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In September 2008, we will be moving to a beautiful new 4,400 sq ft,
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EXTERNAL FIXATION OF DISTAL RADIUS FRACTURES
External fixation has been used for the treatment of distal radius fractures
for more than 50 years. Although the fixator configurations have undergone
considerable modification over time the type of fixator itself is not
as important as the underlying principles which provide the foundation
for external fixation. Though volar plate fixation is currently in vogue,
the indications for external fixation remain largely unchanged. Newer
fixator designs have also expanded the traditional usage to include nonbridging
applications which allow early wrist motion. The following discussion
will focus on the myriad uses for external fixation as well as the shortcomings
and potential pitfalls.
There are some important anatomical points one must bear in mind when
considering external fixation of the distal radius. The articular surface
of the radius is triangular with the apex of the triangle at the radial
styloid. It slopes in a volar and ulnar direction with a radial inclination
of 23° (range 13-30°), a radial length of 12 mm (range 8 - 18
mm) and an average volar tilt of 12° (1 - 21°). 1 The dorsal surface
of the distal radius is convex and irregular and it is covered by the
6 dorsal extensor compartments. The dorsal cortex is thin which often
results in comminution that may lead to an abnormal dorsal tilt. Lister’s
tubercle acts as a fulcrum for the extensor pollicis longus (EPL) tendon
which lies in a groove on the ulnar side of the tubercle. The volar side
of the distal radius, which is covered by the pronator quadratus, is flat
and makes a smooth curve which is concave from proximal to distal. When
inserting the dorsal pins it is important to engage the volar ulnar lip
of the distal radius where the bone density is highest, especially in
The dorsum of the radius is cloaked by the arborizations of the superficial
radial nerve (SRN) and the dorsal cutaneous branch of the ulnar nerve
(DCBUN). The SRN exits from under the brachioradialis approximately 5
cm proximal to the radial styloid and bifurcates into a major volar and
a major dorsal branch at a mean distance of 4.2 cm proximal to the radial
styloid (Figure 1). Either partial or complete overlap of the lateral
antebrachial cutaneous nerve (LABCN) with the SRN occurs up to 75% of
the time. 3 The DCBUN arises from the ulnar nerve 6 cm proximal to the
ulnar head and becomes subcutaneous 5 cm proximal to the pisiform. It
crosses the ulnar snuffbox and gives off 3-9 branches that supply the
dorsoulnar aspect of the carpus, small finger and ulnar ring finger. Open
pin insertion allows identification and protection of these branches.
The proximal pins are placed at the junction of the proximal and middle
thirds of the radius. At this level the radius is covered by the tendons
of extensor carpi radialis longus (ECRL) and extensor carpi radialis brevis
(ECRB) as well as the extensor digitorum communis (EDC). The proximal
pins can be inserted in the standard midlateral position by retracting
the brachioradialis (BR) tendon and the SRN, in the dorsoradial position
between the ECRL and ECRB or dorsally between the ECRB and EDC which carries
less risk of injury to the SRN. 4
External fixation of distal radius fractures may be used in a bridging
or nonbridging manner. Bridging external fixation of distal radius fractures
typically relies on ligamentotaxis to both obtain and maintain a reduction
of the fracture fragments. As longitudinal traction is applied to the
carpus, the tension is transmitted mostly through the radioscaphocapitate
and long radiolunate ligaments to restore the radial length. In a similar
vein, pronation of the carpus can indirectly correct the supination deformity
of the distal fragment.
Limitations of ligamentotaxis
Ligamentotaxis has a number of short comings when applied to the treatment
of displaced intra-articular fractures of the distal radius. Firstly,
since ligaments exhibit viscoelastic behavior 5, there is a gradual loss
of the initial distraction force applied to the fracture site through
stress relaxation.6 The immediate improvement in radial height, inclination
and volar tilt are significantly decreased by the time of fixator removal
( Figure 2 A, B). 7
Traction does not correct the dorsal tilt of the distal fracture fragment.
This is because the stout volar radiocarpal ligaments are shorter and
they pull out to length before the thinner dorsal radiocarpal ligaments
exert any traction.8 Excessive traction may actually increase the dorsal
tilt (Figure 3 A - C). 9 A dorsally directed vector is still necessary
to restore the normal volar angulation. This is usually accomplished by
applying manual thumb pressure over the dorsum of the distal fragment.
With intra-articular fractures, ligamentotaxis reduces the radial styloid
fragment but for the above reasons it does not reduce a depressed lunate
fragment.10 When there is a sagittal split of the medial fragment, traction
causes the volar medial fragment to rotate which often necessitates an
open reduction. External fixation cannot control radial translation and
cannot therefore be used with an unstable distal radioulnar joint (Figure
4 A, B).
Biomechanical considerations for External Fixation
Fracture site loads
External fixation is considered flexible fixation. 11 The biomechanical
requirements of external fixation for fractures of the distal radius have
not been ascertained since until recently, the magnitude and direction
of the physiologic loads on the distal radius were dynamic and unknown.
Recent work by Rikli et al however has shed new light on this point. 12
Using a new capacitive pressure-sensory device his group measured the
in- vivo dynamic intra-articular pressures under local anesthesia in the
radioulnocarpal joint of a healthy volunteer. With the forearm in neutral
rotation, the forces ranged from 107N with wrist flexion to 197N with
wrist extension. The highest forces of up to 245 N were seen with the
wrist in radial deviation and the forearm in supination. Presumably any
implant or external fixator would need to be strong enough to neutralize
these loads in order to permit early active wrist motion. Rikli et al
also identified 2 centers of force transmission. The first center was
opposite the scaphoid pole, which would represent the radial column. The
second center, which would represent the intermediate column of the wrist,
took a considerable amount of the load and was opposite the lunate, extending
ulnarly over the triangular fibrocartilaginous complex (TFCC).
Fixator frame rigidity
The strength of the fixator depends on the rigidity of the connecting
rods and the clamps. Many external fixator rods are 0.5 to 1.0 cm in diameter,
although radiolucent rods made from PEEK, Ultem or Carbon fiber may be
larger. Increasing the diameter of the rods increases the rigidity by
a factor of 4. Uniplanar fixators are common, but the rigidity of the
construct can be increased by adding a second parallel rod. Placing the
rod as close to the skin as possible also increases the stability against
bending loads by reducing the lever arm from the neutral joint axis. Most
distal radius external fixators use 3.0 or 4.0 mm threaded half pins.
Modern threaded pins are hence designed with a larger core diameter and
smaller core-thread diameter. If the pin threads are buried, the larger
pin diameter at the near bone interface resists bending forces whereas
the small core thread resists pull out forces at the far cortex. A bicortically
inserted pin with a very short thread will provide the best pin-bone fixation.
Theoretically, under drilling the pin hole by 0.1 mm provides the best
pin fixation with the least risk of bone resorption and pin loosening.
It is also desirable to spread the force evenly across the entire shaft
of the bone by creating a wide separation of the fixator pins. In order
to achieve stable fixation and reduce the lever arm of displacing forces,
the pins should inserted close to the fracture site. One pin is hence
inserted close to the fracture site while the second is placed as far
away as possible. 13
Increasing the rigidity of the fixator does not appreciably increase the
rigidity of fixation of the individual fracture fragments. 14 There are
a number of ways however in which to augment the stability of the construct.
