Functional Outcome of Unstable Distal Radius Fractures: ORIF With a Volar Fixed-Angle Tine Plate Versus External Fixation Thomas W. Wright, MD, MaryBeth Horodyski, EdD, Gainesville, FL, Dean W. Smith, MD, Houston, TX Purpose: The purpose of this study was to compare the outcomes of 2 treatments for unstable distal radius fractures: open reduction internal fixation (ORIF) through a volar approach with a fixedangle implant and a standard external fixation (EF) method. Methods: This study included patients with comminuted unstable intra-articular and extra-articular distal radius fractures treated by a single surgeon. Data were gathered retrospectively on 11 patients treated with EF who had been followed up for an average of 47 months (range, 12 84 mo). Prospective data were gathered on 21 patients who were treated with ORIF through a volar approach with a fixed-angle implant. Follow-up evaluation for this group averaged 17 months (range, 12 24 mo). The 2 groups were compared for range of motion (ROM), strength, and functional outcome as measured by the Patient Rated Wrist Evaluation (PRWE) and the Disability of the Arm, Shoulder, and Hand Questionnaire (DASH). Fracture reduction was evaluated from radiographs taken at the last follow-up visit and compared between groups. Results: The mean passive wrist ROM at the final follow-up evaluation in EF patients was 59 extension and 57 flexion, compared with 63 extension and 64 flexion in patients treated with ORIF. Passive pronation/supination arc of motion was similar for the 2 groups, as were the DASH and PRWE scores. Grip strength as a percentage of the opposite wrist was significantly greater in the external fixation group, a possible consequence of longer follow-up evaluation. Final radiographic measurements for the EF group averaged 5 volar tilt and 25 radial inclination, with 2.2-mm ulnar-positive variance. The ORIF with volar plating group averaged 10 volar tilt and 22 radial inclination, with.5-mm ulnar-negative variance. Radial length and volar tilt were significantly greater for the ORIF group. The average final intra-articular step-off was significantly different, with 1.4-mm step-off in the EF group and.4 mm in the ORIF group. From the Division of Hand and Upper Extremity Surgery, Department of Orthopaedics and Rehabilitation, University of Florida, Gainesville, FL; and Department of Orthopaedics, University of Texas School of Medicine, Houston, TX Received for publication January 29, 2004; accepted in revised form November 12, 2004. 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. Supported by Avanta Orthopaedics, San Diego, CA. Reprint requests: Thomas W. Wright, MD, Department of Orthopedics, Box 112727, University of Florida, Gainesville, FL 32611. Copyright 2005 by the American Society for Surgery of the Hand 0363-5023/05/30A02-0010$30.00/0 doi:10.1016/j.jhsa.2004.11.014 The Journal of Hand Surgery 289
290 The Journal of Hand Surgery / Vol. 30A No. 2 March 2005 Conclusions: The use of ORIF with a volar fixed-angle implant resulted in stable fixation of the distal articular fragments, allowing early postsurgical wrist motion. The PRWE and DASH scores for the groups were equivalent, whereas intra-articular step-off, volar tilt, and radial length were better in the ORIF group. There were few complications, implant removal was not necessary, and early postsurgical wrist ROM was initiated without loss of reduction. (J Hand Surg 2005;30A:289 299. Copyright 2005 by the American Society for Surgery of the Hand.) Key words: Distal radius fractures, ORIF, external fixation, volar approach, PRWE. The goal of surgical fixation in the unstable distal radius fracture is to restore intra-articular and extraarticular anatomic alignment. 1 3 Volar open reduction internal fixation (ORIF) for comminuted intraarticular or extra-articular fractures is an accepted method of stabilizing Smith or volar Barton fractures. There are few reports, however, on volar plating for dorsal displaced fractures. 4 6 The management of distal radius fractures continues to evolve as improved techniques and fixation systems are developed. Treatment options expanded with the introduction of the volar fixed-angle plate, which supports the subchondral bone from the volar side of the radius. Potential advantages for this new technique include stable subchondral fixation, early postsurgical active wrist motion, restoration of articular and extra-articular alignment, and fewer complications when compared with external fixation (EF). 