Complex Intra-articular Distal Radius Fractures Research Articles

Volar versus combined dorsal and volar plate fixation of complex intraarticular distal radius fractures with small dorsoulnar fragment \u2013 a biomechanical study

Complex intraarticular distal radius fractures (DRFs), commonly managed with volar locking plates, are challenging. Combined volar and dorsal plating is frequently applied for treatment, however, biomechanical investigations are scant. The aim of this biomechanical study was to investigate volar plating versus double plating in DRFs with different degrees of lunate facet comminution.Thirty artificial radii with simulated AO/OTA 23-C2.1 and C3.1 DRFs, including dorsal defect and lunate facet comminution, were assigned to 3 groups: Group 1 with two equally-sized lunate facet fragments; Group 2 with small dorsal and large volar fragment; Group 3 with three equally-sized fragments. The specimens underwent volar and double locked plating and non-destructive ramped loading in 0° neutral position, 40° flexion and 40° extension.In each tested position, stiffness: (1) did not significantly differ among groups with same fixation method (p ≥ 0.15); (2) increased significantly after supplemental dorsal plating in Group 2 and Group 3 (p ≤ 0.02).Interfragmentary displacements between styloid process and lunate facet in neutral position were below 0.5 mm, being not significantly different among groups and plating techniques (p ≥ 0.63).Following volar plating, angular displacement of the lunate facet to radius shaft was significantly lower in Group 1 versus both Group 2 and Group 3 (p < 0.01). It decreased significantly after supplemental dorsal plating in Group 2 and Group 3 (p < 0.01), but not in Group 1 (p ≥ 0.13), and did not differ significantly among the three groups after double plating (p ≥ 0.74).Comminution of the lunate facet within its dorsal third significantly affected the biomechanical outcomes related to complex intraarticular DRFs treated with volar and double locked plates.Double plating demonstrates superior stability versus volar plating only for lunate facet comminution within its dorsal third. In contrast, volar plating could achieve stability comparable with double plating when the dorsal third of the lunate facet is not separated by the fracture pattern. Both fixation methods indicated achievable absolute stability between the articular fragments.

Radiographic Outcomes following K-Wire Augmentation of Dorsal Spanning Plate Fixation for Intra-Articular Fractures of the Distal Radius.

Background Restoration of articular surface alignment is critical in treating intra-articular distal radius fractures. Dorsal spanning plate fixation functions as an internal distraction mechanism and can be advantageous in the setting of highly comminuted fracture patterns, polytrauma patients, and patients with radiocarpal instability. The addition of K-wires to support articular surface reduction potentially augments fracture repair stability. Questions/Purposes We examined the radiographic outcomes and maintenance of reduction in patients with comminuted intra-articular distal radius fractures treated with K-wire fixation of articular fragments followed by dorsal spanning plate application. Patients and Methods We reviewed 35 consecutive patients with complex intra-articular distal radius fractures treated with dorsal spanning plate and K-wire fixation between April 2016 and October 2019. AO classification was recorded: B1 (3), B3 (2), C2 (2), C3 (28). A two-tailed paired t -test was used to compare findings immediately post-dorsal spanning plate surgery and at final follow-up after dorsal spanning plate removal. Results Mean patient age was 43.3 years (19-78 years). Mean follow-up was 7.8 months (SD 4.3 months) from surgery and 2.5 months from pin removal (SD 2.6 months). All patients achieved radiographic union. Radial height (mean interval change (MIC) 0.2 mm, SD 2.2, p = 0.63), articular step-off (MIC 0.1 mm, SD 0.6 mm, p = 0.88), and radial inclination (MIC -1.1 degrees, SD 3.7 degrees, p = 0.10) did not change from post-surgery to final follow-up. Ulnar variance (MIC -0.9 mm, SD 2.0 mm, p = 0.02) and volar tilt (MIC -1.5 degrees, SD 4.4 degrees, p = 0.05) were found to have decreased. Conclusion Dorsal spanning plate augmented with K-wire fixation for comminuted intra-articular distal radius fractures in polytrauma patients allows for immediate weightbearing and maintains articular surface alignment at radiographic union and may provide better articular restoration than treatment with dorsal spanning plate alone. Level of Evidence This is a Level IV , therapeutic study.