After restoration of radial length and alignment by the external fixator,
percutaneous pin fixation can lock in the radial styloid buttress and
support the lunate fossa fragment. 15 A 5th radial styloid pin attached
to the frame of a spanning AO (Synthes, Paoli, PA, USA) external fixator
prevents a loss of radial length through settling and leads to improved
wrist range of motion as compared to a 4-pin external fixator.16 The addition
of a dorsal pin attached to a sidebar easily corrects the dorsal tilt
found in many distal radius fractures.17, 18
K-wire fixation enhances the stability of external fixation. The combination
of an external fixator augmented with 0.62 k-wires approaches the strength
of a 3.5 mm dorsal AO plate (Synthes, Paoli, PA, USA). 19 Supplemental
k-wire fixation is more critical to the fracture fixation than the mechanical
rigidity of the external fixator itself.14 Stabilizing a fracture fragment
with a nontransfixing K-wire that is attached to an outrigger is just
as effective as a k-wire that transfixes the fracture fragments.20
Bridging External Fixation
Temporary external fixation: Indications
(Video: temporary external fixation)
As compared to conventional plate fixation, bridging external fixation
may be used in a temporary manner or it may be used for definitive management
of the distal radius fracture. Bindra has listed the following indications
for this technique: 21
1. Initial management of severe grade open fractures with extensive soft
tissue loss (Figure 5 A - C).
2. Temporizing measure to resuscitate a polytraumatized patient.
3. Pending transfer to a tertiary referral facility for definitive fracture
Rikli et al use temporary bridging external fixation for complex fractures
to both aid in the provisional fracture reduction and to allow a better
CT evaluation of the fracture characteristics prior to double plate fixation.
Definitive external fixation: Indications
1. Unstable Extra-articular distal radius fractures.
2. Two-part and selected 3-part intra-articular fractures without displacement.
3. Combined internal and external fixation.
Bridging external fixation should not be used as the sole method of stabilization
in the following situations:
1. Ulnar translocation due to an unstable distal radioulnar joint.
2. Intra-articular volar shear fractures (Bartons, reverse Bartons).
3. Disrupted volar carpal ligaments / radiocarpal dislocations.
4. Marked metaphyseal comminution.
Combined index and middle finger metacarpal fractures preclude the use
of this technique due to the interference with distal pin site placement.
The patient is positioned supine on the operating table with the arm abducted
on an arm board. Finger traps with some type of traction either with weights
and an overhead arm holder or an arthroscopy tower may be used unless
the fixator has distraction capabilities. The use of a tourniquet facilitates
pin insertion, but it is not mandatory, especially in the face of massive
soft tissue swelling, vascular impairment or marked infection. The fixator
is applied under fluoroscopic control. A 2 cm incision is made over the
radial aspect of the index metacarpal base, although the middle finger
metacarpal may be substituted. The interosseous fascia overlying the metacarpal
is incised and reflected laterally. The extensor tendon(s) are identified
and protected as well as branches of the superficial radial nerve. Homann
spike retractors simplify soft tissue retraction. The fixator pin hole
is pre-drilled with a smaller drill diameter to increase the friction
fit. The pin is then inserted by hand to minimize the risk of thermal
bone necrosis and subsequent pin loosening or infection. A double pin
clamp or any supplied pin guides are then used to insert the second pin,
parallel to the first pin. Pin convergence or divergence make double pin
clamp application laborious, but does not interfere with single pin clamp
It is my preference to apply the distal pin clamp and provisionally attach
the fixator frame in order to gauge the proper site for placement of the
proximal pins. It is desirable to place the proximal pins near the mid-forearm
since more proximal placement becomes exceedingly difficult due to interposed
muscle and the branches arising from the posterior interosseous nerve.
If the fixator is used to restore radial length, the distractor module
should be prepositioned close to it’s starting point to allow the
maximum potential amount of elongation. Alternatively, the fracture can
be distracted with longitudinal traction which simplifies the fixator
application. A 3 cm incision is made over the mid lateral line of the
radius shaft. The brachioradialis tendon is identified and retracted along
with the superficial radial nerve. The proximal pins can be inserted in
the standard dorsoradial position or they may be inserted dorsally between
the extensor carpi radialis brevis and extensor digitorum with less risk
of injury to the superficial radial nerve. The pins holes are also pre-drilled
and inserted by hand.
The fracture is distracted under fluoroscopic control. Overdistraction
of the carpus should be avoided since this will lead to extensor tendon
tightness and intrinsic muscle contraction. The wrist should be placed
in neutral or slight extension. Full passive flexion of all of the fingers
should be possible. The index is the most sensitive to traction and can
be used to gauge this.
Fixator loosening with loss of fracture position can be avoided by periodically
checking and tightening the fixator connections. Fixator failure by itself
is uncommon but many commercially available fixators are approved for
single use only due to the risk of unrecognized material fatigue or failure
of any locking ball joints. Pin site complications include infection,
loosening and interference with extensor tendon gliding. The risk of injury
to branches of the superficial radial nerve mandate open pin site insertion.
Bad outcomes associated with external fixation are often related to Over
distraction. One biomechanical study documented the effect of distraction
of the wrist on metacarpophalangeal (MCP) joint motion. More than 5 mm
of wrist distraction increases the load required for the FDS to generate
MCP joint flexion for the middle, ring, and small fingers. For the index
finger, however, as much as 2 mm of wrist distraction significantly increases
the load required for flexion at the MCP joint.23 Many cases of intrinsic
tightness and finger stiffness that are attributed to reflex sympathetic
dystrophy are a consequence of prolonged and excessive traction which
can be prevented by limiting the duration and amount of traction and instituting
early dynamic MP flexion splinting even while in the fixator (Figure 6).
The degree and duration of distraction correlates with the amount of subsequent
wrist stiffness. 24 Distraction, flexion and locked ulnar deviation of
the external fixator encourage pronation contractures (Figure 7). Distraction
also increases the carpal canal pressure which may predispose to acute
carpal tunnel syndrome 25 (Video: Overdistraction). Metaphyseal defects
should be grafted to diminish bending loads and to allow fixator removal
after 6-7 weeks which minimizes the fixator related complications.
Margaliot et al performed a meta-analysis of
forty-six articles with 28 (917 patients) external fixation studies and
18 (603 patients) internal fixation studies. They did not detect a clinically
or statistically significant difference in pooled grip strength, wrist
range of motion, radiographic alignment, pain, and physician-rated outcomes
between the 2 treatment arms. There were higher rates of infection, hardware
failure, and neuritis with external fixation and higher rates of tendon
complications and early hardware removal with internal fixation. Considerable
heterogeneity was present in all of the studies which adversely affected
the precision of the meta-analysis.26
Westphal and colleagues performed a retrospective comparative study of
166 out of 237 patients who underwent surgery for AO/ASIF A3 or C2 distal
radius fractures. The fractures were treated with either external fixation
or open reduction and internal fixation using palmar or dorsal plates.
Open reduction and internal fixation, in particular palmar plate fixation,
demonstrated the best radiological and functional results.27 External
fixation falls short when used as the sole treatment for displaced intra-articular
fractures. In a study of 27 patients with comminuted, displaced intra-articular
fractures of distal radius that were treated exclusively by external fixation,
Arora and co-authors concluded that although the external fixation is
reliable in maintaining the reduction in displaced comminuted intra-articular
fractures, it is inadequate in restoring articular congruity in many cases.28
Augmented External Fixation
The use of supplemental k-wire fixation can expand the indications for
external fixation. As noted above, k-wire fixation not only enhances the
reduction of the fracture fragments but also increases the rigidity of
the entire construct. Many authors have stressed the importance of using
the external fixator as a neutralization device rather than a traction
device. Ligamentotaxis is used to obtain a reduction of the fracture fragments,
which is then captured with percutaneous k-wire fixation. The traction
on the fixator can then be reduced, which allows positioning of the wrist
in neutral or slight extension (Figure 8). 9 This serves to reduce extensor
tendon tightness and facilitates finger motion. In a study of intra focal
pinning, Trumble and colleagues noted that In patients over 55 years of
age and younger patients with comminution involving two or more surfaces
of the radial metaphysis (or > 50% of the metaphyseal diameter) bridging
fixation was necessary in addition to percutaneous pin fixation to prevent
late fracture collapse.29 In 4-part fractures where there is a sagittal
split of the medial fragment longitudinal traction accentuates the palmar
translation and rotation of the volar medial fragment (Figure 9 A - E).
