New developments in external fixator frames, combination and multiple modalities like combined internal and external fixation for highly unstablefractures, addition of bone grafting, biodegradable cementing and newer information on muscle – tendon physiology, wrist ligaments and 3 – dimensional motion studies will increase the understanding the surgical anatomy and accurate anatomic reduction of the fracture.
Some authors have studied whether factors such as age and sex would affect the final outcomes, as these factors play a major role in determining the bone mineral density (BMD)  . Hollevoet et al. studied the correlation of clin- ical parameters with the bone mineral density to a greater extent compared to the radiological parameters. They suggested that osteoporosis may be one of the factors affecting the outcome of comminuted intra-articular distal radial frac- tures. In contrast, Dhainaut et al. did not observe any significant association between the reduced BMD of the cortical bone of the hand analyzed by digital radiography (DXR) and the risk of having an intra-articular or extra-articular fragility fracture in the distalradius. They concluded that the use of glucocorti- coids may be responsible for the increase in the risk of having an intra-articular fracture, more than BMD, which can cause more severe fractures .
The extrinsic ligaments of the wrist play a major role in the use of indirect reduction techniques. The palmar extrinsic ligaments are attached to the distalradius, and these ligaments are relied on to reduce the components of a fracture using closed methods. There are two factors about these ligaments that make them significant for reduction. First, the orientation of the extrinsic ligaments from the radial styloid is oblique relative to the more vertical orientation of the ligaments attached to the lunate facet.
by one case of postoperative re-displacement occurred in this study. 2) A good exposure is needed to avoid repeated fluoroscopic exami- nation and prolonged operative time. The pro- nator muscle should be protected during the operation. Dos Remedios et al.  pointed out pronator muscle played an important role in the wrist function, including forearm rotation and distal ulnar joint stability. Above all, minimally invasive was advocated to avoid pronator mus- cle damage. 3) As to patients with type C2 frac- tures, especially who had crushing volar corti- cal bone, loss of the distalradius would occur even though Kirschner wire fixation was per- formed after reduction. Thus, it would be better to fix distal end of fracture firstly, then loosen oval foramen of the plate and draw again, and finally tight the screws after distalradius restor- ing to normal height. 4) Palmar approach might be associated with tendon rupture or other complications. Tarallo et al.  conducted a retrospective study to investigate the complica- tion incidence s of volar locking plate fixation for unstable DRFs. The result showed that 18 of 303 (5.9%) DRFs patients suffered from complications after volar locking plate fixation and extensor tendon injury accounted for 50% of all complications due to technical defect of the internal fixation. In our study, we also found that the complications of volar locking plate fixation of DRFs were related to technic- al defects during internal fixation. Fortunately, this complication could be avoided by careful operative procedure. 5) For unstable DRFs, distal radioulnar join dislocation should be noticed and corrected timely. In our study, one patient obtained not well rotation function dur- ing follow-up because his dislocation was not observed in time. 6) The protection for soft tis- sue should be considered during the surgery because of the poor flexibility of the skin and soft tissues were relatively poor in elderly patients; the affected limbs should be elevated postoperatively to lessen edema.
Anatomically , the ulna is stable axis of rotation of the forearm around which the radius moves.If there is a dislocation , it is technically the radius that displaced dorsally or palmarly with respect to the ulna.The distal radioulnar joint has both rotational and translational components of motion and does not have a single center of rotation.Four structures play main role in stabilizing the distal radio ulnar joint in different positions of forearm rotation 7 .
