1 Colles fracture: A Colles fracture is a fracture of the radius within 2.5 cm of the wrist (1), with a characteristic deformity if displaced. It is the commonest of all fractures. It is seen mainly in middle-aged and elderly women, and osteoporosis is a frequent contributory factor. It usually results from a fall on the outstretched hand (2), and generally the distal radial fragment remains intact. (See Frame 45 et seq. for those other cases where the radiocarpal joint is involved.)

2 Displacements (a): The six characteristic features of a displaced Colles fracture (see later for details) are shown in this foreshortened view of the pronated right arm, viewed from below. The slight obliquity of impact (F) produces the two most striking features of dorsal and radial displacement (D & R) of the distal fragment. (T = triangular fibrocartilage; U = ulnar styloid; M = medial; L = lateral)

3 Displacements (b): The deformity can be followed by studying the wrist in the two planes in which the radiographs are usually taken. The impact (F) fractures the radius through the cancellous bone of the metaphysis. With greater violence the anterior periosteum tears, and the distal fragment tilts into anterior angulation (1) with loss of the 5° anterior tilt of the joint surface.

4 Displacements (c): With greater violence there is dorsal displacement of the distal fragment (2). The shaft of the radius is driven into the distal fragment leading to impaction (3). (The dotted lines indicate the position of the distal fragment prior to any displacement.)

5 Displacements (d): The altered contour of the wrist in a badly displaced Colles fracture is striking, and is referred to as a ‘dinner fork deformity’. When viewed from the side, the wrist has the same curvature as a fork, with the tines resembling the fingers.

6 Displacements (e): This radiograph shows a typical displaced Colles fracture. The anterior angulation, dorsal displacement, and impaction are obvious (deformities 1,2,3).

7 Displacements (f): In the AP plane, a small lateral component of the force of impact causes lateral (radial) displacement of the distal fragment (4). The distal fragment is attached to the ulnar styloid by the triangular fibrocartilage, and generally this leads to avulsion of the ulnar styloid. Note that in the AP projection of the normal wrist that the joint surface has a tilt of 22°.

8 Displacements (g): Sometimes the triangular fibrocartilage is torn; in either case there is disruption of the inferior radio-ulnar joint. The distal fragment tilts laterally into ulnar angulation (5) (reducing the tilt to less than 22°) and impacts. The sixth feature is a rotational or torsional deformity (6 in Frame 2), not obvious in either AP or lateral projections.

9 Displacements (h): In this AP radiograph of a Colles fracture, note the features just mentioned, i.e. radial deviation, ulnar angulation and impaction of the distal fragment.

10 Diagnosis: 1. If there is pain in the wrist and tenderness over the distal end of the radius after a fall, radiographs must be taken in every case. The site of maximum tenderness will help to differentiate fracture of the scaphoid (but see scaphoid fractures). 2. Where there is marked displacement the characteristic appearance leaves little diagnostic doubt. Note that in the normal wrist the radial styloid lies 1 cm distal to the ulnar.

11 Radiographs (a): In the majority of cases the fracture is easily identified. Sometimes it may be missed because impaction has rendered the fracture line inconspicuous. If in doubt, look at the angle between the distal end of the radius and the shaft in the lateral radiograph. Decrease to less than 0° is suggestive of fracture (but enquire about previous injury).

12 Radiographs (b): The minimally displaced fracture will also reveal itself in the lateral projection by an increase in the posterior radial concavity, often with local kinking (1) or by a separate or accompanying break in the smooth curve of the anterior surface of the radius (2).

13 Radiographs (c): In the AP view of the wrist, look for any irregularity in the smooth lateral aspect of the radius.

If there is any doubtful radiographic feature suggesting fracture, return to the patient and confirm whether there is any localised tenderness over the suspect area

14 Diagnosis ctd: As stated, a Colles fracture is generally caused by a fall on the outstretched hand – a mechanism common to many upper limb fractures. Although other injuries in the arm occurring in association with Colles fracture are uncommon, clinically the scaphoid, elbow and shoulder should be examined, and on the radiographs the scaphoid should be scrutinised. (Special views are required if an associated scaphoid fracture is strongly suspected.)

15 Treatment: Does the fracture require manipulation? (a): If the fracture is grossly displaced, it obviously should be reduced (1). If undisplaced, no manipulation is needed (2). Between these extremes, the following additional factors may be considered: if there is a readily appreciated naked eye deformity (3) manipulation should be carried out (but distinguish between swelling and deformity.)

