve forces and the potential displacement of the fracture are
with the use of open pin insertion and the proper use of parallel and in the same direction. In dorsiflexion, the volar
screw guides and drill guides, and incision and detachment ligaments are taut and tend to pull the fracture anteriorly,
of the periosteum reduces the postoperative pain response thereby placing the deforming forces at an angle, which
[71–74, 84]. Predrilling was shown to reduce temperature tends to reduce the displacement of the fracture. This tight-
during pin insertion, which is further lowered by using ening manoeuvre of the volar ligament complex is termed
cooling during the drilling procedure [85]. After pin place- “Gupta’s manoeuvre” or multiplanar ligamentotaxis.
ment the internal fixation of the intra-articular fragments is In 2000 Dee et al. showed that by using an external fix-
performed by individual fixation and the external fixator is ation with two ball joints, this manoeuvre can be integrat-
applied at the end of the operation in neutral ulnar/radial ed into the reduction technique for comminuted distal
abduction and slight dorsal extension to allow for full radius fractures [79]. After preliminary restoration of radi-
power grip [79]. Special attention is paid to the position and al length, the proximal ball joint is adjusted to the radio-
alignment of the carpus and any intracarpal rotation, which carpal joint space and the distal ball joint is set to the so-
can be corrected by ligamentotaxis. Overdistraction should called centre of rotation of the wrist joint (between capitate
be detected and released. and lunate, Fig. 6). Palmar translation of the carpus in the
K. Mader, D. Pennig: Comminuted intra-articular fractures of the distal radius 11

unlocked proximal ball joint provides restoration of the

physiological palmar tilt, while traction via the radiodorsal Different operative techniques and implants for internal
ligament complex adjusts the distal fragment with no need fixation
for flexing of the wrist. The distal part of the fixator is
extended dorsally in the midcarpal level and the distal ball Column model
joint then locked. As discussed before, flexion in midcar-
pus does not control the dorsally tilted distal fragment Jakob et al. showed that the distal radius and the distal ulna
because of the mainly proximal insertion of the dorsal form a three-column biomechanical construction [90]. The
wrist ligaments on the proximal carpal row [86], but trans- medial column is the distal ulna, the triangular fibrocarti-
lation and dorsiflexion tethers the stronger palmar liga- lage and the DRUJ. The intermediate column is the medial
ments, thus stabilising the reduction result while the added part of the distal radius, with the lunate fossa and the sig-
longitudinal traction protects against redisplacement. moid notch, and the lateral column is the lateral radius with
Overdistraction led, in their clinical series, to loss of the scaphoid fossa and the styloid process. They were able
reduction and dorsal tilt of the fragment and a pressure rise to achieve stable internal fixation with two 2.0 AO titanium
in the carpal tunnel. This reduction technique allowed for plates placed on each of the ‘lateral’ and the ‘intermediate’
anatomical positioning of the distal radius in neutral or columns of the wrist at an angle of 50°–70° [89].
even dorsiflexion and avoids overdistraction and the so-
called “extrinsic-extensor-plus” position (Cotton-Loder or
Schede position), which may lead to finger stiffness and
increased carpal tunnel pressure. Free MP joint motion is Different implants and techniques
the major clinical indicator of the correct use of the Gupta
multiplanar technique. Ligamentotaxis can only be trans- In recent years, it became clear that anatomic reduction
mitted to the fragment with intact capsular attachments and internal fixation with plates with minimising intra-
and therefore can only be executed after refixation of the articular incongruency led to an excellent or good func-
ligament-bearing fractures of the distal radius. tional outcome [8, 10, 91]. A variety of internal fixation
plates have since been developed with emphasis on biome-
chanical testing and the clinical use of angle-stable
implants [8, 30, 32, 35–37, 40, 92–95]. The clinical and
Mobilisation of the external fixator functional benefit of these new implants has not so far been
demonstrated (see section ‘Evidence-based medicine and
The benefit of unlocking a transarticular fixator at the meta-analyses, randomised trials’). Several authors have
wrist joint level to allow for early mobilisation is a matter recommended the supplementary use of arthroscopic tech-
of debate. While the beneficial effect of limited motion on niques to improve anatomic reduction [2, 5, 96] and have
cartilage water content and proteoglycan synthesis was shown the benefit of supplementary use of external fixation
demonstrated by Behrens et al. in animal experiments in after articular joint reconstruction [9, 10, 97].
the dog knee [87] and on wrist function in a clinical setting
[88, 89], the clinical benefit of mobilising a transarticular
wrist fixator has not been demonstrated so far [83]. In a
prospective, randomised study, Sommerkamp et al. com- Lunate facet fragment
pared the results of a dynamic external fixation (the
Clyburn device) with those of static external fixation (the Axelrod et al. and Apergis et al. have shown clinically the
AO/ASIF device) [83]. Mobilisation of the wrist in the importance of addressing the lunate facet fragments, either
dynamic-fixator group provided little gain in the mean palmar or dorsal first, in order to reconstruct the DRUJ [98,
motion of the wrist at the time of the removal of the fixa- 99]. In our opinion this is crucial for restoration of forearm
tor and at follow-up. On the contrary, motion of the wrist rotation, and therefore reconstruction of the articular sur-
in the dynamic-fixator group resulted in a statistically sig- face should start with the intermediate column [90].
nificant loss of radial length compared with that in the stat-
ic-fixator group and complications were more frequent in
the dynamic-fixator group.
In our opinion and experience, strict radial application Preferred operative technique: the minimal invasive
of the fixator pins, with correct alignment of the mobilisa- osteosynthesis technique (MIOT)
tion axis to the main centre of motion of the wrist and
avoidance of overdistraction, may be the critical points to The preferred operative technique of the authors is based on
achieve the beneficial effect of mobilising the transarticu- the experience with treating 250 comminuted distal radius
lar external fixator [13]. fractures according to a prospective protocol. After application
12 K. Mader, D. Pennig: Comminuted intra-articular fractures of the distal radius