4,6 The purpose of this study was to compare the outcomes of unstable distal radius fractures treated by a single surgeon using either ORIF (followed up prospectively) with a volar fixed-angle implant or a standard EF method (reviewed retrospectively). Both were evaluated with a validated upper-limb functional outcome score, the Disability of the Arm, Shoulder, and Hand Questionnaire (DASH) questionnaire, and a joint-specific outcome measure, the Patient-Rated Wrist Evaluation (PRWE). We used an implant plate in this study (Avanta Subchondral Support Vvolar; San Diego, CA). Materials and Methods All patients who had been treated by the primary author at the institution s hand clinic after 1995 for unstable distal radius fractures were considered for this study. These patients were referred to the senior author s clinic through the emergency department, other physicians offices, and self-referral. For the purpose of this investigation an unstable distal radius fracture was defined as a distal radius fracture with greater than 10 of dorsal angulation, extensive dorsal comminution, greater than 2 mm of shortening, or an intra-articular step-off greater than 1 mm. Eighteen patients were identified who had been treated with an external fixator (Agee Wrist Jack external fixator; Hand Biomechanics Lab, Sacramento, CA) (Fig. 1) between 1995 and 2000. Seven patients were lost to follow-up evaluation, leaving 11 patients who met the study criteria. These patients constituted the EF group, which included 8 women and 3 men with a mean age of 50 years (range, 21 64 years). Ten of the 11 patients were right handed. Eight of the 11 fracture patterns were comminuted and intra-articular. From 1999 to 2001 there were 25 patients who were treated for distal radius fractures by using ORIF Figure 1. Wrist external fixator (Agee).
Wright, Horodyski, and Smith / Distal Radius Fractures and Volar ORIF 291 Figure 2. (A) Volar fixed-angle tine plate (distal AP view) (Avanta). (B) Volar fixed-angle tine plate (lateral view) (Avanta). and the volar fixed-angle subchondral support/volar plate (Avanta Orthopaedics, San Diego, CA) (Fig. 2). Three of these patients were lost to follow-up evaluation and 1 patient died from unrelated causes. The remaining 21 patients were included in the study and formed the ORIF group. There were 11 men and 10 women with a mean age of 50.1 years (range, 19 74 years). Nineteen of 21 patients were right-handed; fracture patterns were comminuted and intra-articular for 19 of 21 patients. Patients who had been treated by other methods or surgeons and those whose fractures were secondary to gunshots were excluded from consideration. Retrospective data from medical records were used for the EF group. Data were gathered prospectively as part of normal clinic examinations after surgical treatment for the ORIF volar implant group. This study was approved by the local institutional review board. Both groups studied were consecutive series. Follow-up examination consisted of range of motion (ROM) measurements, grip strength, and radiographic evaluation. In a 2000 study comparing the sensitivity of several patient questionnaires MacDermid et al 9 found the PRWE to be more sensitive than the DASH in evaluating recovery after distal radius fractures. Thus both the PRWE 7 and DASH 8 questionnaires were administered at the final follow-up evaluation and scores were used as measures of functional outcome. Descriptive analyses were completed on all the variables of interest. Analysis of variance was used to assess differences between the groups for ROM, functional outcome, time to union, and radiographic data. Time to union was based on clinical and radiographic examination. Variables of interest at final radiographic follow-up evaluation were articular step-off, radial inclination, volar tilt, and ulnar variance. The radiographic results were measured by the senior author on plain radiographs with a goniometer. Categoric data were analyzed using the chi-square test. The level of significance was set at p.05. Surgical Technique EF was performed using an external fixator (Agee) and applied according to the technique manual. 10 Bone graft and/or K-wires were used on some patients to supplement fixation. For the ORIF group the implant was applied through a volar approach to the radius. The flexor carpi radialis subsheath was opened and the tendon was retracted in an ulnar direction along with the flexor tendons and the median nerve. The sheath was released distal to the wrist flexion crease so that it could be mobilized adequately. The pronator quadratus was exposed and elevated off the volar aspect of the radius from a radial to ulnar direction (Fig. 3). Fracture fragments were evaluated directly and with fluoroscopy. A preliminary reduction was made with the aid of bone graft, pereosteal elevators, bone tamps, K-wires, and finger traps. Reduction was facilitated by applying traction to the index and middle fingers with a folded towel placed dorsal to the carpometacarpal joints (not the wrist because this will make reduction more difficult). The volar cortex, which usually is of good quality bone, can be reduced directly. If considerable intra-articular comminution and displacement existed, then the brachioradialis and the first dorsal compartment were elevated off the distal radius and the radial shaft was pronated to facilitate exposure. 