The use of an externalfixator alone or in conjunction with percutaneous or limited internal fixation, for unstable fractures of the distal end of the radius has produced good or excellent results. We attribute to these good or excellent results to the early removal of the fixator that allows early range-of-motion exercises and to avoid complications commonly associated with the prolonged use of external fixators 18 . We believe that intra-articular (AO type-B/C) fractures of the distal part of the radius can be treated by closed reduction and external fixation. Our series demonstrates that this technique, supplemented by k-wires as needed, is a satisfactory treatment that can lead to a high rate of return to work and sports, a high level of patient satisfaction, and a low rate of complications.
issuesdon’t affect elderly people and low-demand patients probably due to low functional and physical demand. In general anatomic reduction should be pursued in younger and high-demand elderlypatients (because of longer healing time and to initiate early mobilization) with extra-articular fracture or intra-articularfractures. Low-demand elders with severely displaced intra- articular fracture or median nerve compression require surgical management but otherwise the prime focus in this group should be on joint movement [3;4] .
A few limitations of our study should be noted. Firstly, this was a retrospective study. Secondly, there was no randomisation of treatment groups. Thirdly, only short- term outcomes (12 months) were measured in this study. Although the sample sizes in the ORIF and nonoperative groups (32 and 28, respectively) after the criteria were applied were by no means small, a larger—ideally prospective and randomised—trial looking into both the short- and long-term outcomes will provide more infor- mation and a higher level of evidence. One notable omis- sion from our radiographic assessment was radiographic changes of osteoarthritis. This was due to the perceived short duration (12 months) from injury when radiographic assessment was performed in our study. In addition, early radiographic changes do not always progress and result in clinically relevant post-traumatic osteoarthritis [19, 20].
This prospective study on ‘Functionaloutcome of intraarticulardistalradiusfractures managed by fragment specific fracture fixation’ was conducted in the Department of Orthopaedic Surgery, Govt. Kilpauk Medical College and Hospital, Chennai from September 2014 to July 2016 after ethical committee clearance was obtained.
necessary preoperatively evaluation of the cardiac status with ECG, Chest x-ray, and 2D ECHO if necessary 2D ECHO was done. For the posted case of distal femoral fracture for surgery, internal fixation was done through the lateral incision just anterior to the intermuscular septum, for condylar buttress plate and locking plate. All cases were done under spinal anesthesia in the operation theatre of NIMS. Image intensifier was used where ever necessary. The implants used are Condylar Buttress Plate [CBP], Locking Compression Plate [LCP], Cancellous Screw Fixation [CSF] and externalfixator and Ilizarov fixator. Both cortical and cancellous bone grafting was done from iliac crest and fibula for severely comminuted metaphyseal and Intraarticular fractures and all Bone grafting were done along with primary operation.
The amount of residual deformity that can be accepted is still controversial . It is difficult to correlate the postoperative radiological findings to the clinical result and to use this as a prognostic factor. In a 10-year fol- low-up, Etter and Ganz  retrospectively examined how the fracture pattern and quality of reduction corre- lated to postoperative arthritis in 41 patients with pla- fond fractures treated with internal fixation. Anatomical reduction was correlated to a better prognosis in terms of a lower risk of post-traumatic osteoarthritis, but it did not guarantee a good clinical result. Severe osteoarthritis present at late follow-up did not correlate with poor subjective or objective function. DeCoster et al.  came to the same conclusions using the rank order method to assess the quality of articular reduction in the outcome of displaced intra-articulardistal tibia frac- tures in 25 patients treated with articulated external fix- ation and limited internal fixation. With ten B3, three C1, ten C2 and twelve C3 fractures, Marsh et al.  rated the quality of reduction as good in 14 ankles, fair in 15 and poor in 6, using the same radiological evalu- ation method as in the present study. They did not find any association between the fracture type and the
From casting to arthroscopic assisted reduction, all treatment modalities have been tried. Sir Abraham Col- les first described the deformities of distal end radiusfractures many years before the advent of X-rays. Since then, a lot of modifications in the management of DRF have taken places, which include closed reduction with casting, percutaneous pinning, intrafocal pinning, external fixation with ligamentotaxis, minimal open to open reduction and internal fixation with various modern gadgets. Even the fragment specific fracture fixation has been tried with good results. Karimi et al. in his study has shown good results in torus fractures in patients less than 17 years of age using removable wrist splint. He, however, studied only the patients of less than 17 (16).Bahari-Kashani et al. (2003) studied the intra-articulardistal end radiusfractures managed by pin and plaster or plating. They concluded that func- tional scoring, radiological indices, grip strength, and supination pronation were better in the plating group (17). Mardani et al. compared the closed reduction with long-arm cast to closed reduction with PCP and found the latter as better option in terms of finger stiffness, but found some pin tract infections, which resolved un- eventfully (18).
