Volar plating is the workhorse of internal fixation for unstable distal radius fractures (DRFs)
Dorsal plate technology has improved, decreasing associated hardware-related complications
Combination plating is a viable option for highly unstable fracture patterns
Fixation strategy should ultimately be chosen based on fracture pattern and stability
A 27-year-old right hand dominant male fell on his outstretched hand and sustained a highly comminuted intraarticular DRF. The fracture had dorsal, palmar, and radial comminution, with pieces of the articular surface impacted. He agreed to have surgical treatment. Which plating method is the most effective for this fracture: volar, dorsal, radial plating, or a combination plating configuration?
Importance of the Problem
DRFs are a common clinical problem with many treatment options available. Unstable and displaced or angulated DRFs are commonly treated with plate osteosynthesis. When considering options for fixation of DRFs, the optimal strategy will maximize function while minimizing complications. This chapter will explore the evidence for different types of plate fixation along with associated tradeoffs and complications.
Which plating method is most effective for ORIF of displaced DRFs: volar, dorsal, radial, or a combination approach?
Most unstable or displaced DRFs are treated with a locked volar plate. However, it is important that the treating surgeon be able to recognize situations in which a different fixation strategy is necessary to achieve stability.
Finding the Evidence
Below is a list of Pubmed search algorithms used to construct this chapter:
For Volar Plating : (“Radius Fractures” [Mesh] OR distal radius fracture*[tiab]) AND (“classification” [Subheading] OR displace* OR dislocat*) AND ((volar AND plating) OR “volar locking” OR “volar plating”)- (199 results)
For Dorsal Plating : (“Radius Fractures” [Mesh] OR distal radius fracture*[tiab]) AND (“classification” [Subheading] OR displace* OR dislocat*) AND (dorsal AND plating)- (83 results)
For Radial Plating : (“Radius Fractures” [Mesh] OR distal radius fracture*[tiab]) AND (“classification” [Subheading] OR displace* OR dislocat*) AND ((radial AND plating) OR “radial plating” OR “radial column plating” OR “radial styloid”)- (128 results)
For Combined Plating : (“Radius Fractures” [Mesh] OR distal radius fracture*[tiab]) AND (“classification” [Subheading] OR displace* OR dislocat*) AND ((combination AND plating) OR dual OR “fragment specific” OR “ulnar column”)- (32 results)
Pubmed Clinical Queries: systematic[sb] AND (Distal radius plating) (6 results), systematic[sb] AND (Distal radius classification) (10 results), systematic[sb] AND (displaced distal radius) (19 results)
Cochrane Database of Systematic Reviews: Displaced distal radius (19 results), distal radius plating (12 results), distal radius classification (26 results)
Quality of the Evidence
Randomized Controlled Trial: 1
Prospective Cohort Studies: 5
Systematic Review of Cohort Studies: 1
Randomized Trial with methodological limitations: 1
Outcomes Research: 1
Retrospective Cohort Studies: 14
Systematic Review of Case-Controlled Studies: 1
Case Series: 1
Expert Opinion: 1
Volar plating has risen to prominence as the preferred choice among most surgeons for internal fixation of DRFs. The technique has been applied to a wide variety of fracture patterns and patient populations with successful radiographic and functional outcomes and a low complication rate.
Fracture Pattern and Displacement
Volar plating can be used successfully to treat a variety of fracture types and patterns of displacement. Both volar and dorsal displacement are amenable to volar plating, as are extraarticular, partial articular, and intraarticular patterns. Erhart et al. studied whether the direction of fracture displacement, dorsal or volar, affected radiographic and clinical outcomes following volar plating. They evaluated 50 patients who underwent volar plating, half of whom had dorsally displaced (Colles) and half with volarly displaced (Smith) fractures. At a mean follow-up of 5 years postoperatively, they found no significant clinical difference between the groups. All patients had progression of arthrosis thought to be secondary to the injury itself. The dorsally displaced group had a trend toward restriction of flexion if the final position had residual dorsal tilt, although this did not affect function.
Braziulis et al. found that all fracture types (AO Types A, B, and C) had improved function and radiographic parameters at 6-months of follow-up following volar plating. Patients with complete articular fractures had worse DASH scores and radiographic parameters than the other two groups, but all were improved from their preoperative status.
