Functional Outcome in Distal Radius Fractures Treated with Locking Compression Plate

Functional Outcome in Distal Radius Fractures Treated with Locking Compression Plate Sanjay Agarwala*, Ganesh S Mohrir**, Shreyans D Gadiya*** Abstract Purpose: To determine outcome of patient on treatment of distal radius fractures using locking compression plate (LCP) with specific emphasis on functional outcome. Method: 25 patients of distal radius fracture treated with open reduction and LCP fixation between May 2005 and October 2009 were evaluated retrospectively. Patients were advised to use operated limb for day to day activities as soon as they were comfortable. Clinical and radiological evaluation was done at weeks, months, 6 months and one year after surgery. Results: Many patients were able to start using operated limb as early as 48 hours post-operatively. At weeks Mayo Wrist Score indicated excellent/good result in 88% and a satisfactory result in 12% of patients. None of the patients had significant 0 loss of reduction (change > 5 ). One patient developed superficial infection. There were no late complications. Conclusion: LCP allows early functional mobility with minimal complications. Introduction ractures of distal end of radius are one Fof the most common skeletal injuries encountered in orthopaedic departments. Management of these fractures has 1 remained a controversial issue. They are often treated with closed reduction and immobilisation but the difficulty here is the possibility that displacement may persist even in the least complex fractures. Other problem with this method is immobilisation of wrist and forearm for at least 6 weeks and the further time required to regain the functions of forearm wrist and hand by physiotherapy. During this entire time duration, patient's ability to *Consultant Orthopaedic Surgeon, **Clinical Associate, ***Clinical Fellow, Department of Orthopaedics, P. D. Hinduja National Hospital, Veer Savarkar Marg, Mahim, Mumbai - 400 016. carry out day to day activities are hampered. The need of the hour is treatment modality that restores and maintains anatomy and allows early functional mobility which allows patient to carry out his activities of day to day life with minimal discomfort. Numerous other methods of treating injuries of this nature like closed percutaneous pinning, external fixation, buttress plating have enjoyed recognition from time to time, testifying the fact that there is no ideal modality of treatment. The anti-glide effect of Buttress plates helps reduce and stabilise intra-articular 2 fractures. However, the need for protection of fracture till it consolidates and the chances of loss of reduction on mobilisation are still areas of concern with 209

Buttress plating. Treatment of comminuted, displaced intra-articular or potentially unstable fractures of the distal radius with open reduction and internal fixation with locking compressions plates (LCP) and screws has increasingly been found to be the better alternative. The functional outcome of treatment of fracture of the distal aspect of the radius is influenced by the anatomical reduction of the articular surface and the extraarticular alignment of the distal part of the 4 radius. By directly restoring the anatomy, plating allows secure internal fixation with resultant early return of wrist function. Furthermore, the increase in the incidence o f s y m p a t h e t i c d y s t r o p h y w i t h immobilisation over long durations is circumvented by this novel method of fixation. This new fixation technique of using LCP for treating distal end radius fracture shows promise in terms of stable intraoperative fixation and restoration of acceptable anatomy, resulting in early mobilisation and good recovery of 5,6,7 function. This holds true even for 7,8 osteopenic bones. Stable internal fixation with minimal complications can be achieved using distal 7,9 radius LCP. We report a