of a monolateral fixator with double ball joints for multiplanar

ligamentotaxis, minimal internal osteosynthesis is performed.
After careful analysis of the trauma X-rays, a CT-scan
is carried out in all AO type C fractures (Figs. 9, 10). The
operation is performed under general or regional anaes-
thesia on a hand table; a tourniquet is advised. Based on
the CT scans the surgical approach is chosen to allow a
minimally invasive technique. Fractures involving the
volar lip will require a volar approach, those involving
the radial styloid alone may required a radio-dorsal or
radio-volar approach, and those that are dorsal intra-
articular will require a dorsal approach, through the
appropriate tendon compartment.
The most common application is on the volar side. A
3–4-cm straight incision is made radial to the flexor carpi
radialis tendon in order to protect the median nerve, stay-
ing close to the tendon in order to avoid an injury to the
radial artery (Figs. 11 and 12). The tendon of the flexor
pollicis muscle is identified and the pronator quadratus
exposed. If the pronator quadratus is intact, an L-shaped
elevation of the muscle with an incision based on the Fig. 9 Conventional X-ray of the right side in a 28-year-old male
radial styloid and close to the volar lip is performed (Fig. patient after a high-velocity injury (motorbike accident)
13). If there is an injury to pronator quadratus, the lacer-
ation may have to be included in the approach.
The fracture lines are exposed and most commonly
two fragments will be visible. It is advisable to start with
the ulnar-sided fragment, which will restore congruency
to both the radio-carpal and the DRUJ (Fig. 14).
Commonly a two- or three-hole T-shaped miniaturised
implant is used in this position. Fine-wire screws (FFS)
with a snap-off are used and the first to be inserted is the
one proximal to the fracture line [100]. It is inserted
through the slotted hole and should not be driven home
completely to allow fine tuning of the implant position.
The FFS snap-off screws are loaded directly in a Jacob’s
chuck. Commonly a 15-mm FFS snap-off screw with the
washer is used in this position. Once the position of the
implant is correct, the FFS snap-off screws close to the
joint are inserted in the transverse position of the T. Here
commonly 19- or 21-mm snap-off screws with washers
are used. Once the two screws in the horizontal position
have been inserted, a fourth screw is inserted into the
long part of the T, usually 13 or 15 mm. An X-ray is
taken to confirm the correct reduction of the volar ulnar
fragment of the radius (Fig. 15). Reattachment of the
radial styloid fragment can be performed with a straight
implant of three or four holes, an L-shaped or a hockey
stick shaped implant (Fig. 16). All these implants are
anatomically precontoured and have the feature of a slot-
ted hole to allow fine tuning of the position. Again, the
first FFS snap-off screw to be inserted is the one just
proximal to the fracture line through the slotted hole.
Fig. 10 CT scan of the right wrist after reduction in finger-trap trac-
This is not driven in completely and on average has a tion and application of a dorsal and palmar cast allows for detailed
length of 15 mm. After correctly positioning the implant analysis and classification of the fracture. According to the CT
and maintaining the reduction of the fragment, the most classification the fracture was classified as type II (dorsal split with
distal screw hole is filled with an FFS snap-off screw dorsal dislocation of the carpus)
K. Mader, D. Pennig: Comminuted intra-articular fractures of the distal radius 13