Use of Surgical Adhesive Tape to Maintain Tension on Intrafocal K-Wires for Easy Reduction and Fixation of Complex Intra-Articular Distal Radius Fractures

Maintaining reduction during fixation of complex intra-articular distal radius fractures with dorsal comminution can be challenging. We describe an operative technique where reduction is achieved with temporary intrafocal Kirschner wires (K-wires), and held using surgical adhesive tape wrapped around the hand, whilst a volar plate is applied to achieve rigid fixation. This is a simple, inexpensive method used at our institutions which allows fixation of these fractures without the need for an operative assistant.

The treatment of complex intra-articular distal radius fractures with turning radius and distal volaris radius plate fixation

BackgroundAlthough distal radius fractures (DRFs) are clinically common, intra-articular DRFs accompanied by dorsally displaced free fragments are much less so. At present, it is very difficult to fix and stabilize the intra-articular distal radius fractures accompanying dorsally displaced free fragments with a plate. Our aim was to investigate the clinical effect of DRFs with distally displaced dorsal free mass treated with distal volaris radius (DVR) combined with turning of the radius via the distal palmar approach.MethodsFrom 2015 to 2019, 25 patients with intra-articular distal radius fractures associated with dorsally displaced free fragments were selected and treated with distal volaris radius (DVR) combined with turning of the radius via the distal palmar approach. This study involved 14 males and 11 females, with an average age of 34.5 years (ranging from 21 to 50 years). The mean follow-up period was 16.5 months (ranging from 12 to 22 months). The dorsal displacement of the free fragments was analyzed by X-ray and three-dimensional computed tomography, allowing characterization of postoperative recovery effects by radial height, volar tilt and radial inclination. For the follow-up, we evaluated effects of the surgery by analyzing range of motion (ROM); Modified Mayo Wrist Score (MMWS); and Disabilities of Arm, Shoulder and Hand (DASH) score. Postoperative wound recovery and complications were also monitored to evaluate the clinical therapeutic effects of the surgical procedures.ResultsX-ray showed that all patients showed reduced fractures, well-healed wounds and recovered function with no obvious complications. Based on the follow-up, patients had a mean radial height of 10.5 mm (ranging from 8.1 to 12.6 mm), mean MMWS of 78.8° (ranging from 61° to 90°), mean DASH score of 16.25 (ranging from 11 to 21), mean ROM for volar flexion of 76.5° (ranging from 62° to 81°), mean ROM for dorsiflexion of 77.1° (ranging from 59 to 83) and mean VAS score of 1.4 (ranging from 1 to 3).ConclusionTreatment of the intra-articular distal radius fractures accompanying dorsally displaced free fragments with turning of the radius and the DVR plate system via the distal palmar approach is effective and has no obvious complications.

A retrospective comparison of clinical and radiological outcomes using palmar or dorsal plating to treat complex intraarticular distal radius fractures (AO 2R3 C3).

Complex intraarticular distal radius fractures are common, and treatment with open reduction and internal fixation (ORIF) can be done through either the palmar or dorsal approach. There is scant evidence, however, indicating which approach is more suitable. We compared clinical and radiological outcomes of patients with AO 2R3 C3 fractures surgically treated with one of these approaches. From January 2015 to November 2018, 72 surgically treated patients with AO 2R3 C3 fractures were radiologically (12months) and clinically (mean 26months) evaluated. Forty-one patients underwent ORIF using the palmar approach (Group 1), and the dorsal approach was used in 31 patients (Group 2). Radiological parameters were measured using the AO scoring system immediately following surgery and 12months later. Clinical assessments included the range of motion, PRWE and DASH scores. At the immediate postoperative assessment, the median AO score was 5.5 (IQR 2-9.5, range 0-30.5) for Group 1 and 8 (IQR 5-15, range 0-27) for Group 2, and 12-month follow-up results were 4.5 (IQR 1.5-10, range 0-41) and 6.5 (IQR 5-11, range 0-29.5), respectively. Group 1 had more favorable results for the flexion, extension, radial abduction, PRWE and DASH parameters. The plate removal and reoperation rates were higher in Group 2. When treating complex intraarticular distal radius fractures, we found the palmar approach was more advantageous for this fracture pattern. Nevertheless, a dorsal approach may still be suitable for intraarticular comminuted distal radius fractures with dorsally displaced joint fragments.

Using mini-arthrotomy for dorsal plating to treat intraarticular distal radius fractures: can it improve radiological and clinical outcomes?