series of 25 distal radius fractures treated by this method of internal fixation with satisfactory results in all. Patients and Methods A total of 45 patients of distal end radius fracture treated with open reduction and Titanium LCP (2.4 mm and.5 mm distal radius LCP; AO Synthes) fixation through standard volar Henry approach between May 2005 and October 2009. Out of 45 patients only 25 patients satisfied our inclusion and exclusion criteria's. Hence only 25 patients were studied in terms of early mobilisation and recovery of function, maintenance of reduction and evidence of any immediate, early or late complication. The fractures were classified according to the OTA classification. There were 1 type-a fractures, 10 type-b fractures and 2 type- C fractures. Inclusion Criterias 1. Fracture of distal end of radius without fracture of distal ulna. 2. Age greater than 18 years. Patients who had regular follow up at weeks, months, 6 months and one year. 4. Patients who had aggressive supervised physiotherapy during immediate post op period. Exclusion Criterias 1. Compound injuries 2. Patient's with open physis. Patients who did not follow up regularly 4. Patient's whose follow up data was inadequate for the study 5. Patients had skeletal injury other than fracture of lower end of radius and ulna. The study included 15 male and 10 female patients who had an average age of 51 years. The youngest patient was a 20 year old female, while the oldest was an 8 year old male. The mechanisms of injury 210

included simple fall (17 patients), fall from height (one patient) and road traffic accidents (7 patients). A simple fall was considered a low-energy injury and fall from height and road traffic accident resulted in high-energy injury. One was a revision surgery following a failed pinning attempt. The follow-up period was of minimum one year duration. Occupation of our patients were student (one patient), retired ( patients), housewife (4 patients), occupation involving heavy work (6 patients), occupation involving light work (11 patients). All the fractures were accessed through volar approach and fixed with Titanium LCP (2.4 mm and.5 mm distal radius LCP; AP Synthes). If any instability was encountered after volar plate fixation, and additional lateral column plate was added to improve stability of construct through the same incision as volar plate alone may be inadequate in fixation of 1 5 fractures with complex pattern. Surgeries were carried by the same surgeon. The average time from injury to operative fixation was approximately six days (range - one to 21 days). During post op period patients were given liberal doses of analgesics and frequent ice fomentation which we believed to reduce post op pain and help patients start early use of operated limb for physiotherapy and day to day activities. Immediate post op X-rays were evaluated quantitatively for radial inclination, volar tilt of radius and qualitatively for presence or absence of articular step. Patients were encouraged to start wrist range of movement exercises and start using operated limb for day to day activities like brushing teeth, eating food, holding glass of water, combing hair, shaving and wear clothes, writing immediately from first post op day. As patients became more comfortable and range of movement increased patients were allowed to use hand for writing, driving and other activities. At weeks (18-28 days) patients were followed up and evaluated radiologically and clinically. On X-ray radial inclination and palmar angulation were measured and compared with immediate post op X-ray. Any presence of articular step and radio-ulnar variance was also noted and compared with immediate post op X-ray for any change. These 2 criteria's were not measured quantitatively because X-rays of our patients were digital X-rays with variable magnification. Clinically patients were evaluated for pain, range of movement (compared