Bridging external fixation and supplementary Kirschner-wire fixation versus volar locked plating for unstable fractures of the distal radius

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1 Bridging external fixation and supplementary Kirschner-wire fixation versus volar locked plating for unstable fractures of the distal radius A RANDOMISED, PROSPECTIVE TRIAL K. Egol, M. Walsh, N. Tejwani, T. McLaurin, C. Wynn, N. Paksima From the New York University Hospital for Joint Diseases, New York, United States We performed a prospective, randomised trial to evaluate the outcome after surgery of displaced, unstable fractures of the distal radius. A total of 280 consecutive patients were enrolled in a prospective database and 88 identified who met the inclusion criteria for surgery. They were randomised to receive either bridging external fixation with supplementary Kirschner-wire fixation or volar-locked plating with screws. Both groups were similar in terms of age, gender, hand dominance, fracture pattern, socio-economic status and medical co-morbidities. Although the patients treated by volar plating had a statistically significant early improvement in the range of movement of the wrist, this advantage diminished with time and in absolute terms the difference in range of movement was clinically unimportant. Radiologically, there were no clinically significant differences in the reductions, although more patients with AO/OTA (Orthopaedic Trauma Association) type C fractures were allocated to the external fixation group. The function at one year was similar in the two groups. No clear advantage could be demonstrated with either treatment but fewer re-operations were required in the external fixation group. K. Egol, MD, Associate M. Walsh, PhD, Assistant N. Tejwani, MD, Associate T. McLaurin, MD, Assistant C. Wynn, BA, Researcher N. Paksima, DO, Assistant Department of Orthopaedic Surgery The New York University Hospital for Joint Diseases, 301 East 17th Street, New York, New York 10003, USA. Correspondence should be sent to K. Egol; egolk01@nyumc.org 2008 British Editorial Society of Bone and Joint Surgery doi: / x.90b $2.00 J Bone Joint Surg [Br] 2008;90-B: Received 23 November 2007; Accepted after revision 13 May 2008 Fractures of the distal radius are common and the literature describing the outcome after operative treatment is extensive. 1-4 Published reports have shown that the functional outcome is improved when anatomical articular alignment at union is achieved. 5,6 Imperfect reduction may not, however, result in post-traumatic osteoarthritis. 7 Treatment options for obtaining acceptable alignment in these injuries have been described and include closed reduction and pinning, bridging and non-bridging external fixation and open reduction with plate-and-screw fixation through a variety of approaches. There have been many complications reported with the use of plate-and-screw fixation around the wrist, including irritation or rupture of extensor tendons and intra-articular penetration of hardware Modification of dorsal plates has done little to improve the outcome. 8 External fixation has enjoyed success, but also has been associated with complications such as stiffness of the fingers, loss of reduction, problems with the radial sensory nerve and pin-track infection The recent advances in locking-plate technology have been applied to distal radial fractures. 2,3,16,17 These implants are used for the treatment of many types of fracture pattern of the distal radius through a volar approach which may be less prone to the complications seen with a dorsal approach. 17,18 A recent systematic review of the literature found that external fixation of fractures of the distal radius led to a better outcome, with lower rates of complications compared with plate-and-screw fixation, but further study was recommended in the form of a randomised, prospective clinical trial. 19 Our aim therefore in this prospective, randomised study was to compare the radiological, clinical and functional outcomes of two groups of patients treated either by bridging external fixation or volar locked plating for a displaced fracture of the distal radius. Patients and Methods Over a period of three years, 280 consecutive fractures of the distal radius presented to one of four attending physicians (KE, NT, NP, TM) 1214 THE JOURNAL OF BONE AND JOINT SURGERY