16 Does the fracture require manipulation? (b): If there is displacement of the ulnar styloid, this indicates serious disruption of the inferior radio-ulnar joint. (Acute ulnar angulation of the distal fragment is also evidence of this.) An attempt at correction should be made irrespective of other appearances

17 Does the fracture require manipulation? (c): If the joint line in the lateral projection is tilted 10° or more posteriorly rather than anteriorly, the fracture should be manipulated: but in the very old, frail patient somewhat greater degrees of deformity may be accepted.

19 Reduction technique (b): Before any manipulation, start by preparing a suitable plaster back slab. The length should equal the distance from the olecranon to the metacarpal heads (1). The width in an adult should be 15 cm (6″), and it should be about eight layers thick. The slab should be trimmed with a tongue (2) for the first web space, a large radial curve to allow elbow flexion (3) and allowance for ulnar deviation (4).

20 Reduction technique (c): The essential first stage in the reduction of a Colles fracture is to disimpact the distal radial fragment. The elbow is flexed to a right angle and the arm held by the interlocked fingers of an assistant (1). Traction is applied in the line of the forearm (2).

21 Reduction technique (d): Traction need only be applied for a few seconds, and disimpaction may be confirmed by holding the distal fragment between the thumb and index. It should be easy to move anteriorly and posteriorly. When disimpacted the radial styloid should lie 1 cm distal to the ulnar styloid.

22 Reduction technique (e): The elbow is now extended (1). The heel of one hand should be placed over the dorsal surface of the distal radial fragment, and the fingers curled round the patient’s wrist and palm (2). This grip allows traction to be re-applied to the disimpacted fracture.

23 Reduction technique (f): Now, by using the heel of the other hand as a fulcrum (3) firm pressure directed anteriorly (4) will correct all the remaining deformities normally visible in lateral radiographs of the wrist (posterior displacement, anterior angulation).

24 Reduction technique (g): Still maintaining traction, alter the position of the grip so that the heel (here of the right hand) is able to push the distal fragment ulnarwards and correct the radial displacement (5). Ulnar angulation, the other deformity seen in the AP radiograph, is corrected by placing the hand in full ulnar deviation at the wrist.

25 Reduction technique (h): Change the grip to allow free application of the plaster (which follows Charnley’s principle of three point fixation). Note that one hand holds the thumb fully extended (1). The other holds three fingers (to avoid ‘cupping’ of the hand) maintaining slight traction (2). The limb should be in full pronation (3), full ulnar deviation at the wrist (4) and slight palmar flexion.

26 Reduction technique (i): Note that the elbow must be extended (either by an assistant (5) or by resting the upper arm against the edge of the table) to maintain this position. The skin may be protected with wool roll (6). If stockingette is preferred, it must be applied prior to reduction.

27 Reduction technique (j): The wetted slab should now be positioned so that it covers the anterior, lateral and posterior aspects of the radius (7). The tongue should be carefully turned into the palm (8). The slab should be held in position with two wetted 10 cm (4″) open-weave bandages (cotton, gauze or Kling^™ bandages) (9). The end can be secured with a wetted scrap of plaster bandage.

28 Reduction technique (k): Before the plaster sets, many surgeons like to apply further pressure over the posterolateral aspect of the distal fragment, and maintain this until setting occurs (‘final moulding’). This precaution ensures maintenance of the reduction, but care should be taken not to dent the plaster.

29 Reduction technique (l): A collar and cuff sling should be applied (1). Make sure that there is no constriction at the elbow (2) or at the wrist (3), and try to flex the elbow beyond a right angle so that the forearm is not dependent.

31 Treatment ctd: Check radiographs should be studied. Severe persisting deformity, especially in the AP projection (Illus.) should not be accepted, and remanipulation should be undertaken. If difficulty is anticipated, radiographs may be obtained before discontinuing the anaesthetic. If the position is acceptable, the patient is shown finger exercises and advised regarding normal plaster care.

32 Aftercare (a): The patient is seen the next day and the fingers examined for adequacy of the circulation and the degree of swelling (1). The palm, fingers, thumb and elbow are checked for constriction caused by bandaging or elbow flexion, and any adjustments made (2). Thereafter the patient should be seen within the next 2-5 days with a view to completion of the plaster.