to opposite wrist), grip strength (compared to opposite wrist) and ability to return to previous employment. Range of movement was measured with goniometer and grip strength was measured with commercially available dynamometer. Both of these parameters were recorded as percentage of range of movement and grip strength of non operated limb respectively. Mayo Wrist score was utilised for quantifying the functional outcome. Similar clinical and radiological evaluation was done at months (80-120 days). At 6 months (5-7 months) and one year (11-1 months) patients were evaluated radiologically and clinically for improvement of Mayo score and occurence of any complication. 211

Table 1 : Mayo Modified Wrist Score Pain intensity Results Functional Status No pain - 25 Regular job - 25 Mild, Occasional - 20 Restricted employment - 20 Moderate, Tolerable - 15 Able to work, but unemployed - 15 Severe, Intolerable - 0 Unable to work due to pain - 0 Range of Movement Grip strength (% of normal side) (% of normal side) 100% - 25 90-100% - 25 75-99% - 20 75-89% - 15 50-74% - 15 50-74% - 10 25-49% - 10 25-49% - 5 0-24% - 5 0-24% - 0 Interpreting the Mayo Wrist Score 91-100 Excellent 61-80 Satisfactory 81-90 Good Below 60 Poor Table 2 : Analysis of Radiological parameters Average Average Articular Radio- Radial Volar Tilt step ulnar inclination Immediate post-op 20.8 9.16 Nil weeks follow up 20.08 8.28 Nil months follow up 20.08 8.28 Nil variance Average change 0.72 0.8 Nil Nil Table : Functional recovery of patients as recorded by mayo scores Mayo scores weeks months 6 months One Year Excellent 4 17 2 25 Good 18 6 2 0 Satisfactory 2 0 0 Poor 0 0 0 0 We recorded or findings as analysis of functional results, analysis of radiological parameters and incidence of any complication. Average change in radial inclination 0 was 0.72. None of the patients had change 0 in inclination more than 5 even at months follow up which was acceptable result. Average change in volar tilt in our 0 patients was 0.8. None of our patients had 0 change in volar tilt greater than 2. None of our patients had articular step in immediate post op or weeks or months follow up X-ray. And none of them had gross change in radio ulnar variance. At weeks 22 patients were pain free and average mayo score for pain was 24.4, 11 patients had wrist and forearm movements same as opposite side and average mayo score for range of movement was 21.8, 17 patients had returned to their pre injury employment status without much discomfort and average mayo score for employment status was 2.4, and 4 patients had grip strength > 90% compared to opposite side and average mayo score for grip strength was 16.2. At months the scores improved and the results were as follows :- 24 patients were pain free with average mayo score of study group being 24.8, 18 patients had wrist and forearm movements same as opposite side with an average mayo score of 2.4, 20 patients had achieved pre fall employment status and the average mayo score was 24, 17 patients had grip strength > 90% of opposite side (average score 21.6). At 6 months all patients were pain free (average score = 25), 22 patients had wrist and forearm movements same as opposite side (average score = 24.6), 2 patients had returned to their pre fall employment status (average score = 24.6) and 24 patients had grip strength > 90% of opposite side (average score 24.6). 212