11 This allowed access through the fracture site to the entire distal radius. Under fluoroscopy the articular fragments were reduced with a bone tamp using the scaphoid and lunate as a mold. Preliminarily the fragments were held in place by tamping in allograft corticocancellous chips or by using K-wires. The use of K-wires was minimized because they frequently get in the way. Once preliminary reduction was achieved the selected volar template was positioned and held in place with stabili-
292 The Journal of Hand Surgery / Vol. 30A No. 2 March 2005 Figure 3. (A) Intraoperative view of surgical exposure of the volar radius. (B) Schematic drawing of volar wrist exposure. zation wires (Fig. 4). The goal was to place the stabilization wires adjacent to the subchondral plate and parallel with the articular surface in both the anteroposterior (AP) and lateral planes (Fig. 4B). Confirmation of preliminary reduction and guidewire placement was obtained with intrasurgical fluoroscopy. It is mandatory that the intra-articular fracture fragments be aligned anatomically before drilling the tine holes. It is not necessary to have the extraarticular fracture aligned perfectly at this time. The tine holes were predrilled and the template was removed (Fig. 5). The previously sized stainless steel implant was positioned and the tines were seated fully into the predrilled holes (Fig. 6). If the preliminary extra-articular reduction was not aligned anatomically and the tines were placed parallel to the articular surface (in both planes) then the plate will be angled proximally to the ulnar and volar side of the radius and not in contact with the radial shaft. By application of a dorsal- and radial-directed force the plate was reduced to the volar surface of the radial shaft, resulting in additional volar tilt and radial inclination to the distal radial fragment (Fig. 7). The final reduction was checked radiographically and the plate was secured to the radial shaft using 3.5-mm cortical screws (Fig. 8). To obtain a lateral x-ray the forearm was raised 20 to 30 relative to the usual lateral position so the surgeon could look directly down the radius from the lateral profile. In a typical lateral x-ray the tines will appear to be in the joint. The goal was to have the tines between 2 and 4 mm from the subchondral surface. If the fixation was greater than 4 mm from the articular surface then the fixation was not as secure (poor bone) and anatomic alignment could be lost. The device also could be applied directly through the fracture. After surgery a volar splint was applied and digital ROM and edema control were begun immediately. Between postsurgical days 1 and 3 gentle active and passive wrist ROM were initiated, with the supportive wrist control splint removed for this purpose. Early ROM was found to be particularly important in highly comminuted intra-articular fractures because it allowed the multiple chondral fragments to be molded into a smooth surface by the action of the moving scaphoid and lunate. Results Distribution of fracture patterns, intra-articular involvement, and patient demographics were similar
Wright, Horodyski, and Smith / Distal Radius Fractures and Volar ORIF 293 Figure 4. (A) Intraoperative view of the template in place. K-wires are parallel to the articular surface in the AP and lateral planes (intra-articular reduction already was performed). Note that template is angled volar and ulnar away from the radial shaft because of incomplete extra-articular reduction. (B) Intraoperative fluoroscopy showing correct positioning of wires and template. for the EF and ORIF groups. The groups did not differ significantly for gender, mechanism of injury (chi-square tests), or patient age (analysis of variance). The external fixation group had significantly longer follow-up times (analysis of variance, p.05). The distribution of fractures in the EF group using the Frykman classification were 3 type II, 2 type III, 1 type VI, 1 type VII, and 4 type VIII fractures. By using the AO classification there were 3 A2, 3 C2, and 5 C3 fracture types. Two of the cases involved worker s compensation. The mean follow-up period was 47 months (range, 12 84 mo) and the average time to union was 8 weeks (range, 7 10 wk). Time to union was defined clinically as the lack of tenderness at the fracture site and radiographically as bridging