33 Aftercare (b): At the next review (usually a fracture clinic) finger swelling is checked: if slight, the plaster is completed (if marked, completion is delayed). Superficial layers of cotton bandage are removed, the slab retained, and encircling plaster bandages applied. The patient is instructed in elbow and shoulder exercises, and unless there is still a fair amount of swelling the sling may be discarded.

34 Aftercare (c): At 2 weeks the plaster is checked for marked slackening (replace), softening (reinforce) and technical faults (see next two frames). Movements in the fingers, elbow and shoulder are examined and appropriate advice given or physiotherapy started. In some centres radiographs are taken at this stage; slight slipping is inevitable, but marked slipping may be an indication for remanipulation (not usually a profitable procedure). At this stage too, if desired, the plaster may be replaced by a resin cast.

35 Aftercare (d): Positional errors: (1) The commonest fault is lack of ulnar deviation. This should be sadly accepted if discovered at 2 weeks (but replastered in the correct position if discovered earlier). Lack of ulnar deviation increases the risks of late problems arising from disruption of the inferior radio-ulnar joint; non-union of the ulnar styloid is common, with frequently some restriction of pronation and supination and local pain. (2) Excessive wrist flexion is liable to lead to difficulty in recovering dorsiflexion and a useful grip, and may be associated with compression of the median nerve. If present, the plaster should be re-applied with the wrist in a more extended position. (Full wrist flexion was once advocated in the treatment of Colles fracture – the Cotton-Loder position – but has been abandoned for the reasons given.)

36 Aftercare (e): Plaster faults: Errors in plastering technique should not occur, but nevertheless are often discovered at this stage. The following faults are common: (1) The distal edge of the plaster does not follow the normal oblique line of the MP joints, and movements of the little and sometimes the ring finger are restricted. The plaster should be trimmed to the dotted line. (2) All the MP joints are restricted by the plaster which has been continued beyond the palmar crease. Trim to the dotted line. (3) The thumb is restricted by a few turns of plaster bandage. Again the plaster should be trimmed to permit free movement. (4) The plaster is digging into the skin of the first web and should be trimmed back to the dotted line. (5) The plaster is too short. Support of the fracture is greatly impaired; the plaster should be extended to the olecranon behind, and as far in front as will still permit elbow flexion.

37 Aftercare (f): The plaster should be removed at 5 weeks (or 6 weeks in badly displaced fractures in the elderly) and the fracture assessed for union. (Radiographs are of limited value.) If there is marked persisting tenderness, a fresh plaster should be applied and union re-assessed in a further 2 weeks.

38 Aftercare (g): If tenderness is minimal or absent, (1) a circular woven support (e.g. Tubigrip^™ or a crepe bandage) may be applied to limit oedema and to some extent increase the patient’s confidence. (2) The patient is instructed in wrist and finger exercises and encouraged to practise these frequently and with vigour. Arrangements are made to review the patient in a further 2 weeks.

39 Need for rehabilitation (a): At about 7 weeks post injury, you must decide whether to discharge the patient or refer her for rehabilitation. Base your decision on: (i) finger movements, (ii) grip strength, (iii) wrist movements, (iv) the patient’s occupation. For example, 1. if finger ‘tuck-in’ (i.e. the last few degrees of flexion) cannot be carried out (loss Illus.) physiotherapy should be considered.

40 Need for rehabilitation (b): 2. Assess the patient’s grip strength by first asking her to squeeze two of your fingers as tightly as possible while you try to withdraw them. Compare one hand with the other. Repeat with a single finger. Marked weakness is an indication for physiotherapy.

41 Need for rehabilitation (c): 3. Assess wrist movements. Initially, material restriction of palmar flexion is normal and by itself is of little importance. If, however, the total range of pronation and supination is less than half normal, physiotherapy is advisable. 4. Where there is only slight restriction of movements and power, rehabilitation may still be indicated through the special requirements of the patient’s work.

42 Alternative fixation methods (a): A Pennig Dynamic Wrist Fixator may be used where the fracture cannot be satisfactorily reduced or held by closed methods. Where the distal radial fragment is intact or occasionally with an undisplaced intra-articular fracture (AO = A2.2, A3.2, C1.2) pins are inserted in the distal fragment and the radial shaft. After assembly of the fixator, the fracture is reduced and the clamp screws locked. The wrist can be mobilised immediately.