2 EXTERNAL FIXATION VERSUS VOLAR LOCKED PLATING FOR UNSTABLE FRACTURES OF THE DISTAL RADIUS 1215 Table I. Clinical details of the patients in the two groups External fixation (%) Volar plating (%) Mean age in years (range) 49.9 (18 to 78) 52.2 (19 to 87) Gender Female (%) 22 (50) 25 (57) Hand dominance Right (%) 39 (89) 39 (89) AO/OTA classification * (%) A 16 (37) 26 (59) B 2 (4) 1 (3) C 26 (59) 17 (38) Income $50 000/yr (%) 37 (84) 35 (79) Co-morbidities (%) Cardiovascular disease 2 (5) 2 (5) Endocrine disease 4 (9) 4 (9) Pulmonary disease 5 (11) 4 (9) Malignancy 0 (0) 1 (2) Open fractures 2 (5) 1 (2) Operative time (mins) 82.2 (28 to 180) 87.8 (38 to 145) * AO/OTA, Orthopaedic Trauma Association at our institution. In total 148 patients were treated conservatively and 132 had surgical stabilisation. Of these, 88 patients met the inclusion criteria of a fracture of the distal radius requiring operative repair amenable to either open reduction and internal fixation or external fixation and Kirschner (K)-wires. Exclusion criteria included volar and dorsal shear fractures, skeletal immaturity and refusal to participate. The Institution Review Board approved the study and the patients gave informed consent. They were then randomised to undergo either bridging external fixation and a K-wire construct or a locked volar small-fragment plate-and-screw fixation. There were no differences between the groups in regard to age, gender, hand dominance, pattern of fracture, socio-economic status or the number of pre-existing medical conditions (cardiovascular disease, endocrine disease, pulmonary disease, or malignancy) (Table I). Baseline clinical details, including mechanism of injury and the Disabilities of Arm, Shoulder and Hand (DASH) functional score was obtained. 20 A complete history was taken and physical examination performed, with attention paid to neurovascular deficits and open wounds. Standard radiographs were obtained at presentation including anteroposterior (AP), lateral, and oblique views. The fractures were classified according to the system of the Orthopaedic Trauma Association (AO/OTA). 21 Open wounds were classified according to the system of de Souza, Gustilo and Meyer. 22 In addition, for comparison, radiographs of the contralateral wrist were obtained to assess reduction. All displaced fractures were initially treated by closed reduction and application of a splint. Measurements of the radial inclination, height, tilt, ulnar variance and articular step-off were made on the post-reduction radiograph (Table II). Patients who met the criteria for initial closed treatment 23 were reviewed within one week and reexamined clinically and radiologically to assess the maintenance of their reduction. These criteria included residual dorsal angulation of < 10 (from neutral), loss of height of < 2 mm compared with the contralateral side, articular step-off of 1 mm and no associated instability of the distal radio-ulnar joint. If the reduction was maintained the patient was reviewed weekly for three weeks with radiological assessment. Surgery was recommended if reduction was lost, if the fracture was open or was unstable due to the presence of any three of the following: initial dorsal angulation > 20, initial shortening > 5 mm, dorsal comminution > 50%, an intra-articular fracture, age > 60 years and an associated ulnar fracture 23 or a fracture-dislocation of the wrist. The patients were randomised to treatment at presentation using a random-number generator, which assigned either external fixation or volar plating to each operative patient. The result was placed in a sealed envelope by a blinded assistant and given to the treating physician. All operations were performed by one of four fellowshiptrained surgeons (KE, NT, NP, TM), three in trauma and one in hand surgery who had been in practice for seven to 11 years and who had experience with both forms of treatment. All the operations were performed under regional or general anaesthesia. A tourniquet was used at the discretion of the surgeon. The external fixation group underwent closed reduction with the placement of two pins in the base of the second metacarpal and two in the distal third of the radius in an open surgical manner. After application of the fixator (EBI, Parsippany, New Jersey or Stryker, Mahwah, New Jersey, depending on surgeon s preference), if acceptable alignment had been achieved, percutaneous K-wires were placed to hold the reduction (Fig. 1). These K-wires were left proud of the skin to facilitate removal with the external fixator as an outpatient. If an acceptable reduction could not be achieved, one or several small incisions were made to reduce and fix the fracture fragments anatomically with K-wires. At the end of the procedure, all traction was released from the frame, and it was left in place as a neutralisation device. All the patients in the plate group underwent a similar procedure. A standard volar approach of Henry 24 was used. All the fractures were reduced in an open manner and stabilised by a locked pre-contoured volar plate (Hand Innovations, Miami, Florida or Stryker, depending on surgeon s preference) (Fig. 2). The patients were followed up at two and six weeks and at three, six and 12 months. Post-operatively, all were placed in a volar plaster splint. After one week the VOL. 90-B, No. 9, SEPTEMBER 2008