callous. One case also involved an ipsilateral distal radioulnar ligament disruption. Postsurgical complications included 3 cases of complex regional pain syndrome (CRPS), 3 pin-site infections, 1 extensor pollicis longus tendon rupture, and 1 early loss of reduction. CRPS was defined as patients with severe pain and active vasomotor changes involving their hand or wrist on the fractured side. The distribution of fractures in the ORIF group using the Frykman classification was 1 each of types I through IV, 4 type VI, 3 type VII, and 10 type VIII fractures. By using the AO classification there were 2 A3, 9 C2, and 10 C3 fracture types. Fracture distribution was not statistically different from that in the EF group (chi-square test, p.05). In 1 case an external fixator applied at an outside facility resulted in inadequate reduction, which was converted to an ORIF with fixed-angle implant at our institution. The mean follow-up period was 17 months (range, 12 24 mo) and the average time to union was 7 weeks (range, 6 10 wk). Six patients also had associated ipsilateral upper-extremity injuries including 2 patients with unstable distal radioulnar joints, 2 with traumatic median nerve neurapraxia, 1 with
294 The Journal of Hand Surgery / Vol. 30A No. 2 March 2005 Figure 5. Schematic diagram showing the drilling of the tine holes through the template. scapholunate ligament disruption, and 1 with scaphoid fracture. When immediate postsurgical radiographs were compared with final x-rays there was no loss of reduction in any patient in the ORIF group. Postsurgical complications included 3 cases of CRPS (2 in patients with median nerve injuries incurred at the time of injury). A clinical example of ORIF through a volar approach with a fixed-angle implant is shown in Figures 9 and 10. Clinical outcomes for both groups are shown in Table 1. Table 2 shows the radiographic outcomes. Values are means of the measures at the final follow-up visit. The means and ranges for the ORIF and EF groups were compared using analyses of variance (p.05). Discussion Most studies of ORIF treatment of unstable apex volar distal radius fractures have focused on a dorsal approach with dorsal plating techniques. 1 3,11 13 In early studies complication rates up to 50% were reported. 12 The need to restore anatomic articular and extra-articular congruity while keeping complications to a minimum fueled the advance of other methods of internal fixation and led to the development of lower-profile and specialty plates/screw systems for the dorsal aspect of the distal radius. 13,14 The potential advantages of the volar fixed-angle implants include a decreased rate of complications when compared with dorsal plating or external fixation, subchondral support through the fixed-angle tines, and initiation of early wrist motion exercises. Volar plate fixation also avoids damage to the extensor tendons and the production of dorsal scarring, which can lead to improved postsurgical wrist flexion. 15 The fixed-angle tines provide subchondral support after volar tilt is restored, preventing collapse while eliminating the need for any external fixation across the wrist joint. A cancellous bone graft can be added to fill any metaphyseal voids created at the time of reduction but is not mandatory except when preliminary support of small depressed subchondral fragments is needed. Complications are low for ORIF through a volar approach with fixed-angle implant. In our study there were 3 complications of CRPS in 21 patients. Two of these cases occurred in patients with known median nerve injury incurred at the time of the trauma. Among the 28 patients treated by this surgeon with ORIF and fixed-angle implant there was 1 case of a ruptured extensor pollicis longus tendon. The tendon rupture occurred early in our experience with the implant and was caused by a technical error when a distal screw penetrated the dorsal cortex. This patient had successful reconstruction of the extensor pollicis longus using the extensor indicis proprius tendon but was not included in this series because she died from