Dorsal to volar k-wire placement carries the risk of injury to the volar
neurovascular bundles especially with k-wire migration. For these reasons
any sagittal split of the articular surface typically requires open treatment.
30 (Video: Volar rim fracture with DRUJ instability)
1. Intra-articular radial styloid fractures.
2. Three 3 -part intra-articular fractures.
3. Following percutaneous reduction of a depressed lunate fragment.
4. Arthroscopic aided reduction of distal radius fractures.
1. Marked metaphyseal comminution.
2. Volar/dorsal intra-articular shear fractures.
Surgical Technique (3-part intra-articular fracture)
(Video: Fragment Specific Fixation)
The technique is similar to that of straight forward external fixation.
A 1 cm incision is made over the radial styloid and the superficial radial
nerve branches and the thumb extensor tendons are retracted. Using a drill
guide, an oblique and a horizontal subchondral 0.62 mm k-wire are pre-positioned
in the radial styloid fragment under fluoroscopic control. Ligamentotaxis
is used to obtain a reduction of the radial styloid fragment. The k-wire
is then driven obliquely across the radial styloid fragment to capture
the reduction and engage the proximal ulnar shaft. A small dorsal incision
is made underneath the medial fragment and a free elevator is used to
elevate a depressed articular fragment and to correct any abnormal dorsal
tilt. The reduction is then captured by advancing the subchondral k-wire.
Care is taken to prevent penetration of the DRUJ, which can be detected
by DRUJ crepitus with passive pronation and supination. Once the reduction
is obtained the traction is diminished and the fixator is applied as described
above. The wrist is then positioned in neutral or slight extension. The
index extensor tendon is the most sensitive to traction. Since ligamentotaxis
is no longer crucial to maintain the reduction, the traction is reduced
until full passive combined flexion of the index MP, PIP and DIP joints
is easily obtained. Any metaphyseal bone defect is then grafted percutaneously
through a small dorsal incision. If desired, percutaneous 3.0 mm screws
can be substituted for the k-wires (Figure 10 A - J).
Kreder et al compared the results of open reduction and internal fixation
(ORIF) v.s. external fixation and pinning. A total of 179 adult patients
with displaced intra-articular fractures of the distal radius were randomized
to receive indirect percutaneous reduction and external fixation (n =
88) or ORIF (n = 91). There was no statistically significant difference
in the radiological restoration of anatomical features or the range of
movement between the groups at 2 years. The patients who underwent indirect
reduction and percutaneous fixation however had a more rapid return of
function and a better functional outcome than those who underwent ORIF,
provided that the intra-articular step and gap deformity were minimized.31
Grewal and co-authors noted the superiority of external fixation and k-wire
fixation over internal fixation with a dorsally placed Pi plate for displaced
intra-articular fractures of the distal radius. The plate group also had
higher levels of pain at 1 year when compared with the external fixator
group; however, this equalized after hardware removal. The external fixator
group showed an average grip strength of 97% when compared with the normal
side v.s. 86% in the dorsal plate group.32
In one study of 70 cases of external fixation and percutaneous pinning,
49% of cases lost more than 5 degrees of volar tilt following reduction
at the 6 month follow up despite the use of pinning. Initial deformity,
patient age, use of bone graft, and duration of external fixation were
not predictors of loss of reduction. No specific predictor of loss of
reduction was noted, although there was a trend toward a loss of reduction
in younger patients. 33
Nonbridging External Fixation
Bridging fixation does not lend itself to early wrist motion. Efforts
to dynamically mobilize the wrist with joint spanning fixators have been
largely unsuccessful. This is related to the difficulty in reproducing
the complex kinematics of the carpus as well as the inability of the fixator
to maintain ligamentotaxis throughout the entire arc of motion.34, 35
Good results have been achieved with nonbridging fixation of extra-articular
distal radius fractures, which does allow early wrist motion. The final
wrist range of motion and grip strengths are superior to those attained
with bridging external fixators.36, 37
Nonbridging external fixation is indicated in any extra-articular fracture
where there is a high risk of late collapse (Figure 11 A – H) or
if there is redisplacement of the fracture following an acceptable closed
reduction ( Figure 12 A – M). Lafontaine et al identified a number
of risk factors that were associated with secondary fracture displacement
despite a satisfactory initial reduction. These included the presence
of dorsal tilt > 20°, comminution, intra-articular involvement,
an associated fracture of the ulna and age greater than 60 years. If three
or more of these factors were present there was a high likelihood of fracture
collapse. 38 When there is significant displacement on the injury films,
there is a high likelihood of collapse even if the initial reduction is
satisfactory. Trumble recommends supplemental internal and/or external
fixation in younger patients for fractures with > 2 mm of radial shortening
and >15 °of dorsal tilt following a closed reduction, especially
if there is comminution of 2 or more cortices.39 Although this is easier
if done early on, the fracture site can be still be freed up with a percutaneous
elevator as late as 3 weeks which then allows a reduction of the distal
fragment using the dorsal fixator pins.
Nonbridging external fixation is contraindicated when the distal fragment
is too small for pin placement. At least 1 cm of intact volar cortex is
required for pin purchase. Dorsal comminution does not preclude a successful
result. This technique is not applicable to volar displaced or volar shear
fractures and in children with open epiphyses. 40
Surgical Technique (Video: Nonbridging Extra-articular
The technique is similar to bridging external fixation, with the use of
a tourniquet and intra operative fluoroscopy, but a traction tower is
not required. Two dorsal 3.0 mm pins are inserted in the distal fragment
through separate longitudinal incisions. The pins can be placed on either
side of Lister’s tubercle or the EPL tendon, as well as between
the EDC and the extensor digit minimi (EDM). The starting position of
the pin should be approximately halfway between the fracture and the radiocarpal
joint. A temporary k-wire can be used to gauge the proper angle. The first
pin is inserted through Lister’s tubercle parallel to the joint
surface in the lateral plane until it engages the volar cortex. The second
dorsal pin is inserted in a similar manner but on the ulnar side of the
EPL or EDC tendons. The dorsal tilt is corrected by levering the pins
distally until the normal volar inclination has bee restored. The fixator
frame is then applied and tightened.
Pin pullout due to fracture of the distal fragment can occur if the distal
fragment is too small or osteopenic, or if the reduction is too vigorous.
If this occurs the fixator can be converted to a bridging construct. An
incomplete reduction is also possible, especially with nascent malunions.
Over-reduction of the fracture can also occur, especially when there is
McQueen et al performed a prospective study of 641 patients with unstable
fractures of the distal radius treated with external fixation. Fifty-nine
percent of these cases were treated with nonbridging external fixation,
mostly in AO type A3.2 and C2.1 fractures. Patients treated with nonbridging
external fixation had statistically significant better radiological results
throughout the period of review. In particular this technique consistently
restored the volar tilt and carpal alignment. Radiological improvement
was mirrored by functional improvement. Most functional indices were statistically
better at an early stage whereas; wrist flexion and grip strength remained
significantly better at the final review. Complication rates were similar
between the two groups.40
Early wrist motion following intra-articular fractures provides a number
of possible benefits including diminished stiffness, stimulation of cartilage
repair 41 and decreased osteopenia of the distal fragments. 42 In order
to accomplish this with nonbridging external fixation, the construct must
be able to withstand the forces generated during active and passive wrist
The author undertook a biomechanical study to examine the feasibility
of nonbridging external fixation of simulated 3 and 4 part intra-articular
fractures.43 The study was performed in 3 phases. In the first phase,
this method was tested in a 3-part intra-articular fracture model using
either 1 or 2 external fixators applied in a nonbridging fashion. Five
fresh frozen cadaver arms underwent biomechanical testing using single
and double nonbridging fixator configurations. During the second phase
the maximum static force that could be withstood during simulated passive
assisted wrist extension and simulated gripping without causing articular
displacement in a 4-part fracture model was examined in 8 cadaver arms.