3 1216 K. EGOL, M. WALSH, N. TEJWANI, T. MCLAURIN, C. WYNN, N. PAKSIMA Table II. Mean (SD) radiological measurements in the two groups External fixation Volar plating p-value * Uninjured wrist at presentation Volar tilt ( from neutral) 10.3 (5.6) 9.6 (4.7) 0.55 Radial inclination ( ) 22.8 (1.8) 22.9 (3.9) 0.84 Radial length (mm) 11.0 (2.5) 11.7 (2.6) 0.33 Ulnar variance (mm) (1.6) (2.1) 0.40 Injured wrist, pre-reduction Volar tilt ( from neutral) (19.1) (22.1) 0.82 Radial inclination ( ) 14.6 (8.0) 13.8 (7.9) 0.69 Radial length (mm) 7.0 (4.2) 6.9 (4.2) 0.93 Ulnar variance (mm) 3.1 (3.5) 3.2 (3.5) 0.87 Injured wrist, post-reduction Volar tilt ( from neutral) 0.3 (12.1) -2.7 (14.7) 0.35 Radial inclination ( ) 18.8 (6.5) 17.1 (4.7) 0.20 Radial length (mm) 9.5 (3.5) 9.3 (3.0) 0.87 Ulnar variance (mm) 0.9 (2.4) 1.0 (2.7) 0.91 Three months post-operatively Volar tilt ( from neutral) 3.3 (7.2) 4.4 (6.9) 0.58 Radial inclination ( ) 19.9 (5.4) 22.2 (4.5) 0.07 Radial length (mm) 10.5 (2.9) 10.9 (2.7) 0.55 Ulnar variance (mm) 1.6 (1.9) 0.6 (2.0) 0.05 Six months post-operatively Volar tilt ( from neutral) 3.2 (10.3) 6.5 (5.1) 0.17 Radial inclination ( ) 19.7 (5.0) 21.2 (3.4) 0.22 Radial length (mm) 9.7 (2.7) 10.3 (1.9) 0.40 Ulnar variance (mm) 1.3 (1.9) 1.4 (4.2) months post-operatively Volar tilt ( from neutral) 2.5 (10.9) 5.7 (6.6) 0.10 Radial inclination ( ) 20.7 (5.3) 20.0 (4.2) 0.14 Radial length (mm) 10.7 (2.8) 9.9 (2.6) 0.24 Ulnar variance (mm) 1.8 (2.6) 1.0 (1.9) 0.28 * Student s t-test dressings and sutures were removed. Patients treated by external fixation began finger exercises and were seen every two weeks for radiological follow-up. A dry sterile gauze dressing was wrapped about the pins to minimise skin-pin movement. No dedicated pin-care regimen was used. Those in the plate group were placed in a removable Velcro splint for comfort and allowed free movement of their wrists and fingers. They were seen after six weeks for radiological follow-up. At six weeks the external fixators and K-wires were removed in the outpatient clinic without anaesthesia. All patients had formal physiotherapy emphasising active and passive finger movement, wrist movement (if able) and forearm movement. At each assessment the number of physiotherapy sessions was recorded and the range of movement of the wrist and fingers was measured by an independent observer using a goniometer. A functional outcome measure, the DASH questionnaire, was completed. 20 Pain was rated by a ten-point visual analogue scale (0, no pain; 10, severe pain). Grip strength was obtained with a dynamometer at each visit and on the uninjured side at three months for comparison. Radiological assessment at each post-operative visit was done from AP and lateral radiographs and included assessment of union of the fracture, loss of reduction and development of arthritis. Measurements of radial inclination, height, tilt and ulnar variance were made on each radiograph (Table II). The presence of arthritic change 25 was noted if observed on the six- and 12-month radiographs. Statistical analysis. Differences in clinical details were assessed using the chi-squared test for categorical variables such as gender, hand dominance, fracture pattern, income level, co-morbidities and Student s t-test for continuous variables such as age. Differences in the range of movement and radiological measurements were assessed using t-tests and in the follow-up DASH score by linear regression while controlling for baseline scores. We also carried out linear regression while additionally controlling for OTA classification. Since the regression coefficients for the type of fixation did not change in THE JOURNAL OF BONE AND JOINT SURGERY

4 EXTERNAL FIXATION VERSUS VOLAR LOCKED PLATING FOR UNSTABLE FRACTURES OF THE DISTAL RADIUS 1217 Fig. 1a Fig. 1b Fig. 1c Fig. 1d Fig. 1e Radiographs of a 32-year-old woman with a) and b) a displaced intra-articular fracture of the distal radius in which closed treatment failed, necessitating c) external fixation and supplementary K-wire fixation with d) and e) good alignment after one year. significance or in substance we excluded the AO/OTA classification from the final models for simplicity of interpretation. The level of significance for all statistical tests was set at p = Our study had 80% power to detect a difference of 20% in any of the range-of-movement parameters in the two experimental groups. This required a total of 32 patients in each group. We extended the study originally to a total of 88 patients, 44 per group, because this would provide 90% power to detect the same difference and therefore allow greater potential variability in the outcome at one year. Results One patient died before the three-month follow-up, one who had sustained a severe open fracture, underwent wrist fusion before six months and was excluded, and seven were lost to follow-up or did not complete follow-up at one year. Two patients were randomised, one to a plate, who received a supplementary external fixator, and one to an external fixator, who received a supplementary volar plate, both at the surgeon s discretion. They completed all the follow-up examinations. However, they were not included in the analysis. This left 77 patients who formed the basis of VOL. 90-B, No. 9, SEPTEMBER 2008