General Information Sr. Age Sex Occupation HH-NO MOI OTA SIDE DOI DOA DOS DISCHARGED No. TYPE 1 20 F Student 77156 RTA A L 15.5.05 16.5.05 18.5.05 20.5.05 2 46 M Business 77161 RTA A2 L 15.5.05 16.5.05 18.5.05 21.5.05 75 M Retired 1210 FALL B2 R 9.11.05 10.11.05 11.11.05 14.11.05 4 8 F Housewife 768671 FALL B2 R 8.12.05 20.12.05 21.12.06 2.12.05 5 40 F Sales Manager 279805 FALL B2 L 18..06 19..06 22..06 24..06 6 54 M Business 796780 FALL A2 R 2.7.06 20.7.06 5.7.06 8.7.06 7 61 F Housewife 802502 FALL A2 R 15.7.06 1.8.06 2.8.06 6.8.06 8 6 F Teacher 807967 FALL A2 L 6.9.06 7.9.06 8.9.06 10.9.06 9 4 M Engineer 807452 RTA B2 L.9.06 8.9.06 9.9.06 11.9.06 10 50 F Service 805274 FALL B L 1.9.06 10.9.06 11.9.06 1.9.06 11 47 F Service 808541 FALL A L 20.6.06 21.9.06 22.9.06 25.9.06 12 47 M Broker 285500 FALL A R 0.9.06.10.06 4.10.06 7.10.06 1 57 M Business 814509 RTA B L 15.10.06 22.10.06 2.10.06 29.10.06 14 4 M Service 866509 FALL-ht B2 L 2.10.07.10.07.10.07 6.10.07 15 49 F Housewife 640871 RTA A R 2.4.08 25.4.08 25.4.08 28.4.08 16 40 M Business 10015 FALL C2 R 26.1.09 26.1.09 28.1.09 29.1.09 17 60 F Housewife 10511 FALL A2 R 22..09 2..09 2..09 25..09 18 70 F Retired 105159 FALL C R 17..09 29..09 0..09 1.4.09 19 40 M Service 1060418 RTA A R 22.4.09 15.5.09 15.5.09 16.5.09 20 49 M C.A. 106058 RTA A R 6.6.09 6.6.09 10.6.06 1.6.09 21 54 M Service 108578 FALL A1 R 15.9.09 17.9.09 18.9.09 21.9.09 22 8 M Business 549578 FALL A R 1.10.09 1.10.09 14.10.09 16.10.09 2 6 M Business 1085046 FALL B2 L 20.10.09 20.10.09 21.10.09 26.4.08 24 58 M Contractor 1084862 RTA B2 R 6.10.09 20.10.09 21.10.09 2.10.09 25 76 M Retired 10850 FALL B R 17.10.09 22.10.09 2.10.09 24.10.09 21

Radiological Assessment Sr. No. H.H.N.O. OTA Volar Tilt Radial inclination Articular Step any change (at months) Radio ulnar variance any change (at months) Post Op weeks months Change Post op weeks months Change 1 77156 A 10 8 8 2 20 20 20 0 no change no change 2 1210 B2 6 6 6 0 18 18 18 0 no change no change 285500 A 12 10 10 2 22 22 22 0 no change no change 4 808541 A 12 10 10 2 20 18 18 2 no change no change 5 866892 B2 8 8 8 0 22 22 22 0 no change no change 6 807452 B2 10 10 10 0 20 20 20 0 no change no change 7 77161 A2 10 10 10 0 22 20 20 2 no change no change 8 768671 B2 12 10 10 2 18 185 185 0 no change no change 9 10511 A2 10 10 10 0 18 18 18 0 no change no change 10 10015 C2 6 6 6 0 18 16 16 2 no change no change 11 549578 A 6 4 4 2 24 22 22 2 no change no change 12 802502 A2 10 10 10 0 22 22 22 0 no change no change 1 1084862 B2 10 10 10 0 26 26 26 0 no change no change 14 10850 B 10 8 8 2 20 18 18 2 no change no change 15 796780 A2 12 12 12 0 24 24 24 0 no change no change 16 279805 B2 8 6 6 0 20 18 18 2 no change no change 17 106058 A 12 10 10 2 22 20 20 2 no change no change 18 1060418 A 10 10 10 0 24 24 24 0 no change no change 19 807967 A2 12 12 12 0 20 20 20 0 no change no change 20 805274 B 12 10 10 2 18 16 16 2 no change no change 21 105159 C 10 8 8 2 20 18 18 2 no change no change 22 814509 B 10 8 8 2 18 18 18 0 no change no change 2 640871 A 4 4 4 0 22 22 22 0 no change no change 24 1085046 B2 2 2 2 0 22 22 22 0 no change no change 25 108578 A1 5 5 5 0 20 20 20 0 no change no change 9.16 8.28 0.8 0.8 20.8 20.08 20.08 0.72 214

Mayo Score Sr. H.H.No. Age Occupation OTA Pain Range of No. Type Movement 6 months Weeks Months Year 6 months Weeks Months Year Employment Status 6 months Weeks Months Year Grp Strength 6 months Weeks Months Year Final Mayo Score 6 months Weeks Months Year 1 77156 20 Student A 25 25 25 25 20 20 25 25 25 25 25 25 15 25 25 25 85 95 100 100 2 77161 46 Business A2 25 25 25 25 25 25 25 25 20 25 25 25 15 25 25 25 85 100 100 100 1210 75 Retired B2 25 25 25 25 25 25 25 25 25 25 25 25 15 25 25 25 90 100 100 100 4 768671 8 Housewife B2 25 25 25 25 20 25 25 25 25 25 25 25 25 25 25 25 95 100 100 100 5 279805 40 Sales Manager B2 25 25 25 25 20 20 25 25 25 25 25 25 15 25 25 25 85 95 100 100 6 796780 54 Business A2 25 25 25 25 25 25 25 25 25 25 25 25 15 25 25 25 90 100 100 100 7 802502 61 Housewife A2 25 25 25 25 20 25 25 25 25 25 25 25 25 25 25 25 95 100 100 100 8 807967 6 Teacher A2 25 25 25 25 20 25 25 25 25 25 25 25 15 25 25 25 85 100 100 100 9 807452 4 Engineer B2 25 25 25 25 25 25 25 25 20 25 25 25 15 15 25 25 85 90 100 100 10 805274 50 Service B 25 25 25 25 20 20 25 25 25 25 25 25 15 25 25 25 85 90 100 100 11 808541 47 Service A 25 25 25 25 25 25 25 25 25 25 25 25 15 15 25 25 90 90 100 100 12 285500 47 Broker A 25 