All of the fractures were stabilized using a single custom nonbridging
external fixator which has an integrated dorsal sidearm (the Fragment
Specific fixator, South Bay Hand Surgery LLC, Torrance, CA) (Figure 13
A). third phase we examined the effects of cyclical loading on a 3 part
intra-articular fracture model with dorsal comminution as described by
Dodds et al. 44 All of the fractures were stabilized with the Fragment
Specific fixator (Video: Fixator Biomechanics ).
The specimens were mounted vertically with an 89 N preload (20 lbs) 45
applied via gravity traction by hanging 5 lb metal plates from the wrist
tendons. Active wrist motion was simulated by manually ranging the wrist
through a complete flexion and extension arc. Passive assisted wrist motion
was simulated by applying an additional load to the carpus with a servohydraulic
materials testing machine (Instron 1321 Biaxial Hydraulic System). Gripping
was simulated by direct axial loading of the lunate fossa. There was a
wide variation in the stiffness of the constructs during phase I, II and
III. Despite this fragment specific external fixation was able to maintain
articular congruity with forces that exceed physiologic loading. The stiffness
of the construct stabilized with the fragment specific fixator averaged
149 N in axial loading with an intact TFC and 117 N with a cut TFC. These
values compared favorably with the stiffness data of 5 commercially available
distal radius plates, which ranged from 95.5 N to 136 N.46 In the 3rd
phase of the study there was no observable articular displacement in any
of the wrists after 200 cycles of wrist flexion and extension with loads
of up to 145 N. The study conclusion was that nonbridging external fixation
with new fixator designs could be applied to the treatment of intra-articular
fractures. Putnam et al have shown that for every 10 N of grip force,
26 N is transmitted through the distal radius metaphysis. They have recommended
that the rehabilitation grip forces should be kept under 140 N with external
fixation in order to prevent or minimize fixation failure. 47 This also
appears to be a safe limit as it pertains to nonbridging external fixation
When using the Fragment Specific Fixator, the 3.0 mm fixator pins are
used in place of k-wires and have dual roles. They provide interfragmentary
fixation but when attached to the fixator, they also act like blade plates
to resist bending moments and buttress the fracture fragments The immediate
subchondral position of the pins support the joint surface and is critical
in maintaining articular congruity during fracture healing. Ligamentotaxis
through joint bridging can be avoided, in order to allow early wrist motion.
Similar to a fixed angle plate, the biomechanical rationale for the Fragment
Specific Fixator is to transfer load from the fixed support of the articular
surface to the intact radial shaft, bypassing any metaphyseal comminution
(Figure 13 B) . Unlike a fixed angle blade plate, the fixator pin angle
is freely adjustable so that it can be adapted to the fracture site plane
which may diminish fracture malalignment.
Nonbridging external fixation is ideally suited for the treatment of 2-
and 3-part intra-articular fractures of the distal radius provided there
is good bone density and a stable DRUJ. It’s use following an arthroscopic-aided
reduction and k-wire fixation of an intra-articular fracture permits early
protected wrist motion although bridging fixation is warranted in the
presence of marked articular comminution.
Volar and dorsal marginal fractures (Bartons and reverse Bartons) are
excluded and should be treated with internal fixation. Fractures with
extensive metaphyseal / diaphyseal comminution require supplemental internal
Surgical Technique using the Fragment Specific Fixator (Video: Nonbridging
Radial styloid reduction
With the aid of a traction tower the radial styloid fragment is reduced
with ligamentotaxis under fluoroscopic control. Any excessive supination
or radial translation of the distal fragment is corrected prior to pin
insertion. The styloid may be held with a provisional .062 k-wire. An
oblique 3.0 mm pin is then hand drilled at approximately a 45° angle
from the tip of the radial styloid across the fracture site to engage
the ulnar cortex of the proximal fragment. The pin is fastened to a single
pin clamp attached to the distal fixator arm. A more proximal pin clamp
is used as a drill guide for insertion of a horizontal styloid pin to
both fixate and provide subchondral support for the lunate fragment. The
k-wire can be removed or left in place for added support as necessary.
Next two proximal pins are inserted in the mid-radius using the double
pin clamp as a drill guide.
Reduction of dorsal tilt
The dorsal tilt can be corrected by using a Freer elevator inserted percutaneously
in the fracture site after the radial styloid reduction. Alternatively
the tilt can be corrected as described for the extra-articular fractures.
In this case the radial styloid is reduced secondarily. Two dorsal 3.0
mm pins are inserted in the distal fragment through separate longitudinal
incisions as described for the extra-articular fractures. The first 3.0
mm pin is inserted through Lister’s tubercle parallel to the joint
surface in the lateral plane until it engages the volar cortex. The dorsal
sidearm is positioned parallel to the joint space. A single pin clamp
attached to the dorsal sidearm is fastened to this pin then both are locked
in place. After the two proximal pins are inserted in the mid-radius,
the distractor unit is used to lengthen the fixator until the volar tilt
of the articular surface has been restored. An additional dorsal pin is
inserted on the ulnar side of the EPL or EDC tendons using the 2nd single
pin clamp on the outrigger bar as a drill guide. The radial styloid pins
are then inserted as described above (Figure 14 A -M )
Protected wrist motion is allowed after the 1st week. If there is difficulty
regaining supination, the patient is held in a long arm splint in supination
in-between wrist motion exercises. The fixator is typically removed in
the office at 6 weeks.
Nonbridging external fixation of intra-articular distal radius fractures
should be reserved for manually active patients with good bone quality
without evidence of prior wrist arthritis. The lunate fragment must be
sufficiently large to support two 3.0 mm pins. A CT scan with AP, lateral
and coronal views is helpful to assess the fracture line patterns in order
to aid pin insertion (Figure 15 A –N).
The immediate complications consist of injury to branches of the superficial
radial nerve or dorsal cutaneous branches of the ulnar nerve. Loss of
fixation due to poor pin placement or interference with extensor tendon
gliding can be minimized by careful technique and open rather than percutaneous
pin insertion. The use of many standard external fixator frames applied
in a nonbridging manner can result in articular incongruity. Late collapse
after fixator removal can occur in osteopenic bone which often requires
subchondral support beyond the 6 weeks of fixator application Due to the
risk of late collapse, adjuvant internal fixation with locking plates
is advised in elderly and osteopenic patients since fracture site settling
may occur for up to 6 months.33
Reports of nonbridging external fixation (or radio-radial external fixation)
for the treatment of intra-articular fractures are sparse and mostly restricted
to the European literature. Krishnan et al reported a clinical trial of
30 patients with Frykman type 7 and 8 fractures who were treated with
the Delta frame nonbridging external fixator (Mathys Medical Ltd., Bettlach,
Switzerland).48 Although favorable wrist motion was reported, the median
intraarticular step was 2.8 mm (range 0-9.1 mm) with a median intra-articular
gap of 1.8 mm (range 0-13.4 mm).42 Gradl et al examined 25 consecutive
patients with fractures of the distal radius who were treated with nonbridging
external fixation for 6 weeks. The stepwise surgical technique comprised
a preliminary joint-bridging construction for reduction purposes, the
subsequent insertion of 3 to 4 K-wires in the distal fragment, the assembling
of the k-wires to a dorsal outrigger bar that was nearly parallel to the
fracture line, and lastly the removal of the joint-bridging part. Clinical
and radiologic evaluation was performed on the first and seventh days,
at 6 weeks and 2 years after surgery. All fractures united with a palmar
tilt of # 0Ean articular step-off of # 2 mm. A loss of radial length occurred
in 4 patients where only 3 k-wires were inserted in the distal fragment.