Our study has been conducted in locally to assess the functionaloutcome of unstable distalradius fracture in adults treated with palmer T-plate Osteosynthesis. Palmer T- plate can be the choice of implant for fixation of unstable distalradiusfractures. Use palmer T- plate provides the best mode of anatomical reduction and in addition to this their buttress modes reduces and stabilize vertical shear intra-articularfractures through an antiglide effect . The purpose for conducting this study is to achieve a validated data by assessing the postoperative range of motion by the use of validated DASH score (Disability of Arm, Shoulder and Hand) and assessment of degree of flexion & extension at wrist post operatively. Evidence was provided of the validity, test-retest reliability, and responsiveness of the DASH & confirming its usefulness across the whole extremity [12,13]. A very strong correlation was noted between DASH & other scoring systems making it reliable in evaluating a subjective outcome. Range of flexion and extension which is most important function of wrist is evaluated.
In the volar locked plating technique, the skin was incised longitudinally along the course of the flexor carpi radialis (FCR) tendon. The FCR sheath was opened and the tendon retracted to the radial side to expose the ulnar corner of the distalradius (this can be extended into a carpal tunnel release). The FCR tendon was also retracted to the ulnar side to expose the radial styloid and scaphoid fossa. Great care was taken to avoid pressure on the median nerve. Underneath the FCR sheath lies the flexor pollicis longus (FPL) tendon. This was retracted ulnarly revealing the pronator quadratus (PQ) muscle. The PQ muscle was elevated from its radial origin and reflected ulnarly to expose the distalradius. If the fracture was very distal, it was not necessary to completely elevate this muscle. The palmar extrinsic radiocarpal ligaments should not be detached from the radius to expose the joint surface as this
Over the years, management of complex distalradiusfractures by closed means has often failed leading to late collapse. We have chosen the principle of ligamentotaxis usingexternal fixation and bone grafting in this study to prevent late complications. Eighty one patients with complex distalradiusfractures belonging to Type IV A, IV B, IV C of Universal classification were treated with an AO externalfixator between 1995 and 2001. Mean age group was 38. 47 years with longest follow up of 7 years. Bone grafting was done primarily in 20 patients and early grafting (within 3 weeks) in 5 patients. Statistically significant differences were observed between the two groups(with or without bone grafting) with respect to postoperative values of (radial length, radial tilt and volar tilt). Results were assessed based on Sarmientos criteria. 56 patients had excellent results, 9 had good results and 16 had poor results. Late collapse with decreased radial length was observed in 18 patients who did not undergo bone grafting. Mean grip strength was 63 percent. Osteoarthritic changes were noted in 20 patients. We conclude that accurate anatomic reduction is necessary for achieving good to excellent functional and cosmetic results. Bone grafting is the mainstay of treatment in comminuted distalradiusfractures along with fracture stabilisation.
Various techniques and implants have been used for treating the distalradiusfractures. From the days of cast application for all the cases the era changed to pinning and casting followed by externalfixator application and indirect reduction of the fracture by the principle of ligamentotaxis. Later buttress plates of various shapes were used for internal fixation 24,28 . The next breakthrough was with the Locking plates which had better anchorage and stability even in the metaphyseal bone 28 . With advancement came the fracture specific smaller plates and anchorage pins 29 . The variable angled 2.4mm locking plates are the newer choice with maximum number of screws in the metaphyseal region in the desired direction of anchorage.
Many studies reviewing various methods of fixation look at radiographic parameters that affect outcome, however few if any have looked at surgeon grade or time to surgery as we have. In a large radiographic study, Mackenney et al. showed that age over 80 years; metaphyseal comminution and positive ulna variance were the main predictors of instability. This and poor radio-carpal alignment were shown to be associated with poor outcome . However this study did not look at results after fixation with a volar locking plate, which has specific design applications for use in osteo- porotic unstable fracture patterns. We chose not to assess radiographic parameters such as residual intra- articular step, correction of normal distal radial anat- omy and presence of post traumatic osteoarthritis as we were interested purely in patient centered outcome and these radiographic features have consistently been Table 3 Time to Fracture Union with varying fracture type
The comminuted fracture in the younger patient is generally a high energy injury secondary to either a fall from a height or high speed motor vehicle accident. With dorsiflexion, the radius fracture in tension on its palmar surface followed by compression on the dorsal surface, results in dorsal comminution. The lunate can exert a compression force on distalradius producing a depressed fracture of the lunate fossa the so called die punch fracture , similarly a scaphoid fossa depression fracture can result from compressive forces exerted by the scaphoid. The ulnar styloidfracture so often seen with distalradiusfractures probably represents an avulsion fracture from a tensile force transmitted through on intact triangular fibrocartilage complex. Treatment of such injuries is difficult. These fractures often are unstable, are difficult to reduce anatomically, and are associated with a high prevalence of complications of post-traumatic osteoarthritis after intra- articular fracture of the distal aspect of the radius. It is also known that extra-articular misalignment can lead to decreased grip strength and endurance as well as limited motion and carpal instability. Closed reduction and cast immobilization has been the mainstay of treatment of these fractures, but invariably it results in mal-union, poor functional and cosmetic outcome. 