25 25 25 25 25 25 25 25 25 25 25 15 15 25 25 90 90 100 100 1 814509 57 Business B 25 25 25 25 25 25 25 25 25 25 25 25 15 25 25 25 90 100 100 100 14 866892 4 Service B2 25 25 25 25 25 25 25 25 20 20 25 25 15 25 25 25 85 95 100 100 15 640871 49 Housewife A 25 25 25 25 20 25 25 25 25 25 25 25 25 25 25 25 95 100 100 100 16 10015 40 Business C2 25 25 25 25 25 25 25 25 20 20 20 25 15 15 25 25 85 90 100 100 17 10511 60 Housewife A2 25 25 25 25 20 25 25 25 25 25 25 25 25 25 25 25 95 100 100 100 18 105159 70 Retired C 20 20 25 25 15 20 25 25 20 20 25 25 10 10 25 25 65 70 90 95 19 1060418 40 Service A 25 25 25 25 25 25 25 25 20 20 25 25 15 25 25 25 85 95 100 100 20 106058 49 C.A. A 25 25 25 25 20 25 25 25 25 25 25 25 15 15 25 25 85 95 100 100 21 108578 54 Service A1 25 25 25 25 25 25 25 25 25 25 25 25 15 25 25 25 90 100 100 100 22 549578 8 Business A 25 25 25 25 20 20 25 25 25 25 25 25 15 25 25 25 85 95 100 100 2 1085046 6 Business B2 25 25 25 25 20 25 25 25 25 25 25 25 15 15 25 25 85 90 100 100 24 1084862 58 Contractor B2 20 25 25 25 15 15 20 20 20 20 20 25 10 15 15 25 65 75 90 95 25 10850 76 Retired B 20 25 25 25 20 20 20 20 20 20 25 25 15 25 25 25 70 90 95 95 24.4 24.8 25 25 21.8 2.4 24.4 24.4 2.4 24 24.6 25 16.2 21.6 24.6 25 85.6 9.8 99 99.4 215

Final Masker Chart Sr. No. H.H.N.O. Age Occupation OTA Type Mayo Score Any loss of alignment Weeks Months 6 Months Year 1 77156 20 Student A 85 95 100 100 no 2 77161 46 Business A2 85 100 100 100 no 1210 75 Retired B2 90 100 100 100 no 4 768671 8 Housewife B2 95 100 100 100 no 5 279805 40 Sales Manager B2 85 95 100 100 no 6 796780 54 Business A2 90 100 100 100 no 7 802502 61 Housewife A2 95 100 100 100 no 8 807967 6 Teacher A2 85 100 100 100 no 9 807452 4 Engineer B2 85 90 100 100 no 10 805274 50 Service B 85 90 100 100 no 11 808541 47 Service A 90 90 100 100 no 12 285500 47 Broker A 90 90 100 100 no 1 814509 57 Business B 90 100 100 100 no 14 866892 4 Service B2 85 95 100 100 no 15 640871 49 Housewife A 95 100 100 100 no 16 10015 40 Business C2 85 90 100 100 no 17 10511 60 Housewife A2 95 100 100 100 no 18 105159 70 Retired C 65 70 90 95 no 19 1060418 40 Service A 85 95 100 100 no 20 106058 49 C.A. A 85 95 100 100 no 21 108578 54 Service A1 90 100 100 100 no 22 549578 8 Business A 85 95 100 100 no 2 1085046 6 Business B2 85 90 100 100 no 24 1084862 58 Contractor B2 65 75 90 95 no 25 10850 76 Retired B 70 90 95 95 no 216

At one year follow up all patients were pain free all of them had achieved pre fall employment status and all of them had grip strength almost equal to opposite hand. patients had terminal restriction of movement of wrist and forearm. At weeks most of the good and excellent results were seen in type-a/b fractures while the satisfactory results were mainly associated with type-c fractures. Even satisfactory results improved by 6 months time. Seventeen of the 25 patients could have been osteopenic but this did not affect the outcome of the surgery. The 7 elderly patients too showed early recovery and functional mobility with negligible complications. One of the patients with satisfactory result had Parkinsonism which resulted in poor post-operative rehabilitation while another case was a revision surgery for a failed pinning attempt carried out at another hospital three weeks before presentation. One patient had superficial infection which settled with course of antibiotics for 2 weeks. These patients had satisfactory outcome at weeks follow up. patient with superficial infection had good outcome by months and excellent outcome by 6 months. Neither early complications such as median nerve and radius superficial nerve injury, not late complications like carpal instability, arthritis and iatrogenic radial aneurysm, tendon rupture or implant loosening were reported. Radiological follow up was available. This study demonstrates that open reduction with locked compression plating is a safe and effective treatment for acute, unstable