No radial shortening was seen in fractures with 4 k -wires inserted in
the distal fragment. The functional results at 2 years after surgery showed
an average extension of 55 degrees and flexion of 64 degrees without significant
differences between extra-articular and intra-articular fractures. There
were no instances of extensor tendinitis or pin loosening in the distal
fragment; however there were 3 cases of proximal pin tract infections.
Arthroscopic Assisted Reduction and Nonbridging external fixation
More than 2 mm of articular displacement or gap are typical indications
for surgical treatment. Isolated radial styloid fractures and simple 3-part
fractures are most suited to this technique. Four-part fractures should
be tackled only after one has gained experience with simpler fracture
patterns. After reduction and percutaneous pin fixation many authors use
a bridging external fixator as a neutralization device or apply a volar
locking plate. In many instances it has been my preference to use the
Fragment Specific Fixator in a nonbridging application to allow early
Large capsular tears which carry the risk of marked fluid extravasation,
active infection, neurovascular compromise and distorted anatomy are some
typical contraindications. Marked metaphyseal comminution, shear fractures
and a volar rim fractures require open treatment, although the arthroscope
can be inserted to check the adequacy of the joint reduction.
Surgical Technique (Video: ARIF nonbridging and ARIF
Intraoperative fluoroscopy is used frequently throughout the case, with
the C-arm positioned horizontal to the floor. It is preferable to wait
3 -10 days to allow the initial intra-articular bleeding to stop. I have
found it useful to perform much of the procedure without fluid irrigation
using the dry technique of del Piñal, which eliminates the worry
of fluid extravasation.50 If fluid irrigation is used, inflow is through
a large bore cannula in the 4,5 or 6U portal with the outflow through
the arthroscope cannula. The working portals include the volar radial
(VR) and 6R portal for fracture visualization and the 3-/,4 portal for
instrumentation - but all of the portals are used interchangeably. Lactated
Ringer’s solution is preferred over saline and the forearm is wrapped
with coban to limit extravasation.
The fracture hematoma and debris are lavaged and any early granulation
tissue is debrided with a resector. Mehta and colleagues described a 5
- level algorithm for reducing the fracture fragments. This included the
“London technique” for comminuted intra-articular fractures
where the k-wires were advanced through the distal ulna into the subchondral
distal radius and withdrawn from the radial aspect so that they did not
encroach on the distal radioulnar joint ( Figure 16 A - N).51
The radial styloid is reduced through ligamentotaxis while the arm is
suspended in the traction tower. A freer elevator may also be placed in
the fracture site under fluoroscopic control to facilitate this step.
A 1 cm incision is made over the styloid to prevent injury to the superficial
radial nerve, and two 0.62 mm k-wires are inserted for manipulation of
the styloid fragment. The fracture site is best assessed by viewing across
the wrist with the scope in the 6R portal, in order to gauge the rotation
of the styloid. The k-wires are used as joysticks to manipulate the fragment
then one k-wire is driven forward to capture the reduction. The radial
styloid fragment is then utilized as a landmark to which the depressed
lunate fragment is reduced. An elevator or large pin is inserted percutaneously
to elevate the lunate fragment, which is then held reduced with large
tenaculum forceps. Forceps with large curved jaws are preferred to prevent
crushing the superficial radial nerve. The tips of the forceps may be
placed directly against the ulna to facilitate this step. Once the fracture
fragments are anatomically reduced, horizontal subchondral k-wires are
inserted, stopping short of the DRUJ. It is paramount to bone graft the
metaphyseal defect through a small dorsal incision to prevent late collapse.
If a dorsal die punch fragment is present, it is important that the k-wires
pins are aimed dorsally to capture this fragment. In this case, use of
the volar radial portal allows superior views of this dorsal fragment.
Alternatively, the k-wire can be inserted retrograde through a cannula
in the VR portal and brought out dorsally.
In a four-part fracture, the lunate facet is split into a volar and dorsal
fragment. The volar medial fragment must usually be reduced through an
open incision since wrist traction rotates this fragment and prevents
reduction by closed means. The radial styloid fragment is reduced with
ligamentotaxis and temporarily held with k-wires. A standard volar approach
to the distal radius through the flexor carpi radialis tendon sheath is
then performed. The pronator quadratus is elevated until the volar medial
fragment is seen. Alternatively, a limited volar ulnar incision can be
made, with radial retraction of the flexor tendons. The volar medial fragment
is reduced back to the shaft and the radial styloid fragment. A 2.0 mm
volar locking plate is provisionally applied to hold the reduction.
The reduction is checked through the 6R and VR portals. The dorso-medial
fragment is then elevated back to the radial styloid and reduced to the
volar medial fragment, which is utilized as a landmark. A small dorsal
locking plate can be applied at this point, or alternatively the distal
screws of the volar plate can be used to lag the volar medial and dorso-medial
fragments. In this event, one or more of the distal screws should be placed
in a non-locking fashion to help compress the fragments.
Wiesler et al recently reported an arthroscopic technique for the management
of volar lunate facet fractures.52 A freer elevator is placed in the 3-/,4
portal and introduced into the fracture line to disengage the dorsal lunate
facet fragment. A stout nerve hook is introduced obliquely through the
fracture line and under the volar cortex of the volar lunate facet fragment,
which is tilted, disimpacted and reduced. It is then fixed to the radial
styloid with k-wires, followed by pinning of the dorsal lunate fragment.
The construct is then k-wired to the radial shaft.
Ulnar Styloid Fractures and DRUJ Instability Ulnar styloid fractures may
or may not be associated with disruption of the deep foveal insertion
of the TFCC and secondary DRUJ instability. Many authors recommend initial
fixation of the distal radius fracture and then assessment of the DRUJ
for instability since fracture reduction often restores DRUJ instability.
If there is more than 5 mm of anteroposterior displacement of the distal
ulna during stress testing wrist arthroscopy is beneficial. Basi-styloid
fractures carry the risk of TFCC detachment but in an arthroscopic study
of the soft tissue lesions associated with distal radius fractures, Lindau
noted that the TFCC is more commonly avulsed off its radial insertion.
Any peripheral TFCC tear is repaired arthroscopically using an outside-in
technique. If the articular disc has normal tension to palpation, the
styloid fracture is ignored or excised if there is the worry of late carpal
impingement. The deep fibers of the DRUJ can be directly assessed through
a volar DRUJ portal. 53 (Video: ulnar styloid ) If there is a disruption
of the deep fibers of the TFCC then an open foveal repair can be performed.54
If the TFCC remains well attached to the ulnar styloid fragment then ORIF
of the styloid using k-wires and tension band fixation, cannulated screws
or mitek bone anchors is performed.
Ruch et al described the use of a dorsal outrigger attached to a bridging
external fixator in cases of associated DRUJ instability.55 They found
that that patients in whom the ulnar styloid can be reduced and maintained
in supination can be treated effectively with fixed supination using an
outrigger attached to the external fixator. This method resulted in a
statistically significant improvement in supination as well as a lower
rate of distal radioulnar joint complications, and it required fewer secondary
Combined fixation can be performed with the fixator applied in either
a bridging or nonbridging mode. In many instances the Fragment Specific
fixator is applied in a radial uniplanar configuration in conjunction
with a combination of a volar and/or dorsal plate (Figure 17 A - J). In
these instances the fixator acts as a “3rd plate” which replaces
the radial styloid plate. Alternatively this can be combined with two
volar plates when there is marked peri-articular dorsal comminution (Figure
18 A - L). The fixator can be applied in a bridging fashion with dorsal
outrigger support (Figure 19 A - J). It can also be applied in a nonbridging
fashion after plate fixation (Figure 20 A - K).
Despite the plethora of volar plate designs, fixation of a small radial
styloid fragment is often tenuous. The Fragment specific fixator can be
applied in a uniplanar radial application when there is a small radial
styloid fragment that cannot be adequately captured with a plate. Any
sagittal split of the medial fragment that cannot be successfully reduced
with percutaneous or arthroscopic methods is treated with fragment specific
implants. Joint bridging fixation is indicated when there is central comminution
to help unload the articular fragments.