Wright, Horodyski, and Smith / Distal Radius Fractures and Volar ORIF 295 Figure 7. Schematic diagram showing the plate being reduced to the radial shaft. By bringing the plate to the shaft in the coronal plane radial-ulnar inclination is obtained. Reducing the plate to the radius in the sagittal plane obtains volar tilt. Figure 6. Intraoperative photograph showing the application of the volar fixed-angle plate. Note proximally it is off the radius in a volar and ulnar direction. an unrelated condition before 1-year follow-up data could be obtained. We no longer use the distal cancellous screws routinely because we have found them unnecessary. All 3 cases of CRPS improved with physiotherapy. Three CRPS complications also occurred in the EF group; all of them resolved with physiotherapy. The complication rate for the ORIF group was 3 of 21 (14%); the EF group had a complication rate of 3 of 11 (27%). There were no significant differences between the 2 groups concerning ROM. This is a result of keeping hardware away from the dorsal side of the wrist, initiation of early wrist motion exercises, and obtaining normal articular surface palmer tilt with the ORIF group. The relative equivalency of ROM between the 2 groups may be attributable to differences in length of follow-up evaluation. Our impression is that the patients treated with EF were relatively stiff when discharged at 3 to 6 months after surgery. When they were followed up nearly 4 years later, however, wrist motion had improved markedly. This series suggests that wrist ROM may continue to recover over many months and possibly years. Another finding in the EF group was that grip strength for the affected wrist was nearly the same as that for the uninvolved wrist. Once again we suspect this was caused by the longer follow-up period although a statistical aberration in this small group of patients cannot be ruled out. In a functional outcome study of 275 patients who had had ORIF for distal radius fractures MacDermid et al 16 reported that although the rate of progress had slowed, considerable improvement occurred between 6 and 12 months. They too suggested that improvements might continue and be measurable for longer periods. Figure 8. Intraoperative photograph of plate in place.
296 The Journal of Hand Surgery / Vol. 30A No. 2 March 2005 Figure 9. Patient with comminuted displaced intra-articular radius fracture with significant scapholunate injury. (A) Presurgical AP radiograph. (B) Presurgical lateral x-ray. (C) AP radiograph after treatment with a volar fixed-angle plate. (D) Lateral radiograph after treatment. Final radiographic evaluations showed that articular step-off, volar tilt, and radial length were better in the ORIF group. An intra-articular step-off of greater than 1 mm has been associated with poorer outcome. 17 19 Knirk and Jupiter 20 associated intra-articular step-offs of 2 mm or greater with posttraumatic arthritis. In our study 74% of patients (14 of 19) in the ORIF group had no measurable intra-articular step-off whereas only 25% (2 of 8) of the EF group could make that claim. Step-offs of 2 mm were found
Wright, Horodyski, and Smith / Distal Radius Fractures and Volar ORIF 297 Figure 10. Photographs of patient s hands 6 weeks after fixation with a volar fixed-angle plate (patient s left wrist was injured). (A) Extension of wrist. (B) Palmar flexion of wrist. (C) Wrist supination (note surgical scar on the left). (D) Wrist pronation. in 16% (3 of 19) of the ORIF group compared with 50% (4 of 8) of the EF group. Both methods restored volar tilt but the ORIF group had a final average of 10 volar tilt, which essentially is normal compared with 5 for the EF group. The volar fixed-angle plate maintains reduction through the fixed subchondral supports, preventing the metaphyseal bone from collapsing and the subsequent loss of volar tilt. The external fixator (Agee) can restore volar tilt through multiplanar ligamentotaxis combined with volar translation of the hand on the forearm. 10 In the ORIF group the radial length was relatively easy to judge because the good volar cortex of the radius could be viewed directly at the time of surgery. In addition the fixed-angle plate prevented shortening of the radius whereas EF can contribute to greater radial shortening because of late setting at the fracture site. The EF group had 2 factors working against them radiographically: (1) reduction of the articular surface was less complete because patients were not treated in an open fashion and (2) settling occurring after removal of the fixator. Final PRWE and DASH outcome scores were not significantly different for the 2 groups despite the shorter follow-up time and larger number of associated upper-extremity injuries in the ORIF group. Time to union was not significantly different (7 weeks for the ORIF group and 8 weeks for the EF group). The results of our study are similar to another published study using a fixed-angle implant through Table 1. Clinical Outcome External Fixator Group Mean (Range) Volar Plate Group Mean (Range) Flexion ( ) 57 (30 85) 64 (30 90) Extension ( ) 59 (20 75) 63 (25 85) Pronation ( ) 82 (50 90) 78 (60 90) Supination ( ) 76 (45 90) 80 (35 100) Radial deviation ( ) 21 (0 35) 23 (10 35) Ulnar deviation ( ) 36 (20 50) 36 (20 60) DASH 15 (0 41) 16 (0 67) PRWE 19 (0 58) 20 (0 80) Grip strength* 99% (66% to 135%) 75% (30% to 103%) *Grip affected 100 grip unaffected. p.05.