fractures of the distal radius, giving adequate stability and allowing early mobility which is not possible by any of the other treatment modality. Discussion This study establishes the use of LCP for fractures of distal radius for early recovery of movement and function; wrist mobilisation as early as first postoperative day as no form of immobilisation is needed after use of LCP with no loss of reduction; followed by early recovery in range of motion and regaining of power. The early mobility seen with LCP is not seen with any other method of treatment and these results compare favourably with other reported series of fractures treated 7,8,10,11,12 by open reduction and fixation. The use of LCP for distal radius fractures resulted in wrist mobilisation as early as first post-operative day and allowed most of our patients to carry out their day to day activities immediately from the next day of surgery leading to improved quality of life and allowing them to get back to their daily routine at an earlier period. Our patients were able to do activities like brushing teeth, eating food, holding glass of water, combing hair, shaving and wear clothes, writing immediately from first post op day. No other treatment modality offers this kind of early functional mobility. Other treatment modalities like close reduction and casting, k-wires stabilisation, external fixator and buttress plating need immobilisation of at least 6 weeks followed by variable period of physiotherapy to achieve pre-injury functional status. Here 217

is the advantage of LCP over other treatment modalities. This was reflected even in the mayo scores recorded at weeks. Patients must strictly follow aggressive physiotherapy protocols for rapid recovery. Emphasis on aggressive and supervised physiotherapy could be one of the key reasons along with accurate reduction and stable fixation provided by locking plate which resulted in rapid recovery of patients. Probably a separate study specifically designed for the role of early, aggressive and supervised physiotherapy for rapid recovery of functions of wrist after fracture of lower end radius would be a better option to comment on this issue. The classification of the fracture was prognostic of the outcome. Most of the good and excellent results were seen in type-a/b fractures while the satisfactory results were mainly associated with type-c fractures. This could lead to conclusion that more complex the fracture pattern more is the time for recovery. The technique also proved to be useful for the elderly patients with osteopenic bones, showing early range of mobility and function. Other than this, early recovery w a s a s s o c i a t e d w i t h n e g l i g i b l e complications, which is established in 1 other studies as well. Though the final results might be same with use of locking plate or any other modality of treatment, maximal improvement in function occurs by 6 months after surgery as (evidenced in 14 other studies as well) most of the patients treated with locking plate, which is quite early as compared to other modalities of treatment which take at least an year for 15 maximal improvement. Incidence of complications is far less with use of locking plate as compared to 16 other modalities. We believe that restoration of the joints and the articular anatomy led to desired results of range of movement, grip strength, pain intensity and functional status. Consequently, it seems rational to use LCP for fracture of distal end radius as an effective treatment method in terms of early functional mobilisation compared to other available methods. References 1. 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; 1(2):75-79. 2. Nana AD, Joshi A, Lichtman DM. Plating of the distal radius. J Am Acad Orthop Surg. 2005; 1(): 159-171.. Kumar D, Breakwell L, Deshmukh SC, et al. Tangential views of the articular surface of the distal radius: Aid to open reduction and internal fixation of fractures. Injury. 