Inadequate or unstable soft tissue coverage or marked swelling would preclude
the use of multiple skin incisions and implants.
[Videos: i)Combined plate and bridging, ii) Nonbridging FSF with double
Various authors have reported the use of joint bridging external fixation
to facilitate fracture reduction and plate application.22, 49. A joint
bridging external fixator is applied in a standard fashion as described
above. The volar medial fragment can then be approached in a number of
ways. A 3 cm volar ulnar incision is made along the ulnar border of the
flexor tendons, which are retracted radially. The interposed tendons protect
the median nerve, and working through the floor of the flexor tendons
gain more distance from the ulnar neurovascular bundle. The pronator quadratus
is identified and elevated from its ulnar insertion, and then reflected
radially. Some authors use an extended carpal tunnel approach which simplifies
exposure of the volar ulnar fragment. It is my preference to use the standard
flexor carpi radialis (FCR) approach and then use a broad periosteal elevator
to retract the flexor tendons and expose the volar ulnar corner. Alternatively
the FCR approach can be combined with a volar ulnar approach through the
same skin incision (Video).
My preferred technique is to first reduce the volar medial fragment to
the radial shaft and to the reduced radial styloid fragment. A unicortical
locking pin is placed through the distal limb of an L-shaped 2.0 mm plate
to engage the volar ulnar fragment. This allows one to control and reduce
the fragment. The traction is then released and the proximal aspect of
the plate is fixed to the radial shaft. The wrist is then again distracted
and a dorsal approach through the 3rd extensor compartment is performed.
The EPL tendon is removed from it’s compartment and retracted. The
4th extensor compartment is elevated without disrupting the extensor tendons
to gain access to the dorso-medial fragment. The dorsal cortex is typically
quite comminuted and can often be opened like a book to expose the articular
surface. Any tilted or depressed articular fragments are elevated and
supported by subchondral structural bone graft. The dorsal cortex is then
folded back down and held in place with a dorsal 2.0 mm locking plate.
It is not always possible to place more than 1 distal screw due to the
small size of the fragments. Additional bicortical locking screws can
however now be applied through the more proximal holes to “sandwich”
the volar and dorsal medial fragments Once again, the traction is released
prior to attaching the plate to the proximal shaft. When using a standard
joint bridging fixator, the radial column can be held with k-wires or
a cannulated screw. Unless there is marked articular comminution, I insert
the two radial styloid pins and apply the Fragment Specific Fixator in
a nonbridging manner to and allow early protected motion. (Video)
The complications are similar to those described above. There is a greater
risk of hardware intereference with tendon gliding and cutaneous nerve
branches as the number of plates increase. The volar and dorsal exposure
may also devascularize small fragments which can lead to delayed healing
or late collapse which is the rationale for the use of locking plates
rather than conventional mini-plates. In elderly populations with osteopenic
bone, some fracture site settling cannot be avoided even following bone
grafting, external fixation and locking plates (Figure 21 A - J).
Although currently not in vogue, ligamentotaxis still has its uses, especially
in situations that would preclude internal plate fixation. Novel fixator
designs are opening new horizons but multi-center clinical trials are
necessary in order to determine whether the superior results obtained
with nonbridging fixation of extra-articular fractures can be duplicated
with intra-articular fractures. The combination of external fixation with
limited internal fixation is a useful adjunctive technique with multi-fragmented
fractures. Gaining an understanding of the principles and limitations
of external fixation allows one to be flexible and adapt the fixation
to the specific fracture pattern in order to maximize the chances for
an acceptable outcome.
Figure 1. Proximity of the superficial radial nerve (SRN) branches (SR1,2,3)
to potential pin placement sites.
Figure 2. Limitations of ligamentotaxis
A. Marked radial shortening.
B. Initial over distraction restores radial length.
C. Note the persistent dorsal tilt of the articular surface even with
Figure 3. Stress Relaxation
A. Note the over distraction of the radiocarpal joint and the restoration
of radial length.
B. 2 weeks later there is a loss of the radial length and the joint space
is no longer over distracted.
Figure 4. Unstable distal radioulnar joint
A. Unstable distal radius fracture with disruption of the distal radioulnar
B. The medial (sigmoid notch) fragment follows the ulnar head due to the
intact radioulnar ligaments and cannot be stabilized with k-wires and
bridging external fixation.
A. Open distal radius fracture.
B. X-ray appearance.
C. Temporary stabilization with a bridging external fixator.
Figure 6. Dynamic MP flexion splints are applied while the fixator is
still in place.
Figure 7. The fixator frame is improperly applied with the wrist in marked
Figure 8. The fracture reduction is captured with percutaneous k-wires
then neutralized with an external fixator with the wrist in slight extension.
A. 4-part intra-articular fracture
B. Increased tear drop angle indicative of a sagittal split of the medial
C. AP view reveals a restoration of the radial height and apparent congruency
of the joint surface.
D. Lateral view reveals the sagittal split and increased rotation of the
palmar medial fragment.
E. Close up with the volar medial and dorsal medial fragments outlined.
Figure 10. Limited internal fixation.
A. AP x-ray of a displaced 4-part fracture.
B. Lateral view demonstrates a sagittal split of the medial fragment.
C. Internal fixation of medial fragment through a limited volar ulnar
D. Fluoroscopy demonstrates the reduction of the medial fragment.
E. Radial styloid is reduced with ligamentotaxis and held with an oblique
F. Percutaneous screw fixation replaces the oblique radial styloid k-wire.
G. Subchondral k-wire inserted to support the joint surface.
H. Percutaneous bone grafting of metaphysis.
I. Second k-wire replaced by a percutaneous screw which stops short of
J. Lateral view demonstrating restoration of normal tilt and reduction
of the sagittal split.
Figure 11. Primary nonbridging external fixation
A. 56 y.o. female with acute displaced extra-articular fracture.
B. Note the 35° of dorsal tilt.
C. Application of nonbridging external fixator.
D. Note correction of volar tilt.
E. Clinical appearance
F. Note distal fragment fixation with 3 percutaneous pins
G. Appearance at 6 weeks with restored alignment.
H. 5° of volar tilt.
Figure 12. Nonbridging external fixation – redisplaced fracture
A. 55 y.o. female with extra-articular radius fracture.
B. Note the marked dorsal comminution.
C. Initial anatomic closed reduction.
D. Restoration of volar tilt.
E. Redisplacement at 8 days with loss of radial height.
F. Loss of volar tilt.
G. Appearance after percutaneous bone grafting.
H. Lateral view after bone grafting.
I. Insertion of dorsal fixator pins.
J. Lateral view with nonbridging external fixator
K. Postoperative x-ray at 1 week with additional radial styloid pin.
L. Appearance at 8 weeks – there is some radial translation but
restored radial height and radial tilt
M. 10° of volar tilt and healed volar defect.
A. Biomechanical study of a 3-part intra-articular fracture using the
Fragment Specific Fixator.
B. Cut-away view of the distal radius demonstrating stacking of the fixator
pins in multiple planes similar to a fixed angle plate.
A. Displaced 3-part distal radius fracture.
B. Dorsal tilt of the joint surface
C. Anteroposterior CT scan highlighting the size of the medial fragment.
D. Lateral CT demonstrating the sagittal split of the medial fragment.
E. Coronal CT showing disruption of the sigmoid notch.
F. Reduction of coronal split with percutaneous bone forceps.
G. Reduction of dorsal tilt and application of nonbridging fixator.
H. AP view demonstrating closure of the coronal gap.
I. Insertion of an oblique radial styloid pin
J. Clinical appearance of fixator after reduction.
K. Palmar view of the radial styloid pin which does not interfere with
L. Passive wrist flexion.
M. Passive wrist extension.
A. X-ray appearance following nonbridging external fixation of 3-part
B. Anterposterior CT shows the anatomic reconstruction of the joint space.
C. Coronal CT demonstrating fixation of the dorsomedial fragment with
the fixator pin.