Function and Radiographic Parameters
Volar plating is an excellent choice with respect to patient function postoperatively, and the available evidence supports that volar plating successfully maintains reduction through standard follow-up intervals. Lattmann et al. prospectively followed 245 patients through 1-year follow-up following volar locking plate treatment of an unstable distal radius fracture. Range of motion and function all improved throughout the 1-year follow-up period with excellent maintenance of reduction. The authors noted an overall complication rate of 15%, with 4% of the cohort requiring a second operation, which is consistent with other studies.
Jose et al. looked at radiographic and functional outcomes of 53 patients with unstable DRFs treated with locked volar plating at 1 year. Of the 53 patients included, 46 had excellent or good radiographic parameters and 37 patients had excellent or good functional outcomes. One case developed a superficial infection that resolved with oral antibiotics. The authors concluded that volar plating is an effective treatment for unstable distal radius fractures in that it allows early motion and return to function while preventing loss of reduction.
Lee et al. prospectively studied 89 patients with dorsally displaced DRFs that were treated with locked volar plates. They assessed functional outcomes at 1 year, including wrist motion, grip strength, and DASH score. Among surgeon-modifiable factors, only positive ulnar variance was associated with lower DASH scores at 1 year.
Volar plating has been shown to be a viable treatment option for a wide variety of patients with respect to age, gender, and comorbidities. Martinez-Mendez et al. prospectively studied 66 patients with a mean age of 68 (range 60–81) to ascertain radiographic parameters over time in the setting of complex intraarticular fractures. They examined the association of fracture type, age, and gender with hand function at 6-month follow-up following distal radius volar plating. The authors retrospectively examined the records of 120 patients, with 28 extraarticular fractures, 70 partial articular fractures, and 22 complete articular fractures. They found no demographic differences between the groups, and found that patients with complete articular fractures had worse function (lower DASH scores and worse radiographic parameters) at 6-month follow-up than the other two groups. In this study, fracture type was associated with function after distal radius plating at 6 months while age and gender were not.
Lee et al. found that patient age was the only significant factor affecting grip strength and range of motion, and diabetes was significantly associated with lower DASH scores.
Despite the widespread familiarity with volar plating and its wide variety of successful applications, surgeons must be cognizant that this treatment modality is not without complications. Alter et al. performed a systematic review of complications of volar plating of DRFs which included 55 studies comprising 3911 patients. They found an overall 15% complication rate, with 5% qualifying as major complications requiring reoperation. The most common complications encountered were nerve dysfunction (including carpal tunnel syndrome and complex regional pain syndrome) in 5.7% of patients. Tendon injury occurred in 3.5% of patients in this study, and of these, extensor tendon issues such as rupture (0.6%) and synovitis (1%) were more common than flexor tendon complications. Hardware-related issues were found in 1.6%, the most common of which was malunion at 0.6%. Hardware prominence, intraarticular screws, and screw loosening were rare.
Although rare, flexor tendon injury, in particular FPL rupture, is a dreaded complication of volar plating. Asadollahi et al. performed a systematic review examining the demographics, clinical characteristics, treatment, and outcome of flexor tendon injuries following volar plating of DRFs. In a total of 47 cases reported in the literature, the FPL was the most commonly ruptured tendon (57% of cases), followed by the FDP to the index finger (15%). The median interval to rupture after surgery was 9 months, and mean age of the affected patients was 61. Most patients had prodromal symptoms of crepitus, pain with finger motion, clicking or a rubbing sensation prior to rupture. The authors recommend careful plate positioning proximal to the watershed line and early removal of the plate in cases with suboptimal positioning or symptomatic warning signs.
It is important to note that although the prevention of flexor tendon injuries deserves significant attention, surgeons must remain cognizant that extensor tendon problems were actually found to be more common overall than flexor tendon problems. These are likely related to dorsal hardware prominence (long screws).
Dorsal plating has historically been associated with higher complication rates, primarily related to prominent hardware. More recently, advances in plate design have been associated with better postoperative outcomes. Low-profile plates, which are thinner than the original dorsal plates, were developed to address the extensor tendon complications often seen with dorsal plating. With the advent of these low-profile plate designs, there is increasing evidence supporting dorsal plating for the treatment of dorsally comminuted DRFs.