43 Alternative fixation methods (b): Where there is severe comminution (Illus.), or splitting of the radial fragment into two or more displaced fragments an external fixator may also be used to bridge the fracture and the wrist joint. The distal pins are usually placed in the shaft of the second metacarpal. This allows control of length while avoiding the necessity of having to put the wrist up in marked flexion to maintain the reduction.

44 Alternative fixation methods (c): Where during a manipulative procedure instability is found to be marked, and it is considered that it will be very difficult to maintain any reduction with a cast alone, then the position may be stabilised with Kirschner wires. The most secure and reliable configuration¹ is thought to be that of Kapandji (modified by Fritz et al) where a third K-wire is used. (Where this should be positioned is indicated by the dotted line on the radiograph above.) An additional plaster cast will be required until union of the fracture is well advanced. The wires may be removed after 3-4 weeks. In similar circumstances, plating of the fracture may also be considered. Anterior plates are most commonly used. A word of caution: the use of K-wires has been shown in the long term to offer no more than a marginal improvement on the radiographic appearances and overall function.²

45 Splitting of the radial fragment (a): There may be a small vertical crack through the radial fragment, showing in the AP view (1). In others the fracture may run horizontally, and the scaphoid or lunate may separate the fragments (2). In the young adult, especially where the main fragments are separated and there is no gross fragmentation, internal fixation is indicated. (Barton’s fracture (see Frame 75) is similar, but with an intact posterior radial buttress.)

46 Splitting of the radial fragment (b): In a number of cases the fracture may be reduced under intensifier control (or under vision using an arthroscope). Kirschner wires may be used to lever the fragments into position prior to the insertion of the Kirschner fixation wires which are shown in this radiograph. Additional support with a cast will be needed. Some permanent joint stiffness is the rule after injuries of this pattern, and prolonged physiotherapy will usually be required.

47 Splitting of the radial fragment (c): Where comminution is not a problem, the distal fragments may be approximated with a cross screw (indicated by an arrow in the illustration). The distal radius may then be aligned with the shaft and held with a plate and screws. In this case a dorsal plate has been employed.

48 Splitting of the radial fragment (d): More commonly a pre-contoured volar plate may be used. This is first attached to the distal fragment with locking screws, resulting in the stem of the plate standing proud of the radial shaft. Levering it back into contact with the anterior surface of the radial shaft then leads to correction of the anterior angulation deformity. This technique may also be used with Colles pattern fractures uncomplicated by splitting of the distal fragment.

49 Splitting of the radial fragment (e): In some cases the degree of comminution or softness of the bone texture may render screw fixation in the distal fragments ineffective. In the case illustrated, although there are two reasonably substantial distal fragments, the horizontal line of the fracture is close to the joint leaving little bone for screw fixation. There is an additional vertical split in the radius.

50 Splitting of the radial fragment (f): In these circumstances the fracture was brought to length using a Pennig fixator, with pins in the radius and index metacarpal. The fragment which includes the styloid process was secured using two Kirschner wires, while the smaller medial fragment was held with an additional K-wire.

51 Complications (a): Persistent deformity or mal-union (i): Radial drift of the distal fragment results in prominence of the distal radius (1). Radial tilting and bony absorption at the fracture site lead to relative prominence of the distal ulna (2) and tilting of the plane of the wrist as seen in the AP radiographs (3). These deformities may be symptom free, and surgery on purely cosmetic grounds is seldom indicated.

52 Mal-union (ii): In some cases there is quite marked pain in the region of the distal radio-ulnar joint, owing to its severe disorganisation. There is generally quite marked local tenderness and supination in particular is reduced. Physiotherapy in the form of grip strengthening and pronation/supination exercises is indicated. If symptoms remain severe, excision of the distal end of the ulna may be considered.

53 Mal-union (iii): Uncomplicated persistence of dinner-fork deformity (i.e. persistent deformity in the lateral but not in the AP radiographs) is accompanied by some loss of palmar flexion, but significant functional disturbance is unusual. This type of residual deformity is generally accepted.

54 Complications (b):Delayed rupture of extensor pollicis longus may follow Colles fracture, and be due to attrition of the tendon by roughness at the fracture site, or by sloughing from interference with its blood supply. Disability is often slight, and spontaneous recovery may occur. There is no urgency regarding treatment, and in the elderly this complaint may be accepted or treated expectantly. In the young, an extensor indicis proprius tendon transfer is advocated.