D. Correction of dorsal tilt seen on lateral CT view.
E. Appearance at 4 weeks after removal of radial styloid pin.
F. AP view
G. Lateral view
H. Wrist flexion in fixator at 4 weeks.
I. AP view at 4 months.
J. Lateral view at 4 months.
K. Wrist flexion of 60°.
L. Wrist extension of 60°.
M. Full pronation.
N. Full supination.
Figure 16. Arthroscopic guided pinning and nonbridging external fixation
A. Comminuted intra-articular distal radius fracture.
B. Lateral View
C. Anteroposterior CT view reveals the extent of the intra-articular fragmentation.
D. Lateral CT highlights the small dorsal rim fragments.
E. Coronal CT view shows the sigmoid notch disruption.
F. Arthroscopic view of joint surface showing the degree of comminution.
G. A percutaneous is inserted through the ulna to capture and control
the medial fragment.
H. Percutaneous reduction of dorsal tilt.
I. Fluoroscopic appearance.
J. Arthroscopic view following reduction and pinning.
K. Fluoroscopic view after arthroscopic reduction.
L. Application of nonbridging external fixator
M. Result at 6 months with restored radial height and tilt.
N. Congruent joint space with neutral lateral tilt.
Figure 17. 23 y.o. male with displaced intra-articular fracture
A. AP view demonstrates marked radial shortening.
B. The lateral view shows a small distal fragment and marked dorsal tilt.
C. Anteroposterior CT images reveal the small medial fragment
D. Lateral CT highlights the thin volar medial articular fragment.
E. Coronal CT reveals a small, comminuted dorso-medial wall fragment with
sigmoid notch disruption.
F. Intra-operative x-rays demonstrating anatomic restoration of the joint
surface but nonrigid pin fixation of the dorsal wall fragments which necessitates
temporary bridging external fixation to unload the joint space.
G. Lateral view shows sandwiching of the fracture fragments with volar
and dorsal plates with restored volar tilt.
H. Postoperative result.
I. PA view at 4 weeks after fixator removal.
J. Lateral view at 4 weeks after fixator removal.
Figure 18. Volar shear fracture with dorsal comminution
A. Intra-articular fracture with marked radial shortening.
B. Lateral x-ray shows a volar shear pattern with dorsal comminution.
C. Anteroposterior CT reveals an undisplaced sagittal split of the volar
D. Lateral CT highlights the marked periarticular dorsal comminution that
precludes plate fixation.
E. Coronal CT demonstrating the sigmoid notch disruption.
F. Initial joint bridging external fixation clarifies the fracture anatomy.
G. Ligamentotaxis alone however does not reduce the articular incongruity.
H. Volar locking plate applied to the radial column.
I. 2nd volar plate applied to the intermediate column.
J. Articular congruity is restored.
K. AP view at 8 weeks.
L. Lateral view at 8 weeks.
Figure 19. Joint bridging external fixation with dorsal outrigger
A. Comminuted intra-articular fracture.
B. Marked dorsal tilt.
C. Fragmentation of medial fragments
D. Sagittal split with peri-articular dorsal comminution.
E. Volar approach highlights the cortical comminution.
F. Lunate is visible through the sagittal split.
G. Volar plate application after bone grafting.
H. Result at 6 months with congruous sigmoid notch and restored radial
J. Reasonable joint congruity but some residual central depression.
Figure 20. Volar plating with nonbridging external fixation
A. Intra-articular fracture with metaphyseal extension.
B. Depression and dorsal tilt of articular fragments.
C. Fixation of palmar medial fragment - note distal screw does not engage
the dorsal fragment as yet.
D. Restoration of sigmoid notch.
E. Distraction with temporary joint bridging external fixation facilitates
reduction of dorsal fragments.
F. Fixator is then applied in a nonbridging configuration.
G. AP view showing restoration of radial height and tilt.
H. Lateral view shows reconstitution of joint surface “sandwiched”
between volar and dorsal plates.
I. Clinical appearance at 4 weeks.
J. AP view at 8 weeks.
K. Maintenance of congruent joint after fixator removal.
Figure 21. 80 y.o. female with fragile skin.
A. AP view of an unstable periarticular fracture with marked radial shortening.
B. Lateral view highlighting the dorsal comminution and dorsal tilt.
C. Volar approach to the fracture site.
D. Pronation of the proximal radial shaft exposes the fracture.
E. Allograft is packed into the metaphyseal defect.
F. Neutralization plate is then applied.
G. External fixation restores a - 1 mm ulnar variance.
H. Note the fragile skin envelope which precludes a large dorsal dissection.
J. Result at 3 months. Note the late settling at the fracture site despite
external fixation, plating and bone grafting, resulting in a 3 mm ulna
positive variance but preserved radial tilt.
1. Feipel V, Rinnen D, Rooze M. Postero-anterior radiography of the wrist.
Normal database of carpal measurements. Surg Radiol Anat 1998: 20: 221-6.
2. Gausepohl T, Worner S, Pennig D, Koebke J. Extraarticular external
fixation in distal radius fractures pinplacement in osteoporotic bone.
Injury 2001: 32 Suppl 4: SD79-85.
3. Mackinnon SE, Dellon AL. The overlap pattern of the lateral antebrachial
cutaneous nerve and the superficial branch of the radial nerve. J Hand
Surg [Am] 1985: 10: 522-6.
4. Emami A, Mjoberg B. A safer pin position for external fixation of distal
radial fractures. Injury 2000: 31: 749-50.
5. Woo SL, Gomez MA, Akeson WH. The time and history-dependent viscoelastic
properties of the canine medical collateral ligament. J Biomech Eng 1981:
6. Winemaker MJ, Chinchalkar S, Richards RS, et al. Load relaxation and
forces with activity in Hoffman external fixators: a clinical study in
patients with Colles' fractures. J Hand Surg [Am] 1998: 23: 926-32.
7. Sun JS, Chang CH, Wu CC, Hou SM, Hang YS. Extra-articular deformity
in distal radial fractures treated by external fixation. Can J Surg 2001:
8. Bartosh RA, Saldana MJ. Intraarticular fractures of the distal radius:
a cadaveric study to determine if ligamentotaxis restores radiopalmar
tilt. J Hand Surg [Am] 1990: 15: 18-21.
9. Agee JM. Distal radius fractures. Multiplanar ligamentotaxis. Hand
Clin 1993: 9: 577-85.
10. Sanders RA, Keppel FL, Waldrop JI. External fixation of distal radial
fractures: results and complications. J Hand Surg [Am] 1991: 16: 385-91.
11. Juan JA, Prat J, Vera P, et al. Biomechanical consequences of callus
development in Hoffmann, Wagner, Orthofix and Ilizarov external fixators.
J Biomech 1992: 25: 995-1006.
12. Rikli DA, Honigmann P, Babst R, et al. Intra-articular pressure measurement
in the radioulnocarpal joint using a novel sensor: in vitro and in vivo
results. J Hand Surg [Am] 2007: 32: 67-75.
13. Behrens F, Johnson WD, Koch TW, Kovacevic N. Bending stiffness of
unilateral and bilateral fixator frames. Clin Orthop Relat Res 1983: 103-10.
14. Wolfe SW, Austin G, Lorenze M, Swigart CR, Panjabi MM. A biomechanical
comparison of different wrist external fixators with and without K-wire
augmentation. J Hand Surg [Am] 1999: 24: 516-24.