Low-profile plating systems have largely alleviated the problems with extensor tendon irritation that historically plagued dorsal plating of DRFs. Rozental et al. assessed a cohort of 28 patients with a comminuted, dorsally displaced DRF treated operatively with dorsal plating. Nineteen patients had a Synthes Pi plate, whereas nine received a low-profile plate. In this cohort, all 28 fractures were satisfactorily reduced. All patients achieved good or excellent functional outcome at final follow-up, regardless of fixation type.
Simic et al. retrospectively reviewed 60 consecutive unstable distal radius fractures that were treated with a low-profile dorsal plating system. 50 (85%) patients (51 fractures) returned for outcome assessment after at least 1 year. The authors reported successful fixation of all fractures, with excellent postoperative radiographic parameters, range of motion, and grip strength. There were no instances of extensor tendon irritation or rupture, and the patients reported minimal dorsal implant tenderness. The mean DASH score in this patient cohort was 11.9. Using the Gartland and Werley scoring system (GWS), 31 (62%) patients had an excellent rating and 19 (38%) patients had a good rating.
Kamath et al. retrospectively reviewed 30 patients who were treated with low profile, stainless steel plates for dorsally angulated DRFs. The authors reported that there were no instances of malunion, plate breakage, infection, compressed neuropathy, soft-tissue complications, or extensor tendon ruptures. The authors reported satisfactory radiographic reduction when comparing preoperative to postoperative radiographs for all but one patient. The mean DASH score in this cohort was 15. When using the GWS, 16 (53%) patients had an excellent outcome, 12 (40%) had a good outcome, and 2 (4%) had a fair outcome.
In the largest cohort included in this chapter, Matzon et al. retrospectively reviewed 110 patients that were treated with dorsal plating for a DRF. All patients received a low-profile titanium plate. At final follow-up (mean 2.25 years), satisfactory reduction was obtained and there were no reported instances of nonunion, hardware failure, or compression neuropathy. The mean flexion extension arc was 138 degrees, with 85 degrees of pronation and 85 degrees of supination. The average DASH at final follow-up in this cohort was 6.3. Using the GWS, 82 (75%) patients had an excellent outcome, 22 (20%) had a good outcome, 5 (4%) had a fair outcome, and 1 (1%) had a poor outcome.
Chen et al. retrospectively reviewed 24 patients with unilateral DRF who were treated with bicolumnar plate fixation via a minimally invasive dorsal approach. At 1 year postoperatively, all patients achieved radiographic union with all anatomical parameters effectively restored. On average, range of motion of the injured side was restored to 85% of extension, 75% of flexion, 93% pronation, and 85% supination of the contralateral side. Patients regained 83% of their grip strength.
In general, patients treated with dorsal plating in the studies outlined in this chapter had dorsally comminuted fractures, which ostensibly dictated the plating strategy. Hamada et al. further subdivided the fracture patterns in their cohort. They retrospectively assessed 24 patients who received low-profile dorsal plates for dorsally displaced, unstable DRFs. Of the 24 included patients, 9 had type 1 fractures and 15 had type 2 fractures. Type 1 was defined as having a volar fracture line distal to the watershed line in the dorsally displaced fragment, and type 2 consisted of a displaced dorsal die-punch fragment along with a minimally displaced styloid shear fracture or transverse volar fracture line. At 6 months postoperatively, both types had similar range of motion and mean grip strength was within 82.5% of the uninjured hand. There were no instances of tendon rupture, neurovascular complication, or prolonged tenderness or discomfort. Mean time to union was 2.7 months, with no nonunions.
Complications and Limitations
While the studies included in this chapter reported mostly positive results when using low-profile plating for dorsally comminuted DRFs, some complications were encountered.
Rozental et al. compared a cohort of patients with a Synthes Pi plate to those treated with a low-profile plate. Nine patients underwent reoperation secondary to postoperative complications, all of whom had a Synthes pi plate placed in their index procedure. Seven of these patients had isolated extensor tenosynovitis, while two had extensor tendon rupture. Plate type was significantly in favor of patients treated with the low-profile plate who had no postoperative complications ( P < .025).