Using palmar plating to treat complex intraarticular distal radius fractures is standard of care. However, fracture fragments can also be managed using a dorsal approach with arthrotomy, which is useful when treating fractures involving the dorsal joint aspect. We compared radiological and clinical outcomes after dorsal plating with or without an intraoperative arthrotomy. 31 of the 359 patients with a distal radius fracture had an AO Type 2R3 C3 fracture surgically treated using a dorsal approach (01/2015-10/2018). Fractures other than C3 were excluded from this analysis. Group 1 (n = 14) had no arthrotomy, Group 2 (n = 17) underwent intraoperative dorsal mini-arthrotomy. Clinical results were measured by range of motion (ROM), Patient-rated wrist evaluation (PRWE) and Disabilities of arm, shoulder and hand (DASH) scores. Radiological results were evaluated using the AO scoring system. ROM, DASH and PRWE did not differ significantly between groups. Joint surface restoration was insufficient in five patients in Group 1 (p = 0.05). A trend towards better radiological results, although not statistically significant, was noted in Group 2 (p = 0.06). Plate removal was performed in 12 patients due to limited ROM (6 patients in each group). One patient (Group 2) with chronic pain and step off in the joint line underwent corrective osteotomy. We did not detect a difference in patient outcomes using the dorsal longitudinal mini-arthrotomy; however, it may prevent incongruent joint reconstruction since all cases occurred in Group 1. In the absence of intraoperative CT scan, longitudinal mini-arthrotomy may be used to enhance visualization and achieve joint surface reconstruction.

Cast immobilization versus volar locking plate fixation of AO type C distal radial fractures in patients aged 60 years and older

ObjectiveThe aim of this study was to evaluate the efficacy of conservative treatment (cast immobilization) for complex intra-articular distal radius fractures (AO type C) in elderly patients and to determine whether or not the application of a volar locking plate (VLP) is necessary. MethodsA retrospective study on patients treated at two different clinics was conducted between 2014 and 2016. A total of 49 elderly patients ≥60 years old were treated either operatively with volar locking plate fixation (n = 25; 7 males and 18 females; mean age: 66.6 ± 7.4 years) or conservatively with cast immobilisation (n = 24; 7 males and 17 females; mean age: 68.9 ± 8.7 years) for complex intra-articular distal fractures. Clinical, functional and radiological evaluations were conducted at the final follow-up examinations of the patients. ResultsThere was no statistically significant difference between the two groups of patients with respect to the follow-up periods, gender, age and fracture type (p > 0.05). At the end of mean follow-up time of 16 months the grip strength (p = 0.03), radial tilt (p = 0.06), radial inclination (p = 0.01), radial height (p = 0.01) and articular step-off (p = 0.02) were significantly better in the volar locking plate group, while there was no significant difference between the functional results (based on the Quick Disabilities of the Arm, Shoulder and Hand score) (p = 0.8) and range of motion. The grip strength was significantly higher in the VLP group when compared to the cast group (p = 0.03). ConclusionThe results of this study suggest that the locking plate fixation for the complex intra-articular distal radius fractures provides better results for the grip strength and radiographic parameters than cast immobilization in patients ≥60 years old, while no difference was found between the clinical and functional results. Level of EvidenceLevel III, Therapeutic Study.

Prospective study of comminuted articular distal radius fractures stabilized by volar plating inthe elderly.

The objective was to assess the ability of the volar locking plate to maintain the radiographic parameters over the time in elderly patients with complex intra-articular distal radius fractures. Prospective cohort of 66 consecutive patients with mean age of 68 (range 60-81) years and AO type C fractures treated with volar locking plate. Radiographic measurements were performed pre and post-operatively at each follow-up. Clinical assessment was made by Patient-Rated Wrist Evaluation scores, Disabilities of the Arm, Shoulder and Hand score, range of motion, and grip strength. The mean post-operative follow-up was 31 (range, 24-47) months. The most difficult parameters to restore intra-operatively were volar tilt and radial height, while radial inclination and ulnar variance were restored in a high rate of patients. There was significant loss of reduction within four post-operative months in volar tilt (p = 0.001) and radial height (p = 0.029). Mean radiographic parameters had no changes from fourmonths to final evaluation. At final follow-up, 50.1% of the patients had all radiographic parameters restored in comparison with the noninvolved wrist, but 83.3% had all radiographic parameters within a functional range (p = 0.001). No significant relationship between radiographic and functional outcomes was found (p = 0.474). This study found that volar locking plate fixation for displaced intra-articular distal radius fractures in elderly patients was an effective procedure to obtain success functional outcomes. Although reduction loss in volar tilt and radial height occurred within four first months, volar plate was able to maintain fracture stabilization with radiographic parameters within functional range over the time in most patients of these elderly patients.