15. Seitz WH, Jr., Froimson AI, Leb R, Shapiro JD. Augmented external
fixation of unstable distal radius fractures. J Hand Surg [Am] 1991: 16:
16. Werber KD, Raeder F, Brauer RB, Weiss S. External fixation of distal
radial fractures: four compared with five pins: a randomized prospective
study. J Bone Joint Surg Am 2003: 85-A: 660-6.
17. Markiewitz AD, Gellman H. Five-pin external fixation and early range
of motion for distal radius fractures. Orthop Clin North Am 2001: 32:
18. Braun RM, Gellman H. Dorsal pin placement and external fixation for
correction of dorsal tilt in fractures of the distal radius. J Hand Surg
[Am] 1994: 19: 653-5.
19. Dunning CE, Lindsay CS, Bicknell RT, et al. Supplemental pinning improves
the stability of external fixation in distal radius fractures during simulated
finger and forearm motion. J Hand Surg [Am] 1999: 24: 992-1000.
20. Wolfe SW, Swigart CR, Grauer J, Slade JF, 3rd, Panjabi MM. Augmented
external fixation of distal radius fractures: a biomechanical analysis.
J Hand Surg [Am] 1998: 23: 127-34.
21. Bindra RR. Biomechanics and biology of external fixation of distal
radius fractures. Hand Clin 2005: 21: 363-73.
22. Rikli DA, Businger A, Babst R. Dorsal double-plate fixation of the
distal radius. Oper Orthop Traumatol 2005: 17: 624-40.
23. Papadonikolakis A, Shen J, Garrett JP, Davis SM, Ruch DS. The effect
of increasing distraction on digital motion after external fixation of
the wrist. J Hand Surg [Am] 2005: 30: 773-9.
24. Kaempffe FA, Wheeler DR, Peimer CA, et al. Severe fractures of the
distal radius: effect of amount and duration of external fixator distraction
on outcome. J Hand Surg [Am] 1993: 18: 33-41.
25. Baechler MF, Means KR, Jr., Parks BG, Nguyen A, Segalman KA. Carpal
canal pressure of the distracted wrist. J Hand Surg [Am] 2004: 29: 858-64.
26. Margaliot Z, Haase SC, Kotsis SV, Kim HM, Chung KC. A meta-analysis
of outcomes of external fixation versus plate osteosynthesis for unstable
distal radius fractures. J Hand Surg [Am] 2005: 30: 1185-99.
27. Westphal T, Piatek S, Schubert S, Winckler S. Outcome after surgery
of distal radius fractures: no differences between external fixation and
ORIF. Arch Orthop Trauma Surg 2005: 125: 507-14.
28. Arora J, Malik AC. External fixation in comminuted, displaced intra-articular
fractures of the distal radius: is it sufficient? Arch Orthop Trauma Surg
2005: 125: 536-40.
29. Weil WM, Trumble TE. Treatment of distal radius fractures with intrafocal
(kapandji) pinning and supplemental skeletal stabilization. Hand Clin
2005: 21: 317-28.
30. Fernandez DL, Geissler WB. Treatment of displaced articular fractures
of the radius. J Hand Surg [Am] 1991: 16: 375-84.
31. Kreder HJ, Hanel DP, Agel J, et al. Indirect reduction and percutaneous
fixation versus open reduction and internal fixation for displaced intra-articular
fractures of the distal radius: a randomised, controlled trial. J Bone
Joint Surg Br 2005: 87: 829-36.
32. 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:
33. Dicpinigaitis P, Wolinsky P, Hiebert R, et al. Can external fixation
maintain reduction after distal radius fractures? J Trauma 2004: 57: 845-50.
34. Kawaguchi S, Sawada K, Nabeta Y, Hayakawa M, Aoki M. Recurrent dorsal
angulation of the distal radius fracture during dynamic external fixation.
J Hand Surg [Am] 1998: 23: 920-5.
35. Sommerkamp TG, Seeman M, Silliman J, et al. Dynamic external fixation
of unstable fractures of the distal part of the radius. A prospective,
randomized comparison with static external fixation. J Bone Joint Surg
Am 1994: 76: 1149-61.
36. McQueen MM. Redisplaced unstable fractures of the distal radius. A
randomised, prospective study of bridging versus non-bridging external
fixation. J Bone Joint Surg Br 1998: 80: 665-9.
37. McQueen MM. Metaphyseal external fixation of the distal radius. Bull
Hosp Jt Dis 1999: 58: 9-14.
38. Lafontaine M, Delince P, Hardy D, Simons M. [Instability of fractures
of the lower end of the radius: apropos of a series of 167 cases]. Acta
Orthop Belg 1989: 55: 203-16.
39. Trumble TE, Schmitt SR, Vedder NB. Factors affecting functional outcome
of displaced intra-articular distal radius fractures. J Hand Surg [Am]
1994: 19: 325-40.
40. McQueen MM. Non-spanning external fixation of the distal radius. Hand
Clin 2005: 21: 375-80.
41. Salter RB, Simmonds DF, Malcolm BW, et al. The biological effect of
continuous passive motion on the healing of full-thickness defects in
articular cartilage. An experimental investigation in the rabbit. J Bone
Joint Surg Am 1980: 62: 1232-51.
42. Mehta JA, Slavotinek JP, Krishnan J. Local osteopenia associated with
management of intra-articular distal radial fractures by insertion of
external fixation pins in the distal fragment: prospective study. J Orthop
Surg (Hong Kong) 2002: 10: 179-84.
43. Slutsky DJ. DQ. Fragment Specific External Fixation of Distal Radius
44. Dodds SD, Cornelissen S, Jossan S, Wolfe SW. A biomechanical comparison
of fragment-specific fixation and augmented external fixation for intra-articular
distal radius fractures. J Hand Surg [Am] 2002: 27: 953-64.
45. Short WH, Palmer AK, Werner FW, Murphy DJ. A biomechanical study of
distal radial fractures. J Hand Surg [Am] 1987: 12: 529-34.
46. 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 [Am] 2003: 28: 94-104.
47. Putnam MD, Meyer NJ, Nelson EW, Gesensway D, Lewis JL. Distal radial
metaphyseal forces in an extrinsic grip model: implications for postfracture
rehabilitation. J Hand Surg [Am] 2000: 25: 469-75.
48. Krishnan J, Chipchase LS, Slavotinek J. Intraarticular fractures of
the distal radius treated with metaphyseal external fixation. Early clinical
results. J Hand Surg [Br] 1998: 23: 396-9.
49. Gradl G, Jupiter JB, Gierer P, Mittlmeier T. Fractures of the distal
radius treated with a nonbridging external fixation technique using multiplanar
k-wires. J Hand Surg [Am] 2005: 30: 960-8.
50. del Pinal F, Garcia-Bernal FJ, Pisani D, et al. Dry arthroscopy of
the wrist: surgical technique. J Hand Surg [Am] 2007: 32: 119-23.
51. Mehta JA, Bain GI, Heptinstall RJ. Anatomical reduction of intra-articular
fractures of the distal radius. An arthroscopically-assisted approach.
J Bone Joint Surg Br 2000: 82: 79-86.
52. Wiesler ER, Chloros GD, Lucas RM, Kuzma GR. Arthroscopic management
of volar lunate facet fractures of the distal radius. Tech Hand Up Extrem
Surg 2006: 10: 139-44.
53. Slutsky D. DRUJ arthroscopy and the Volar Ulnar Portal. Techniques
in Hand and Upper Extremity Surgery 2007: 11: 1-7.
54. Atzei A L, Carità E, Papini Zorli I, Cugola L. Arthroscopically
assisted foveal reinsertion of peripheral avulsions of the TFCC. J Hand
Surg (Br) 2005: 30: 40.
55. Ruch DS, Lumsden BC, Papadonikolakis A. Distal radius fractures: a
comparison of tension band wiring versus ulnar outrigger external fixation
for the management of distal radioulnar instability. J Hand Surg [Am]
2005: 30: 969-77.