The cohort in the study published by Simic et al. received low-profile dorsal plates. There were no instances of extensor tendon irritation or rupture. However, hardware removal was performed for one patient who was experiencing dorsal wrist pain at 1 year postoperatively. Intraoperative examination in this case did not reveal evidence of tendon irritation or tenderness over the plate. Plate removal did not relieve the patient’s symptoms.
Similarly, the Kamath et al. cohort was treated with low-profile plates exclusively. One patient had loss of anatomic reduction, but reported fair functional outcome at 25 months. Three patients underwent a second operation (10%), one for superficial scarring on the extensor retinaculum, and two for the removal of a single metaphyseal screw as a result of loosening. No patients required plate removal and there were no extensor tendon ruptures.
The cohort in the study by Matzon et al. received low-profile titanium plates. While satisfactory alignment was achieved in all cases, nine patients (8%) had hardware removed. Intraoperative evidence of extensor tenosynovitis was found in six patients (5%). These six complications comprised the fair ( n = 5) and poor ( n = 1) GWS.
Hamada et al. reported only one serious complication, one patient who experienced a collapse of the dorsal ulnar fragment because of a lack of distal locking screws in the buttress plate. As a result, the patient underwent implant removal and an ulnar shortening osteotomy 1 year after the index procedure. Clinical outcomes improved in this patient 3 months after revision surgery, and ultimately, the patient had a positive outcome. They also reported three cases of mild discomfort of the dorsum of the wrist, however all resolved within 6 months postoperatively. Two patients (8%) lost reduction of their fracture within 1 month.
Chen et al. reported a 13% complication rate (3 of 24 patients). One complication was screw loosening in an elderly, osteoporotic patient. By 6 months, the patient went on to osseous union with pain-free range of motion. Two patients with soft tissue complications reported extensor tendon irritation, with only one requesting removal of all implants. There were no cases of wound infection or extensor tendon ruptures.
Radial Column Plating
Radial column plates typically serve as an adjunct to volar or dorsal locking plates in severely comminuted DRFs, or in fracture patterns that displace large fragments of the radial styloid. They can also be used in isolation, although much less frequently than either volar or dorsal plating alone. A number of retrospective reviews examining both objective and subjective outcome scores, as well as radiographic evaluation of reduction and union, have stated that dual radial styloid and volar plating achieved acceptable clinical and radiographic outcomes.
Function and Radiographic Parameters
The evidence available for radial column plating as an adjunct to volar plating shows favorable results with regard to patient function and maintenance of reduction. Helmerhorst et al. conducted a retrospective review on 14 patients treated with locked volar plate fixation and an additional radial column plate with an average follow-up of 30 months. They found that 13 of the patients achieved union within 7 weeks after surgery, and all 14 had either good or excellent functional outcome scores. This is also reflected in the findings of Tang et al., who conducted a case series on eight patients treated with dual plating, with an average follow-up of 35 weeks. All patients went on to union and had an average DASH of 19.9. Similarly, a retrospective chart review of 10 patients treated using a similar plating technique by Jacobi et al. with an average follow-up of 4 months found that all patients achieved anatomic reduction and bony union. 90% of these patients had outcome scores rated as either excellent or good. Garner et al. conducted a retrospective review of 36 patients treated with radial column and volar locking plates with an average follow-up of 15.6 months. These patients had an average DASH of 20.7, and all had acceptable radial height, radial inclination, and volar tilt at final follow-up.
The evidence supporting radial column plating alone is limited, as clinical scenarios in which a radial column plate alone is sufficient for fixation are rare. A randomized controlled trial by Wei et al. looked at 46 patients with unstable DRFs who were treated with a locked volar plate, external fixation, or a locked radial column plate. Outcome measures, including DASH, grip strength, range of motion and pinch strength, were collected at 3 months, 6 months, and 1 year. They found that within the first 3 months, the use a locked volar plate resulted in better outcome measures than external fixation and radial column plates. However, at 6 months and 1 year, all three fixation methods were found to have satisfactory outcome measures.
Biomechanical studies of radial column plating have also demonstrated favorable results. Grindel et al. compared the stability and construct strength of volar plating alone to a combination of volar and radial styloid plating in eight matched pairs of cadaveric arms. Load-to-failure testing revealed that dual plating resulted in a 50% increase in construct rigidity and a 76% increase in failure strength compared to volar plating alone. In a similar comparison, Blythe et al. found a significantly higher construct rigidity in a cadaveric fracture model fixed with a combination of volar and styloid plating when compared to one fixed with volar plating alone.