2001; 2:78-786. 4. Koi K, Hattori Y, Otsuka K, et al. Intra-articular fractures of the distal aspect of the radius: Arthroscopically assisted Reduction Compared with Open Reduction and Internal Fixation. J Bone Joint Surg. 1999; 81:109-110. 5. Konstantinidis L, Helwig P. Strohm PC et al. Clinical and radiological outcomes after stabilisation of complex intra-articular fractures of the distal radius with the volar 2.4 mm LCP. Arch Orthop Trauma Surg. 2009; 10(6):751-757. 6. Kwan K, Lau TW, Leung F. Operative treatment of distal radial fractures with locking plate system - a prospectively study. J. Hand Surg. Am. 2010; 21(1):1-9. 7. Smith DW, Henry MH. Volar Fixed-Angle Plating of the Distal Radius. J Am Acad Orthop Surg. 2005; 1(1):28-6. 218

8. Berglund LM, Messer TM. Complications of volar plate fixation for managing distal radius fractures. J Am Acad Orthop Surg. 2009; 17(6):69-77. 9. Jupiter JB, Marent-Huber M. Operative of distal radial fractures with 2.4-millimeter locking plates: A multicenter prospective case series. J Bone Joint Surg. Am. 2010; 92:96-106. 10. 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. Am. 1989; 71(6): 89-47. 11. Catalano LW, Cole RJ, Gelbermann RH, et al. displaced intra-articular fractures of the distal aspect of the radius; long-term results in young adults after open reduction and internal fixation. J Bone Joint Surg. Am. 1997; 79(9): 1290-02. 12. Joglekar SB, Ilyas Am. The role of locking technology in the upper extremity. J Hand Micro surg. 2009; 1(2):82-91. 1. Orbay J, Fernandez D. Volar fixed-angle plate fixation for unstable distal radius fractures in the elderly patient. J Hand Surg. 2004;29(1):96-102. 14. Santiago A. Lozano-calderion et. al wrist mobilisation following volar plate fixation of fractures off distal part of radius. J bone joint surg. Am 2008;90: 1297-104. 15. Arora R, Lutz M et. al Complications following internal fixation of unstable distal radius fracture with a palmar locking-plate. J Orthop Trauma. 2007 May;21(5):16-22. 16. Tamara D. Rozental, Philip E. Blazre et. Al Functional Outcomes for Unstable Distal Radial Fractures Treated with Open Reduction and Internal Fixation or Closed Reduction and Percutaneous Fixation. J bone joint surg. Am 2009; 91:187-1846. Non-Alcoholic Fatty Liver Disease Non-alcoholic fatty liver disease (NAFLD) is now recognised as a common condition (or spectrum OF disease) affecting both adults and children, especially those with obesity, type 2 diabetes, insulin resistance, and dyslipidaemia. Most obese adults and many obese children have it, as do some people of normal weight. It is often asymptomatic or discovered incidentally on routine blood tests. It may be more than just a manifestation of the metabolic syndrome: it may actually contribute to cardiovascular disease through the release of pro-inflammatory mediators that damage the endothelium. In a minority of patients it may progress to liver fibrosis, cirrhosis, and liver cancer. There is no definitive diagnostic test apart from liver biopsy, and no specific treatment. However, it is now the commonest cause of abnormal liver biochemistry in many developed countries, and it is estimated to affect 40-70% of people with type 2 diabetes. Prognosis is also uncertain, and since there is no specific treatment to offer patients, one could question the benefit of diagnosis. They can benefit from weight loss and exercise, management of other risk factors, and surveillance for cirrhosis and liver cancer. However, there's insufficient evidence for routine screening of the general population. All obese children with abnormal liver function tests should have initial screening with magnetic resonance imaging, ultrasonography, and liver function tests. While we await some answers, NAFLD presents another urgent reason to address the global timebomb of obesity. F. Godlee, BMJ, 2011; Vol. 4; 201-204 219