55 Complications (c): Sudeck’s atrophy/complex regional pain syndrome: This is often detected about the time the patient comes out of plaster. The fingers are swollen and finger flexion is restricted. The hand and wrist are warm, tender and painful. Radiographs show diffuse osteoporosis (Illus.). Treatment. (1) The mainstay of treatment is intensive and prolonged physiotherapy and occupational therapy, but (2) if pain is very severe a further 2-3 weeks rest of the wrist in plaster may give sufficient relief to allow commencement of effective finger movements. (3) If the MP joints are stiff in extension and making no headway, manipulation under general anaesthesia followed by fixation in plaster (MP joints flexed, IP joints extended) for 3 weeks only may be effective in initiating recovery. (4) In severe cases, a sympathetic block may be attempted by infiltration of the stellate ganglion. (See Ch. 5 for a fuller discussion.)

56 Complications (d): Carpal tunnel (median nerve compression) syndrome: Paraesthesiae in the median distribution is the main presenting symptom, but look for sensory and motor involvement. If detected before reduction: (i) Complete lesion: reduce, plaster and re-assess. If no improvement, explore, and divide not only the roof of the carpal tunnel but the antebrachial fascia. (ii) Partial lesion: reduce and apply a cast; if motor symptoms remain, or if symptoms persist for a week, decompress.

57 Median nerve compression syndrome ctd: If detected after reduction: Release the splints, put the wrist in the neutral position, and use Kirschner wires or an external fixator to hold the reduction; if symptoms persist, explore. If detected after union: Exploration is generally advised, as symptoms otherwise tend to persist. Note that the diagnosis at the late stage may be suggested by the response to tapping over the nerve (Illus.), or by nerve stretching, tourniquet, or nerve conduction tests.

58 Complications (e): Persisting stiffness: Restriction of movements, even after prolonged physiotherapy, is not uncommon, but is seldom severe enough to impair limb function to a material extent. This is due to compensatory (trick) movements developed by the elbow, shoulder and trunk (e.g. in case of loss of supination).

59 Complications (f): Associated scaphoid fracture: This may be treated by manipulation of the Colles fracture and application of a scaphoid plaster. After the Colles fracture has united, further immobilisation may be required for the scaphoid. Alternatively, the scaphoid fracture may be fixed with an AO lag cancellous screw (Illus.) (or a Herbert screw), the Colles fracture manipulated, and fixation discontinued as soon as the latter has united.

60 Related fractures (a): A number of fractures involving the distal end of the radius, produced by falls on the outstretched hand, have certain similarities to the classical Colles fracture. The commonest of these is the undisplaced greenstick fracture of the radius. In its most minor form it may be overlooked; the only sign may be slight local buckling. These are sometimes referred to as torus or buckle fractures.

61 Undisplaced greenstick fracture of the radius ctd: The level of the fracture is variable, and it may be situated fairly proximally. This type of fracture may be treated by the application of a plaster slab, completed after 1-2 days, and retained for about 3 weeks. This fracture may also be treated successfully with an off-the-shelf brace. The Futura wrist splint, which is held in position with Velcro fasteners, is perhaps the most popular of these devices.

62 Related fracture (b): Angled greenstick fracture of the radius: In this type of injury there is both clinical and radiological deformity. Manipulation is required as for a Colles fracture, and the aftercare is similar; the period of plaster fixation may be reduced to 3 or 4 weeks, depending on the age of the child.

63 Related fractures (c): Overlapping radial fracture: In children the radius often fractures close to the wrist, with off-ending (i.e. complete loss of bony contact). On the ulnar side there may be: 1. detachment of the triangular fibrocartilage; 2. separation of the ulnar epiphysis; 3. fracture and angulation of the distal ulna; 4. fracture and displacement of the distal ulna (Illus.), in effect a fracture of both bones of the forearm; 5. dislocation of the ulna (Galeazzi fracture-dislocation).

64 Overlapping radial fracture ctd: If the fracture line is transverse (1), reduction is straightforward by traction (2) and local pressure (3). When, however, there is a fracture running obliquely forward from front to back (4), reduction by traction is often impossible owing to the integrity of the periosteum on the dorsal surface (5) and the overlapping bony spikes (6).