alignment of the fragments and the articular congruity and allowed early mobilization of the wrist and fingers. The external fixation does not provide the absolute sta- bility to maintain the comminuted intrarticular frac- tures. It takes a longer time for the fracture gap to be filled by new bone formation. In study of Overggard et. al over a seven-year follow-up, seventeen (30 per cent) of their fifty-six patients had radiographic evidence of osteophytes and eight patients (14 per cent) had advanced radiographic changes . In our study late collapse was not noticed in patients who underwent bone grafting after 7 year followups. By pushing the grafts towards the distal articular surface many of the die punch fragments which cannot be reduced by liga- mentotaxis alone can be adequately lifted, reduced and supported to achieve congruent articular surface . Bone grafts supply an interosseous distension force which enhances the ligamentotaxis and helps to line up
Distalradiusfractures (DRF) occur more frequently than any other fracture. Various operating methods for distalradius fracture fixation have used by orthopedic surgeons, including K-wire fixation, external fixation and open reduction and internal fixation with different implants are well established and widely used . External fixation with additional use of K-wires fixation to achieve stable fixation, may be associated with prolonged postoperative stiffness and pin tract infection and with loss of reduction. Dorsal plate Osteosynthesis may cause extensor tendons irritations and some time even rupture, so their removal is often necessary, in contrast volar plate can be left in place for most of cases [15- 17]. Several studies have conducted for the treatment unstabledistalradius fracture and showed satisfactory results with each method but treatment of choice for such unstable fracture remain controversial. With the exception of a very recent study, not even randomized control trials could convincingly show better results for any of the procedures [16-19]. While dorsal plate used for treating unstabledistalradius fracture, it requires exposure of the fragments, frequently spongioplasty, and usually removal of the implant later on. However, with the palmar approach for the reconstruction of the articular surface and restoration can easily be achieved with the T-plate.
approach, the reduction-fixation method, and outcome prediction. Currently, most authors select surgical treat- ment for displacement of more than 1~2 mm for intra-ar- ticular fractures of the distalradius [15 – 21]. Therefore, we regarded displaced ICF as unstable fracture for which sur- gical treatment was indicated, and non-obvious displaced ICF as stable fracture for which conservative treatment was indicated. Surgical approach must be selected accord- ing to the position of the fracture, a dorsal approach was used for the dorsal type, a volar approach was used for the volar type, the central group may use a dorsal or a volar approach, but the volar approach is superior to the dorsal approach as it may avoid injury to the tendons. The col- lapse type requires pry-poking reduction and fixation with screws or bone grafts to support the collapsed fractures, and the split type requires pressurized fixation as
Various authors have attempted to define intuition. Benner and Tanner provide a succinct definition of ‘understanding without a rationale’(104). Rew provides a more comprehensive description of intuition as ‘a component of complex judgement, the act of deciding what to do in a perplexing, often ambiguous and uncertain situation(105). It is the act of synthesising empirical, ethical, aesthetic and personal knowledge. Intuitive judgement is the decision to act on a sudden awareness of knowledge, that is related to previous experience as a whole and difficult to articulate’(94). Several themes arise in all the definitions of intuition, firstly, the role of experience and, secondly, that this is an unconscious process. Benner and Tanner suggest that as clinicians gain knowledge with experience, their decision-making is enriched thus reducing their reliance upon analytic cognitive processes(94, 104). King and Macleod Clark, studied the expertise of surgical and intensive care nurses of various degrees of experience(106). Although all nurses displayed a degree of intuitive awareness, the ability to understand the basis of their intuitive concern, and the importance in relation to the patient’s condition, improved with the degree of expertise(106).