7) G.S.Roysam: The distal radio ulnar joint in colles fracture. - Journal of Bone and Joint Surgery (Br) 1993; 75-B, 58-60. 8) J.J Dias, C.C Wray, J.M Jones, P.J.Gregg: The value of early mobilization in the treatment of colles fractures. - Journal of Bone and Joint Surgery(Br) 1987, 69-B; no.3, 463-467. 9) M.M.McQueen : Redisplaced unstable fracture of distalradius. – Study of bridging versus non bridging external fixation - Journal of Bone and Joint Surgery (Br) 1998; 80-B, 665-669. 10) William P. Cooney, James H. Dobyns, Ronald L
Objectives: This study compared the clinical and radiological outcomes of two different methods for the treatment of distal radial intra-articular frac- tures. Patients and Methods: Forty-six patients with distalradiusintra-arti- cular fractures were divided into two groups. Group I included 24 patients with type C fracture treated by externalfixator augmented by percutaneous K-wires. Group II included 22 patients with type C fracture treated by volar locked distal radial plate augmented by K-wires. Two patients had complex injuries necessitating double plating (sandwich). All patients were evaluated clinically by Mayo Wrist Score and radiologically by Sarmiento’s radiological score. Results: Both groups reported good personal satisfaction according to Mayo Wrist Score, and the results were not statistically different between the two groups. In Group I, 19 patients (79.2%) had excellent radiological out- come and five patients (20.9%) had good radiological outcome according to Sarmiento’s radiological score. In Group II, 20 patients (90.9%) had excellent outcome, and two (9.1%) had good radiological outcome; there was no or in- significant deformity. Conclusions: Complex distal radial fractures can be treated either by external fixation (ligamentotaxis) or by locked pre-contoured plating. The clinical outcome of plating and externalfixator in our study did not show any statistically significant difference. The radiological outcome had no correlation with the clinical outcome.
There are so many unproved axioms and beliefs about the phylogenetic evolution of human wrist and upper limb. The morphogenetic evolution of wrist was believed to be originated some 400 million years before from the pectoral fins of the primitive fish 39 . When amphibians evolved, for locomotion in ground and for weight bearing, syndesmosis appears between radius and ulna distally. As arthropod apes evolved, brachiation of the upper limb and the development of bipedalism emphasise wrist joint mobility for free climbing and to catch hold food or prey 40 . As hominids evolved from primates, for fine skilled movements of hand and wrist led to the development of synovial lined distal radio ulnar joint, radio carpal joint allowing multiplanar motions in the wrist joint.
easy recognition and temporary and final fixation of the fracture. If these soft-tissue structures do not heal well, ma- jor weakness of external rotation of the shoulder or poste- rior instability of the joint may develop. Hence, we sutured back each and every muscle that was raised to its anatom- ical location which led us to have a better functional out- come. The patients in this series were all healthy, young or middle aged adults who wished to remain physically ac- tive. All had substantial displacement of the articular sur- faces. We had good outcome in most of the patients; hence, this lead us to conclude that open reduction and internal fixation with the distalradius plate should be considered for patients who have articular displacement over 2 mm and wish to remain active.
Committed intraarticulardistalradiusfractures often pose a great challenge to the treating orthopedic surgeon. Fixed and variable angled locking compression plates are the implants of choice in such fracture patterns. The use of variable angle locking plates has an upper edge according to the recent studies in maintaining the joint biomechanism and yield a better patient reported outcome which is necessary for our population. The use of volar plates also offer the luxury for early rehabilitation without the fear of decrease in radiographics indices and hence functional results. We would like to conclude by stating that though this is a study with a small sample size, the volar locked plates are a useful modality in unstable intra-articularfractures of distalradius and the present series should provide a future prospective study for the evolving plate osteosythesis for distalradiusfractures.
Recently surgical management has been widely recommended and performed to prevent disability. Several studies have shown convincingly that functionaloutcome is good when the anatomy is restored by obtaining good reduction of fracture fragments maintaining the angulations of the articular surface of radius and radial length, and to minimize those related complications as well. This study evaluates the surgical and functional outcomes of intra- articularfractures of distal end radius in a comparative study between closed reduction usingexternal fixation and distraction osteosynthesis to align fragments versus open reduction internal fixation (ORIF) with buttress plating.
There was a significant difference in the final outcome in both the study groups, assessed using The Modified Green O‟Brien System. However, we preferred using the externalfixator application in the treatment of intra-articularfractures of the distalradius (Frykman Type VII and VIII). Although open reduction and internal fixation has advantages such as direct visualization and manipulation of the fracture segments, stable fixation and the possibility of immediate postoperative motion but we preferred the use of externalfixator since it provides continuity of reduction under fluoroscopic control, improved reduction by ligamentotaxis, 15 and the ability to protect the reduction until