65 Overlapping radial fracture ctd: Two closed techniques may be tried. For the first, two assistants are essential to apply maximal traction to the limb (1). While this is being strongly maintained, the surgeon should press forcibly with the heel of one hand on the distal fragment (2) and use the other to apply counter-pressure (3). Reduction is achieved by shearing off one of the bone spikes (4).

66 Overlapping radial fracture ctd: Alternatively, by increasing the deformity (1) and applying pressure directly over the distal radial fragment (2), whilst maintaining traction (3), reduction may be achieved. After the fragments have interlocked the angulation is corrected. Thereafter plaster fixation is carried out as in other fractures in this region.

67 Overlapping radial fracture ctd: If shortening is marked, and closed methods fail, open reduction may be considered. (Performed through a small dorsal incision under a tourniquet; internal fixation is not required, although a Kirschner wire may be used to hold the fracture temporarily – being withdrawn as soon as the plaster has been applied.) Nevertheless, if persisting overlap is reluctantly accepted, a good result from remodelling is the usual outcome (Illus.) provided any angulation is corrected.

68 Related fractures (d): Slipped radial epiphysis: This injury is common in adolescence, and the displaced distal radial epiphysis is usually associated with a small fracture of the metaphysis (Salter-Harris Type 2 injury). Unless displacement is minimal, manipulation followed by plaster fixation (as for a Colles fracture) is indicated. Growth disturbance is rare, but reduction should be carried out promptly (it is often difficult to reduce after 2 days).

69 Related fractures (e): Fracture of the radial styloid: This fracture may be caused by an engine starting-handle kickback (the so-called ‘chauffeur’s fracture’) or by a fall on the outstretched hand. Displacement is usually slight, and manipulation is unlikely to be of value. Every case should be checked for scapho-lunate dissociation. A Colles plaster is usually adequate, although some prefer fixation with a lag screw or Kirschner wires. Physiotherapy is usually required, and Sudeck’s atrophy a common complication.

70 Related fractures (f): Smith’s fracture (i): This injury frequently results from a fall on the back of the hand, although a clear history is not always obtainable. The distal radial fragment is tilted anteriorly (posterior angulation) and may be displaced anteriorly. The fracture is usually impacted. Greenstick fractures of this pattern are common.

71 Smith’s fracture (ii): This fracture is frequently referred to as a reversed Colles fracture, because the deformities when viewed from the side are in the opposite direction to those seen in a Colles fracture. (Note, however, that the two fractures may be identical in AP radiographs.) Comminuted Smith’s fractures may involve the articular surface of the radius (Illus.). Adult fractures are best treated by the application of a volar plate.

72 Smith’s fracture (iii): As an alternative to surgery (e.g. in children or where the patient, because of other injuries or poor health, is unfit for prolonged anaesthesia) these fractures may be treated conservatively. Traction is first applied to the arm (1) in supination (2) until disimpaction is achieved. (This may be confirmed as in a Colles fracture.) Pressure may be applied with the heels of the hands to force the distal fragment dorsally (3).

73 Smith’s fracture (iv): The reduction is difficult to hold, and a long arm plaster is required (1). This may be more conveniently applied in two stages, and a complete plaster is better than a simple slab. The arm is held in full supination and dorsiflexion (2). This is easily maintained with the elbow extended (3). The arm is measured for an anterior forearm slab (4) and wool roll applied to the arm.

74 Smith’s fracture (v): The anterior slab is trimmed (5) and positioned (6) before completion of the forearm part of the cast (7) which may be moulded while setting. The cast is then extended above the elbow. Aftercare: Split if necessary; radiographs at weekly intervals for the first 3 weeks (treat any slipping by remanipulation or moulding); change slack plasters with care. Six weeks’ fixation is usually required, with physiotherapy after removal of the cast.

75 Related fractures (g): Barton’s fracture: This is a form of Smith’s fracture in which the anterior portion only of the radius is involved. Closed reduction may be attempted along the lines indicated for Smith’s fracture, but this often fails with the carpus wedging the fragments apart.

76 Barton’s fracture ctd: In the young patient these potentially unstable and disabling fractures are therefore best treated by open reduction and internal fixation. The most satisfactory procedure is to expose the fracture anteriorly and reduce it under vision; thereafter it is best held with a volar plate (e.g. with an LCP radius plate, a buttress plate, or an AO right angled or oblique T-plate (Illus.)).