298 The Journal of Hand Surgery / Vol. 30A No. 2 March 2005 Table 2. Radiographic Outcome External Fixator Group Mean (Range) Volar Plate Group Mean (Range) Ulnar variance (mm) 2.2 (0 5).5 ( 3 1)* Radial inclination ( ) 25 (10 38) 22 (16 28) Volar tilt ( ) 5 (0 12) 10 (0 18)* Articular step off (mm) 1.4 (0 5).4 (0 2)* *p.05., volar. a volar approach 11 even though the implant in that study was of a different design made by another manufacturer (Hand Innovations, Miami, FL). The other design implant works by the same principle as the fixed-angle (Avanta Subchondral Support Volar) plate used in this study. The report by Orbay et al 11 noted the following outcomes: wrist extension 59, flexion 57, and grip strength 79%. This compares with 63 extension, 66 flexion, and an identical 79% grip strength compared with the normal side in the current study. Comparison of radiographic outcome parameters between Orbay et al 11 and the current study include volar tilt 5 versus 10, radial inclination 21 versus 22, and articular incongruity 0.0 versus 0.4 mm. As was the case in the current study Orbay et al 11 did not experience any postsurgical loss of reduction. Constantine et al 21 reported outcomes of volar fixation with a non fixed-angle implant for dorsally unstable distal radius fractures. Their premise was that if good volar reduction of strong volar cortex was obtained then the rest of the wrist would reduce even though the construct might remain extended slightly. 21 Our results cannot be compared directly with those of Constantine et al 21 because of differences in measured outcomes methodology. It is worth noting, however, that Constantine et al 21 achieved neutral volar tilt compared with 10 obtained in this study. The shortcomings of a non fixed-angle construct include limitations on obtaining initial fracture reduction, difficulty maintaining reduction in patients with severe comminution or bone loss, and the possibility for dorsal settling. A fixedangle implant can be used as a fine-tuning reduction tool and can be very effective at maintaining reduction because of the fixed-angle nature of the implant. A non fixed-angle implant can allow for dorsal radius settling with associated toggling of the screws in the plate. Weaknesses of this study include the limited number of patients in the EF group, the short follow-up period in the ORIF group (1 year minimum), and the difference between surgical methodologies (ORIF vs closed-reduction EF). In addition clinical data were obtained prospectively in the ORIF volar fixed-angle implant group but were obtained retrospectively from medical records for the EF group. This difference in methodology along with the substantial difference in length of follow-up time may have introduced a number of potential flaws. When patients from the EF group were asked to return for a voluntary follow-up visit patients with better outcomes may have been more likely to return than patients with poorer outcomes. In addition the ORIF group included patients treated during the surgeon s initial learning experience whereas this was not the case for the EF group. This factor may have influenced the ORIF group in a negative fashion. At the time the external fixator was used in this study some articular incongruity was allowed, whereas it would not be acceptable under current standards and reduction would be attempted through a limited dorsal incision and a bone graft would be used to support the reduction if needed. The greatest benefits of the implant are that it is strong and it permits stable fixation even in the most comminuted unstable fractures. Therefore immediate wrist ROM is possible with minimal use of external support (removal wrist splint). Osada et al 22 evaluated 6 different constructs in a biomechanical model and showed that only the volar fixed-angle plate could support 250 N, which is the anticipated physiologic force associated with active wrist and finger motion. The greatest differences between the 2 fixation methods occur within the first 3 months of treatment. Although patients treated with ORIF were back to work with a splint or no support by 8 weeks patients in the EF group remained limited by the device for 8 weeks. One of our patients was a neurosurgeon who went back to work in 2 days and was performing surgery after 5 days (against our advice, although he did extremely well). If this individual had been treated with a fixator he would have been out of the operating room for a minimum of 2