5 1218 K. EGOL, M. WALSH, N. TEJWANI, T. MCLAURIN, C. WYNN, N. PAKSIMA Fig. 2a Fig. 2b Fig. 2c Radiographs of a 43-year-old man with a) and b) a comminuted intra-articular fracture of the distal radius which required c) treatment by volar locked plating with d) and e) good alignment after one year. Fig. 2d Fig. 2e the study. In total, 38 patients received external fixation and supplementary K-wire fixation and 39 volar plating. There was no significant difference between the two groups with respect to sub-classification of the fracture pattern. All patients completed a minimum follow-up of one year. There were two open fractures in the external fixation group and one in the plate and screw group. At presentation, eight patients, four in the external fixation group and four in the plate group, had symptoms of carpal syndrome. The mean length of the operative procedure was 82.2 minutes (28 to 180) for the external fixation group and 87.8 minutes (38 to 145) for the plate group. Between surgery and six months, both groups attended an equal number of physiotherapy sessions. Between six months and one year, patients in the external fixation group received a mean of 43.5 (4 to 82) physiotherapy sessions compared with 20.4 (9 to 60) sessions in the plate and screw group (t-test, p = 0.02; Table III). The mean pain scores obtained at each interval were similar for each group and lacked statistical significance (Table III). There were no differences in the mean DASH scores at each follow-up point, compared with the patients self-reported baseline levels. There was only a marginal difference at six months (mean difference, 7.6; linear regression, p = 0.06). By one year, there was no discernable difference between the two groups (linear regression, p = 0.15; Table III). For each group, the mean range of movement of the wrist improved at each successive assessment (Table III). For all parameters, as a percentage of the uninjured side, the range of movement was better in the internally-fixed group. For pronation (p < 0.001), supination (p = 0.05), extension (p = 0.05) and radial deviation (p = 0.002) this difference reached statistical significance at three months. These differences were somewhat attenuated by six months, with extension of the wrist and pronation still better in the plated group (p < and p = 0.001, respectively). These differences were still present at one year. Despite a better range of movement in the wrist in the plated group, there was no difference with respect to grip strength between the two groups at any point. Radiologically, all the fractures united except one. The radiological data (Table II) showed that both groups had similar anatomy according to the assessments made of their uninjured wrists. Each sustained similar amounts of initial displacement and in each the fracture was reduced to a similar extent. In addition, acceptable reduction parameters were obtained and maintained at each follow-up. None of THE JOURNAL OF BONE AND JOINT SURGERY

6 EXTERNAL FIXATION VERSUS VOLAR LOCKED PLATING FOR UNSTABLE FRACTURES OF THE DISTAL RADIUS 1219 Table III. Mean (SD) outcome measures expressed where applicable as a percentage of the uninjured side at three, six and 12 months Outcome External fixation Percentage of uninjured side Volar plating Percentage of uninjured side p-value * Three months Grip strength (%) 29 (17.5) (15.2) Pain (mm) 1.8 (2.2) 2.3 (2.5) 0.16 Extension (%) 61 (17.4) (8.1) Flexion (%) 60 (14.4) (14.5) Supination (%) 71 (23.2) (21.8) Pronation (%) 82 (16.3) (10.2) 13 < Ulnar deviation (%) 66 (8.9) (9.2) Radial deviation (%) 39 (9.5) (20.4) Function (DASH score) 25.4 (21.1) 19.5 (20.1) 0.10 Mean number of physiotherapy sessions 14.7 (9.8) 16.4 (8.5) 0.20 Six months Grip strength (%) 52 (23.0) (22.2) Pain (mm) 2.3 (2.3) 2.6 (2.4) 0.49 Extension (%) 56 (16.3) (12.1) 17 < Flexion (%) 71 (10.1) (17.8) Supination (%) 86 (15.9) 7 85 (12.8) Pronation (%) 62 (16.9) (14.6) Ulnar deviation (%) 75 (12.9) 9 70 (5.8) Radial deviation (%) 91 (11.2) (8.1) Function (DASH score) 32.6 (23.8) 25.0 (21.7) 0.06 Mean number of physiotherapy sessions 32.8 (22.0) 34.2 (16.7) months Grip strength (%) 100 (57.0) (27.5) Pain (mm) 2.1 (2.7) 2.5 (2.9) 0.50 Extension (%) 90 (13.5) (13.1) Flexion (%) 84 (9.7) (13.3) Supination (%) 99 (10.3) (9.3) Pronation (%) 95 (5.7) (6.7) Ulnar deviation (%) 79 (7.4) (9.4) Radial deviation (%) 99 (8.3) (18.3) Function (DASH score) 17.2 (33.7) 13.0 (30.9) 0.15 Mean number