General considerations
These are complete articular fractures of the distal radius, with no part of the articular surface in continuity with the diaphysis. As these are intraarticular fractures they require anatomic reduction, except in very low demand patients.
Any patient who has had a fall on the outstretched hand may have sustained an intercarpal ligament injury; these may easily be missed on initial clinical assessment.
Note: CT scans may be helpful for treatment decisions.
In fractures with extension into the diaphysis, open treatment with a long T-plate (bridging plate) is preferred due to the longer time to healing of the diaphyseal fracture component.
| Nonoperative treatment - Cast | ||
| Main indication | Skill | Equipment |
|---|---|---|
| Unfit or low-demand patient, undisplaced fracture |  |
 |
Indications
- Relatively undisplaced and stable fracture
- Patient not fit for surgery
- Poor state of soft tissues
- low-demand patient
Contraindication
- Displaced fracture
Disadvantage
-
Increased risk of long-term mobility loss
| Joint-spanning external fixation (temporary or definitive) | ||
| Main indication | Skill | Equipment |
|---|---|---|
| Temporary stabilization in polytrauma, unfit patient, insufficient hold in a cast, patient not suitable for ORIF |  |
 |
Indications
- Temporary stabilization in polytrauma/ unfit patient
- Open fracture
- Unacceptable shortening or dorsal inclination
- Extension of fracture into diaphysis
- Local soft-tissues compromised for plating
- Closed reduction possible
Contraindications
- Poor state of local soft tissues increasing risk of pin track infection
- Patient not fit for surgery
- Severely comminuted injury
- Osteoporosis
- Significant metaphyseal defect after restoring radial length
Advantages
- Reduced risk of infection at the fracture site compared to plating
- Lower risk in cases of significant local soft-tissue injury than ORIF
- Straightforward technique
- Restoration of articular anatomy (both radiocarpal and DRU joint)
Disadvantages
- Radial sensory nerve injury
- Risk of metacarpal fracture
- Risk of loss of radial length
- Risk of injury to extensor tendon
- Stiffness, especially with over distraction
- Risk of complex regional pain syndrome (type I) (CRPS-I)
- Risk of pin-track infection
- Risk of redisplacement after removal
- Unable to accurately control fragments without supplementary pinning
| ORIF - Palmar bridge plate | ||
| Main indication | Skill | Equipment |
|---|---|---|
| Marked metaphyseal comminution |  |
 |
Indications
- Small articular fragments
- Impacted fragments
- Persistent or recurrent displacement following other methods
- Carpal instability
- High-demand patients
- Marked metaphyseal comminution
Contraindications
- Poor state of soft tissues
- Severe swelling
- Patient not fit for surgery
Advantages
- Anatomical reduction
- Stability
- Early motion
- Identification of associated intercarpal ligament injury
- Restoration of articular anatomy (both radiocarpal and DRU joint)
Disadvantages
- Risk of nerve injury
- Risk of tendon irritation
- Possible need for later implant removal
| ORIF - Joint-spanning distraction plate | ||
| Main indication | Skill | Equipment |
|---|---|---|
| Severe comminution | |
|
Indications
- Small articular fragments
- Impacted fragments
- Persistent or recurrent displacement following other methods
- Carpal instability
- Polytrauma patients
- Marked metaphyseal comminution
Contraindications
- Poor state of soft tissues
- Severe swelling
- Patient not fit for surgery
Advantages
- Anatomical reduction
- Stability
- Early motion
- Identification of associated intercarpal ligament injury
- Restoration of articular anatomy (both radiocarpal and DRU joint)
Disadvantages
- Risk of nerve injury
- Risk of tendon irritation
-
Possible need for later implant removal
| ORIF - Dorsoradial double plate | ||
| Main indication | Skill | Equipment |
|---|---|---|
| When a posterior approach is necessary to treat intercarpal instability | |
|
Optimum hold and stability is probably best obtained with separate plating of the radial and intermediate columns. The fixation of the small, distal fragments is more secure with locking plates, and additional bone graft is not then necessary.
Indications
- Dorsally displaced fractures (using indirect reduction technique for locking plates if required)
- Loss of radial length
- Displaced coronal split in lunate fossa
- Impacted articular fragments and associated carpal ligament tears
- Small articular fragments
- Complex metaphyseal and/or diaphyseal components
- Open fractures
Contraindications
- Dorsal soft-tissue injury
- Poor state of soft tissues
- Patient not fit for surgery
Advantages
- Stable 3-column reconstruction
- Stable restoration of radial length
- Stable anatomical reduction of both radiocarpal and DRU joints
- Significantly greater stability in osteoporotic bone with locking plate
- More likely to achieve anatomical reduction
- Early motion
- Identification of associated intercarpal ligament injury
Disadvantages
- Tendon irritation (less likely with 2.4mm implants)
- Possible need for later implant removal
- Cost for locking plates
- Dorsal approach technically more demanding than palmar approach
- Diaphyseal component may require separate reconstruction
- Nerve injury
| ORIF - Dorsoradiopalmar triple plate | ||
| Main indication | Skill | Equipment |
|---|---|---|
| Gross articular injury which can be reconstructed | |
|
Optimum hold and stability is probably best obtained with separate plating of the radial and intermediate columns. The fixation of the small, distal fragments is more secure with locking plates, and additional bone graft is not then necessary.
Indications
- Hyperextended palmar articular fragments
- Irreducible dorsal ulnar fragments
- Impressed articular fragments
- Significant ligament injury of the proximal carpal row
- Small articular fragments
- Complex metaphyseal and/or diaphyseal components
- Open fractures
Contraindications
- Significant closed skin injuries
- Poor state of soft tissues
- Patient not fit for surgery
Advantages
- Stable 3-column reconstruction
- Stable restoration of radial length
- Stable anatomical reduction of both radiocarpal and DRU joints
- Significantly greater stability in osteoporotic bone with locking plate
- More likely to achieve anatomical reduction
- Early motion
- Identification of associated intercarpal ligament injury
Disadvantages
- Tendon irritation (less likely with 2.4mm implants)
- Possible need for later implant removal
- Cost for locking plates
- Multiple approaches required, which is the most technically demanding procedure
- Diaphyseal component may require separate reconstruction
- Nerve injury
| *Skill | |
|---|---|
|
Basic surgical experience, no specialized skills |
|
Some specialized surgical experience |
|
Highly experienced and skilled surgeon |
| *Equipment | |
|---|---|
|
Basic equipment only |
|
Simple surgical and imaging resources |
|
Full specialized surgical and imaging resources |