Distalradiusfractures are one of the most common upper extremity injuries, accounting for about 8–15 % of all skeletal injuries treated by orthopedic surgeons [1–3]. Late- diagnosed fractures are frequently complicated with many sequelae; among them, malunion and post-traumatic wrist arthritis due to post-traumatic distalradius deformity are most frequently seen [4–6]. Common deformities follow- ing an extra-articular distalradius fracture include loss of the normal volar tilt of the articular surface in the saggital plane, decreased ulnar inclination in the frontal plane, and loss of length relative to the ulna . Post-traumatic deformity results in alteration of normal anatomy, biome- chanics of distalradius, and functional impairment in hand and wrist [6–8]. Many surgical modalities in the treatment of acute fractures of the distalradius have been proposed [9, 10]. Intramedullary nailing is currently used to treat unstable extra-articular fractures of the distalradius . Bearing the advantages of allowing load transfer across the fracture site and lessening soft-tissue dissection, intrame- dullary fixation can be used to stabilize the fracture bones through a less invasive approach and maintain periosteal vascular blood supply to promote fracture healing . The purposes of this retrospective study were to describe our experience with mini-open osteotomy, local bone grafting, and fracture stabilization with the intramedullary nail
Elimination of ligamentotaxis for reduction prevents problems with hand stiffness and allows late intervention. Three-dimensional, direct, closed control of the distal fragment with anatomic restoration of radial length, volar tilt, and radial inclination is the biggest advantage of the fixator described above. Other methods of transarticular external fixation cannot exert sufficient longitudinal trac- tion to reduce neglected fractures, since they would cause distraction of the carpus instead [1, 7, 14–16, 25, 26]. In vivo studies, found reduction with a nonbridging fixator to be much more effective than with bridging, due to direct control of the distal fragment (similar to the mechanism seen in HEF), which is especially valuable for restoring the volar tilt [15, 20]. On the other hand, one important disadvantage is the lack of a ‘‘traction view’’ typical of bridging fixators, which visualizes occult midcarpal liga- mentous injuries that might require early surgery . There are, however, contrary opinions saying that distrac- tion of scapholunate joint may be detrimental to ligamentous healing .
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 external fixator 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.
percutaneous pinning and bridging external fixation. Independent but not blinded evaluators administered the DASH quality-of-life questionnaire at postoperative months 6 and 24, performed functional assessment of pain, range of motion, and palm grip strength, and radiographic examinations (volar and radial angle, and height of the radius) before the operation, immediately afterwards, and at 6 and 24 months postoperative. Modified De Palma percutaneous pinning patients used an above-elbow cast whereas external fixation group had unrestricted elbow motion after surgery. Patients who for any reason demonstrated treatment failure or required additional interventions were followed up and their results were included in the group into which these patients had initially been randomised according to the intention-to-treat principle. A significance level of 5% (alpha = 0.05). was used for all statistical tests, such that tests presenting a p-value less than 0.05 were considered statistically significant.
fragments in fractures with major joint involvement. Excessive distraction of the hardware, to obtain satisfactory reduction, can result in delayed union, nonunion, complex regional pain syndrome (CRPS) or digital stiffness [3, 4]. Despite the fact that randomized trials do not provide strong evidence regarding the type of surgical intervention that is the most appropriate treatment for fractures of the distalradius in adults, superior functional and radiological results of ORIF with respect to external fixation have been reported recently . Standard straight plates result in optimal diaphyseal stabilization but may be inadequate for fixing metaphyseal and epiphyseal fractures. When posi- tioned on the volar aspect of the radius, straight plates are too bulky and may create attritional damage to flexor tendons; they need to be bent to follow the radial volar inclination, and are not sufficiently wide to adequately fix the epiphysis and capture small articular pieces for such fractures. A new technique described by Ginn et al.  involves ‘‘bridging’’ the fracture using a standard 3.5 mm plate applied dorsally and fixed in distraction from the radius to the third metacarpal shaft distally. The distraction plate technique also uses the concept of ligamentotaxis and, like external fixation, is especially indicated for intra- articular fractures with small, comminuted fragments which may be difficult to manage with plates or other nonbridging methods; when distraction fails to obtain adequate reduction, the use of bone grafts, K-wires and supplementary screws are included in the procedure. The hardware is removed after radiographic evidence of con- solidation (mean time: 124 days) and wrist motion has been initiated. Excellent clinical and radiographical results are reported with this technique . Disadvantages of this method include the long period of immobilization of the wrist, the need for a second operation to remove the Fig. 3 Radioulnar synostosis at 9 months after osteosynthesis (Syn-
Background: Various treatments are available for reducible unstablefractures of the distalradius, such as closed reduction combined with fixation by external fixator (EF), and rigid internal fixation using a locked volar plate (VP). Although there are studies comparing these methods, there is no conclusive evidence indicating which treatment is best. The hypothesis of this study is that surgical treatment with a VP is more effective than EF from the standpoint of functional outcome (patient-reported).