Radial column plating does have some associated complications unique to the position of the hardware. If the radial plate is too prominent, it predictably will irritate tendons in the first dorsal compartment, creating a De Quervain-like clinical picture. Among the 10 patients evaluated by Jacobi et al., 5 of them had De Quervain symptoms, and benefitted from the plate being removed. Galle et al. retrospectively analyzed functional outcomes of 63 patients who underwent radial column plating. Of the 17 patients that had their hardware removed, 8 were because of De Quervain’s symptoms. Although this did not reach statistical significance, it was the leading cause of hardware removal in this study, followed by hardware removal for activity-related pain.
Radial column plating has a higher hardware removal rate than other types of plating. Although they reported no complications or wound infections in their cohort, Garner et al. performed hardware removal in 13 of their 36 patients within the average follow-up time of 15.6 months. In the Galle et al. cohort, 17 patients had their plates removed and 44 retained their hardware, but ultimately there were no clinically or statistically significant differences between the two groups in DASH, VAS, and grip strength. Although reoperation is burdensome, these findings suggest that hardware removal has no long-term adverse effect on outcome. Patients undergoing radial column plating should be counseled about potential hardware-related symptoms and a roughly 25% chance of needing hardware removal.
For the majority of surgeons performing open reduction and internal fixation for unstable DRFs, volar plating is the workhorse technique. However, in some injuries with complex fracture patterns, a volar plate alone may not provide adequate stability. Surgeons must be able to recognize when volar plating alone is not sufficient and the construct may require multiple plates to achieve satisfactory fixation. The most common combinations of plates for severely comminuted, intraarticular DRFs include radial column/volar plating and dorsal/volar plating. The instances in which these strategies are employed are highly dependent on both the fracture pattern and surgeon discretion.
The evidence for dorsal/volar combination plating is described in this section. For radial column/volar combination plating, please refer to the Radial Column Plating section of this chapter.
Dorsal/Volar Combination Plating
A number of studies examining combination plating have determined that this technique achieves satisfactory outcomes, and have advocated for its use in the setting of complex fractures of the distal radius. A case series by Ring et al. examined 25 patients that received combined dorsal/volar plate fixation with an average follow-up of 26 months. They found an average grip of 78% compared to the contralateral side, a GWS of good or excellent in 98% of patients, and satisfactory union achieved in all patients. In addition, average extension was 54 degrees, flexion was 51 degrees, pronation was 79 degrees, and supination was 74 degrees. They concluded that this fixation technique can achieve a stable, mobile wrist in patients with very complex fractures.
Day et al. retrospectively analyzed the data of 10 patients that had received dorsal/volar combination plating with an average follow-up time of 17 months. Their cohort had an average grip of 72% compared to the contralateral side, a GWS of good or excellent in 70% of patients, DASH of 16, and satisfactory union in all, without any tendon ruptures. Extension was 46 degrees, flexion was 46 degrees, pronation was 80 degrees, and supination was 71 degrees. This study concluded that this “sandwich” plating technique is an effective method of regaining near-anatomic reconstruction of intraarticular, volarly, and dorsally comminuted DRFs.
A retrospective review by Farhan et al. examined 24 patients receiving combined dorsal/volar locked plating with an average follow-up of 17 months. They reported an average grip strength of 69% compared to the contralateral side, satisfactory union in all patients, extension of 52 degrees, flexion of 49 degrees, pronation of 77 degrees, and supination of 86 degrees. This study concluded that combined dorsal/volar plating enables early mobilization and good outcomes for certain complex comminuted DRFs. A retrospective cohort study by Sagerfors et al. reviewed 102 consecutive patients receiving combined dorsal/volar plating with an average follow-up of 27 months. Compared to the contralateral side, they found grip strength to be 80%, extension 74%, flexion 70%, pronation 94%, and supination 90%. Average DASH was 19.4, and VAS scores were 0 at rest and 3 with activity. They concluded that a good outcome can be expected after combined dorsal/volar plating. This data can be found in Table 1 .