of physiotherapy sessions 43.5 (33.4) 20.4 (8.0) 0.02 * Student s t-test the differences between the groups at follow-up was significant. However, there were more type-c fractures (58%, 22 patients) in the external fixation group than in the plated group (38%, 15 patients). The rate of complications was similar for both treatment methods with seven patients (18.4%) in the external fixation group having seven complications compared with eight (20.5%) in the plate group (Table IV). This difference was not statistically significant (chi-squared test, p = 0.45). Two patients in the external fixation group and five in the plate and screw group required further surgery. In the external fixation group one underwent capsulectomy and tenolysis for post-operative stiffness and one had a tendon transfer for rupture of extensor pollicis longus. In the plated group, one patient had removal of hardware and incision and drainage with the administration of antibiotics for the treatment of a post-operative wound infection, one had removal of hardware for symptomatic prominence of the plate and screws, one who developed nonunion required further fixation with a dorsal plate and bone graft with subsequent union and two had tendon transfer for a ruptured extensor pollicis longus. Discussion Improved results were found with regard to range of movement in the patients with a volar plating as early as three months post-operatively compared with those who had external fixation. This trend diminished over time. We acknowledge that the randomisation process allocated almost one-third more patients with type-c fractures to the external fixator group and a similar additional proportion of patients with a type-a fracture to the volar plate group. This may have had some bearing on the outcome. Other parameters, such as pain and function, were equivalent at all time points. Patients who received a plate had palmar flexion and radial deviation of a mean of 6 greater than those treated by external fixation at one year. While statistically significant, these small improvements in the range of VOL. 90-B, No. 9, SEPTEMBER 2008

7 1220 K. EGOL, M. WALSH, N. TEJWANI, T. MCLAURIN, C. WYNN, N. PAKSIMA Table IV. Details of the complications in both groups External fixation Post-operative nerve deficit 3 2 Wound infection 0 1 Pin-track infection 2 0 Painful-retained hardware 0 1 Tendon rupture 1 2 Tendonitis 1 1 Nonunion 0 1 Further surgery 2 5 Volar plating movement of the wrist were not likely to be clinically relevant. While the overall rates of complications between the groups were similar, the necessity for subsequent surgical intervention in the plate and screw group was greater. The goal of surgery for a distal radial fracture is to obtain and maintain an acceptable reduction and to allow restoration of function. Parameters associated with an improved outcome include the minimisation of the post-operative fracture gap and step and the restoration of radial length. 6 Historically, closed reduction has been the mainstay of treatment. The mechanism of fracture reduction using indirect methods is ligamentotaxis of the dorsal and volar capsule which realigns the fracture with respect to length, inclination and tilt. We did not find plate and screw fixation to be superior to external fixation in the ability to maintain reduction. The minor improvements in the range of movement seen early did not translate into a better functional outcome at any stage. Improved wrist movement was demonstrated early, but by one year most of these differences were not present. It is possible that the earlier free range of wrist movement afforded to the plate and screw patients allowed for earlier improved movement. However, it should be noted that patients who had been treated by external fixation received twice as much physiotherapy between six months and one year post-operatively. Wakefield and McQueen 26 performed a randomised, prospective study, comparing a formal physiotherapy programme with none after non-operative treatment of a distal radial fracture in patients older than 55 years. They found that good results were possible without a formal rehabilitation and that factors such as malunion and the pre-injury level of function correlated with poorer results. However, they also found that physiotherapy was associated with an improved range of palmar and dorsiflexion of the wrist at six months. Good to excellent clinical and radiological results from the operative treatment of distal radial fractures have been frequently reported. In one meta-analysis which included 46 papers, with 916 patients treated by external fixation and 603 by internal fixation, the authors could find no evidence to support one treatment method over the other. 