There are many plausible explanations for these re- sults. In view of anatomy, the sigmoid notch of the ra- dius constitutes the intermediate column. The sigmoid notch which serves as an anchor for the TFCC probably plays a role in DRUJ stability . It makes sense: when the displaced fracture fragment involving the sigmoid notch apparently changed the tension of the TFCC, there would produce a rotation dysfunction of the fore- arm. Moreover, the displaced fragment could cause ar- ticular incongruity of the DRUJ and jeopardize the rotation of the forearm [4, 10]. Ishikawa et al. reported that the malposition of the ulnar head might result in re- stricted pronation because of the change of the tension of the surrounding soft tissues . Adams confirmed that displaced distal radial fractures could place im- mense stress on the TFCC, which may result in a de- creased pronation and/or supination . Delclaux et al. found the patient with distalradius fracture malunion Table 2 Radiographic and clinical outcomes in the matched cohorts
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
Those fractures amenable to open reduction and inter- nal fixation were posted for fixation in elective opera- tive list. Highly comminuted fractures not amenable to ORIF were stabilized by transarticular external fixator. Patients with closed reduction, cast, and percutanous pinning with cast were discharged on the same day. Any fracture showing displacement at one or two weeks of follow-up were considered unstable and managed as unstable type of fracture. Sixteen patients lost to the follow-up and were excluded from the study. Patients were followed in the outpatient department in 1, 3 and 6 weeks. Around 6 weeks period, cast, K-wires, or exter- nal fixator were removed and the patient was sent for physiotherapy. In those patients with internal fixation, range-of-motion exercises were started on the second postoperative day. Radiological union was considered when a minimum of 3 cortices showed trabeculae cross- ing at the fracture site. Mayo wrist scoring was done at final follow-up.
Despite the proven benefits of direct reduction and anatomic fixation for distal radial fracture, the authors have adopted the concept of extra-articular realignment during prospective enrollment, especially for indirect re- duction of metaphyseal fragments in accordance with MIPO technique. Compared with the concept of con- ventional anatomical reduction, extra-articular realign- ment is more focused on realignment of the injured limb by restoring the alignment index (length, rotation, and axis) rather than by anatomic reduction of the frac- ture fragments (Fig. 4). The reduction of distal radial fractures should focus on the restoration of radial length because most problems occurred in patients who achieved fair or poor restoration of radial length after conservative management . Radial length was found to be automatically re-established upon restoration of anatomic continuity of the volar cortex through direct reduction . Automatic restoration should not be ex- pected, however, if a volar cortex is comminuted at the metadiaphyseal area or the fracture surfaces could not be opened, such as in the PQ-sparing approach, and an additional procedure might be needed to achieve the ori- ginal length. A distractive technique using a spreader could be easily applied, similar to a femoral distractor Table 2 Complications related with bridge plating through pronator-sparing approach in distalradiusfractures
Hence internal fixation is required to provide stability and maintain reduction. Immobilization in casts has the disadvantage of immobilizing the joints adjacent to the fracture often leading to joint stiffness. Furthermore, a cast does not control fracture shortening which is often seen in osteoporotic bone; and if the subcutaneous tissue is very mobile, as it often is in the elderly, cast fixation will not provide adequate fracture fixation. Metaphyseal fractures in osteoporotic bone are associated with specific fixation problems as the metaphyseal fragment is often very small. The major problem in osteoporotic fracture treatment is fixation of the device to the bone as bone failure is much more common. Problems in osteoporotic fractures are,