Fig. 11 Intraoperative images of the pal-

mar approach: after marking the distal
radioulnar joint and the palmar lip on
the skin (using image intensification) a
3–4-cm straight incision is made radial
to the flexor carpi radialis tendon (left);
the pronator quadratus muscle is expo-
sed, using Langenbeck retractors (right)

Fig. 12 Schematic drawing of the palmar approach: Langenbeck Fig. 13 Schematic drawing of the palmar approach after L-shaped
retractors are used on the ulnar side to protect the median nerve, incision of the pronator quadratus muscle; the muscle is placed under
which is ulnar to the flexor carpi radialis tendon (FCR) the Langenbeck retractor for protection of the ulnar-sided structures

Fig. 14 On the left, disimpaction of the

ulnar-sided palmar fragments is demon-
strated, and on the right a T-shaped mi-
niaturised implant is inserted to recon-
struct the ulnar-sided palmar fragment

Fig. 15 Printouts of intraoperative image

intensification demonstrating reconstruc-
tion of the ulnar die-punch fragments (in-
termediate column) with dorsal and pal-
mar implants
14 K. Mader, D. Pennig: Comminuted intra-articular fractures of the distal radius

Fig. 16 Schematic drawing of the

implants used for reconstruction of the
palmar articular surface: a T-shaped im-
plant is used for the ulnar die-punch
fragment and a straight implant is used
for the radial column (or styloid) frag-
ment; the intraoperative image on the
right shows the closure of the pronator
quadratus muscle

Fig. 17 Intraoperative images of the dor-

sal approach: after marking the distal
radioulnar joint and the dorsal outline of
the radius on the skin (using image
intensification) a 1-cm straight incision
is made radial to the distal radioulnar
joint over the fourth extensor tendon
compartment

Fig. 18 Intraoperative images of the dor-

sal approach: after identification and
incision of the extensor retinaculum
(left) the dorso-ulnar facet fragment is
elevated, reduced and fixed with a fine-
threaded screw with a washer

with a washer aiming at the tip of the radial styloid and most cases it will be sufficient to use the implants as a but-
X-rays are taken to confirm the position (Fig. 15). tress splint with a first FFS snap-off screw being inserted
Once the correct position has been confirmed radi- through the slotted hole. Division of the extensor retinacu-
ographically, the remaining holes are filled with screws of lum is generally advisable to distance the gliding tendons
appropriate length. The screw tips should not be protruding from the implant. Again a limited incision is sufficient
from the dorsal side and should sit inside the cancellous (Fig. 17). A second screw is inserted in the proximal frag-
bone or just inside the cortical bone. Assessment of the ment and these screws measure in general 15 mm for the
dorsal pathology should now be performed. If the dorsal first and second screw. The remaining hole(s) do not nec-
fragments can be reduced by ligamentosis, reduction can essarily have to be filled with screws if they act as a but-
be maintained with transarticular external fixation. tress splint. If the fragment is large enough or if the sur-
Dorsal approaches in general require a CT scan in geon has to stabilise one solid fragment an FFS snap-off
order to understand the position of the articular fragments screw may be inserted through the distal holes. Again ver-
(Fig. 10). An approach through the appropriate tendon ification of the correct implant position and length is
compartment is performed after marking of the joint line required by obtaining a radiograph (Fig. 19).
and the dorsal aspect of the DRU joint under image inten- Bone grafting may be required if a corticocancellous
sification (Figs. 17 and 18). In general single screws or bone defect cannot be reconstructed. Bone is best taken
straight implants with three, four or five holes are used. In from the ileum with the use of a trephine and should con-
K. Mader, D. Pennig: Comminuted intra-articular fractures of the distal radius 15

with dorsal radiocarpal subluxation. J Bone Joint Surg Am

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