19 In a second systematic review of the literature by Paksima et al, 14 of 31 articles there were only two randomised clinical trials and two non-randomised comparisons. They concluded that operative treatment was favoured for unstable patterns and that external fixation was superior to internal fixation. 14 Finally, in a Cochrane database review of 48 randomised trials, involving over 4300 patients, it was concluded that the studies lacked robust evidence for the success of one method of treatment over another. 27 In one randomised trial comparing dorsal plating with mini-open reduction and external fixation no difference in outcome was found with regard to the DASH scores, but a higher rate of complications was seen in the dorsal plating group. In another randomised study on 90 patients with displaced intra-articular distal radial fractures, with the treatment options of closed treatment and plaster, external fixation, or non-locking plating and screws, external fixation alone was found to give the best results. 28 One problem in trying to compare the results of previous studies with our findings is that most of the earlier studies used dorsally-applied plates and screws. Dorsal plating of distal radial fractures is known to lead to irritation of the extensor tendon and potential rupture. 8,29,30 This has led to the recent interest in the volar application of locked plates for the treatment of these fractures. There is clinical and biomechanical evidence that volar locked plating is an improvement over dorsal, non-locked plating for unstable fractures because of its stiffer construct and lower rates of complications. 2,31,32 Despite the apparent biomechanical stability, improvement in outcome has yet to be demonstrated. In regard to the external fixation device which we used, we chose a joint-spanning construct because it could be applied in most distal radial fractures. Studies have compared bridging with non-bridging external fixation. In one study, McQueen 33 randomised 60 patients who had lost an acceptable reduction to treatment by either bridging external fixation, without supplementary K-wire fixation, or non-bridging external fixation. At all post-operative intervals the functional results in respect of grip strength and movement of the wrist were better in the non-bridging group. We agree that some type of fixation must be provided for the distal fragments in these fractures. However, we have little experience of the non-bridging technique. We therefore chose to use the bridging type of external fixation with K-wire fixation of fracture fragments. Currently, there is little information on a direct comparison of external fixation and volar locked plating. Wright, Horodyski and Smith 34 retrospectively reported 21 patients who had been treated by a volar locked plate and compared them with 11 patients who had been treated by external fixation. While no functional difference was reported between the two groups the final radiological results were better in the plating group. However, the small numbers and retrospective nature of the study made it difficult for conclusions to be drawn. In conclusion, we looked at external fixation vs locked volar plates in a prospective randomised manner and found THE JOURNAL OF BONE AND JOINT SURGERY

8 EXTERNAL FIXATION VERSUS VOLAR LOCKED PLATING FOR UNSTABLE FRACTURES OF THE DISTAL RADIUS 1221 an improved range of movement and radiological outcome at three and six months after locked plating, but although the improved early ranges of wrist movement were statistically significant, the actual difference was of little clinical significance. None of the improvements was associated with a better outcome. Furthermore, while the number of complications between the two methods was similar, there was a greater incidence for re-operation in the plating group. Despite this finding, our study showed no evidence for the superiority of one treatment over the other. Supplementary Material A further opinion by Ms S. Fullilove is available with the electronic version of this article on our website at Although none of the authors has received or will receive benefits for personal or professional use from a commercial party related directly or indirectly to the subject of this article, benefits have been or will be received but will be directed solely to a research fund, foundation, educational institution, or other nonprofit organisation with which one or more of the authors are associated. References 1. Grewal R, Perey B, Wilmink M, Stothers K. A randomized prospective study on the treatment of intra-articular distal radius fractures: open reduction and internal fixation with dorsal plating versus mini open reduction, percutaneous fixation, and external fixation. J Hand Surg [Am] 2005;30: Orbay J, Badia A, Khoury RK, Gonzalez E, Indriago I. Volar fixed-angle fixation of distal radius fractures: the DVR plate. Tech Hand Up Extrem Surg 2004;8: Rozental TD, Blazar PE. 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