Wright, Horodyski, and Smith / Distal Radius Fractures and Volar ORIF 299 months. Other advantages of the volar subchondral support are that implant removal is not necessary and the more robust volar cortex (when compared with the dorsal cortex) can be reduced under direct visualization, allowing for an accurate determination of radius length. A subsequent project reporting specifically on the short-term clinical results will be performed in the near future. References 1. Bradway JK, Amadio PC, Cooney WP. Open reduction and internal fixation of displaced, comminuted intra-articular fractures of the distal end of the radius. J Bone Joint Surg 1989;71A:839 847. 2. Jupiter JB, Lipton H. The operative treatment of intraarticular fractures of the distal radius. Clin Orthop 1993;292:48 61. 3. Amadio PC. Open reduction of the intraarticular fractures of the distal radius. In: Saffar P, Cooney WP III, eds. Fractures of the Distal Radius. London: M. Dunitz Ltd, 1995:193 202. 4. Orbay JL. The treatment of unstable distal radius fractures with volar fixation. Hand Surg 2000;5:103 112. 5. Kapoor H, Agarwal A, Dhaon BK. Displaced intra-articular fractures of distal radius: a comparative evaluation of results following closed reduction, external fixation and open reduction with internal fixation. Injury 2000;31:75 79. 6. Orbay JL, Fernandez DL. Volar fixation for dorsally displaced fractures of the distal radius: a preliminary report. J Hand Surg 2002;27A:205 215. 7. MacDermid JC. Development of a scale for patient rating of wrist pain and disability. J Hand Ther 1996;9:178 183. 8. Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand). The Upper Extremity Collaborative Group (UECG). Am J Ind Med 1996;29:602 608. 9. MacDermid JC, Richards RS, Donner A, Bellamy N, Roth JH. Responsiveness of the short form-36, disability of the arm, shoulder, and hand questionnaire, patient-rated wrist evaluation, and physical impairment measurements in evaluating recovery after a distal radius fracture. J Hand Surg 2000;25A:330 340. 10. Agee JM. Distal radius fractures. Multiplanar ligamentotaxis. Hand Clin 1993;9:577 585. 11. Orbay JL, Badia A, Indriago IR, Infante A, Khouri RK, Gonzalez E, et al. The extended flexor carpi radialis approach: a new perspective for the distal radius fracture. Tech Hand Upper Extremity Surg 2001;5:204 211. 12. Axelrod TS, McMurtry RY. Open reduction and internal fixation of comminuted, intraarticular fractures of the distal radius. J Hand Surg 1990;15A:1 11. 13. Campbell DA. Open reduction and internal fixation of intra articular and unstable fractures of the distal radius using the AO distal radius plate. J Hand Surg 2000;25B:528 534. 14. Ring D, Jupiter JB, Brennwald J, Buchler U, Hastings H 2nd. Prospective multicenter trial of a plate for dorsal fixation of distal radius fractures. J Hand Surg 1997;22A:777 784. 15. Fernandez DL. Should anatomic reduction be pursued in distal radial fractures? J Hand Surg 2000;25B:523 527. 16. MacDermid JC, Richards RS, Roth JH. Distal radius fracture: a prospective outcome study of 275 patients. J Hand Ther 2001;14:154 169. 17. Fernandez DL, Geissler WB. Treatment of displaced articular fractures of the radius. J Hand Surg 1991;16A: 375 384. 18. Trumble TE, Schmitt SR, Vedder NB. Internal fixation of pilon fractures of the distal radius. Yale J Biol Med 1993; 66:179 191. 19. Trumble TE, Schmitt SR, Vedder NB. Factors affecting functional outcome of displaced intra-articular distal radius fractures. J Hand Surg 1994;19A:325 340. 20. Knirk JL, Jupiter JB. Intra-articular fractures of the distal end of the radius in young adults. J Bone Joint Surg 1986; 68A:647 659. 21. Constantine KJ, Clawson MC, Stern PJ. Volar neutralization plate fixation of dorsally displaced distal radius fractures. Orthopedics 2002;25:125 128. 22. Osada D, Viegas SF, Shah MA, Morris RP, Patterson RM. Comparison of different distal radius dorsal and volar fracture fixation plates: a biomechanical study. J Hand Surg 2003;28A:94 104.
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