Wrist Hemiarthroplasty for Distal Radius Fractures

Objective: Since 2005, we use a replacement and resurfacing prosthesis for complex intra-articular fractures of the distal radius. The prosthesis is composed of a radial stem and an epiphyseal-metaphyseal block articulating both with the carpal condyle and the ulnar head. This prosthesis is used in elderly and osteoporotic patients when reconstruction of the distal radius is too difficult, particularly when comminution and central impaction are associated. Materials and Methods: Since March 2005, 23 prosthesis were implanted on 23 patients (22 women and 1 man), the mean age was 77 years, from 38 to 102. Twenty-two cases concerned elderly and osteoporotic patients: 17 times for complex intra-articular fractures and 5 times for malunions. In one case, the procedure concerned a young man with a pathologic fracture (giant cell tumor). The patients were reviewed at 3 weeks, 6 weeks, 3 months, 1 year, and then each year. Results: Twenty patients came to follow up regularly. A patient operated in 2005 died in 2010; she retained a good result at the wrist. Two patients are lost at follow-up. The mean follow-up is 56 months, from 3 to 128 months. Seventeen patients are satisfied or very satisfied, and 3 patients are moderately satisfied. Twelve patients had no pain (Visual Analog Scale [VAS] = 0), and 8 patients complain of pain during strength activities or barometric pain. The Disability of the Arm, Shoulder and Hand (DASH) score is 26. The mean mobilities are as follows: extension 62°, flexion 37°, ulnar deviation 26°, radial deviation 21°, pronation 72°, and supination 68°. The mean strength was 79% of the contralateral strength. The implants are perfectly stable on the x-rays with a mean follow-up of 56 months. In 16 cases, we found periprosthetic ossifications. Wrist hemiarthroplasty for distal radius fractures is a simple solution for very complex problem. This concept allows the treatment of the most complex distal radius fractures with metaphyseal instability and intra-articular comminution. The clinical results are good, better, and quicker than those obtained with complex reconstruction surgery. Mobility is greater than that obtained with palliative surgery: radiolunate or radioscapholunate arthrodesis. The extension of the wrist allows these old patients to push up on their hands. Conclusions: The treatment of complex intra-articular distal radius fractures by an hemiarthroplasty of the wrist is a solution we can now use in elderly and osteoporotic patients. This solution must be known for distal radius tumors.

Outcomes of Complex Intra-articular Distal Radius Fractures Treated with Cross-Pin Fixation and a Nonbridging External Fixator (CPX System) in 36 Patients

Outcomes of Complex Intra-articular Distal Radius Fractures Treated with Cross-Pin Fixation and a Nonbridging External Fixator (CPX System) in 36 Patients

AO type-C distal radius fractures: the influence of computed tomography on surgeon's decision-making

Computed tomography (CT) has become a widely accepted adjunct imaging tool in the preoperative evaluation of complex intra-articular distal radius fractures. The aim of this study was to evaluate the impact of CT scanning compared with plain X-rays on the choice of intervention in complex distal radius fractures. Five orthopaedic surgeons were given the de-identified plain films (AP, lateral and oblique) of 20 closed complex intra-articular distal radius fractures (AO23-C), randomly selected from our institution's prospectively maintained fracture database. Each surgeon individually selected a management option for each patient from a series of five interventions, ranked in increasing level of invasiveness. The same patients' CT scans (in randomized order) were blindly reviewed after a 1-week interval by the same clinicians with the same management options again offered. Kappa statistic was used to measure the intra-observer agreement between X-ray and CT decisions, and inter-observer agreement within each modality. The intra-observer agreement on management between X-rays alone versus CT scan was poor, with an average kappa score of 0.038. Inter-observer agreement based on X-ray alone was higher than that based on CT alone. Regression analysis indicated a trend towards a slightly higher level of invasiveness when the management decision was based on the CT compared with plain X-rays. There is a very poor intra- and inter-rater agreement between decision-making based on X-ray and on CT. Decision-making based on CT could increase the level of invasiveness in the surgical management of complex distal radius fractures.

Radial Styloid Fractures

Radial styloid fractures can occur in isolation or in association with other injuries, including complex intra-articular distal radius fractures, carpal fractures, carpal dislocations, and radiocarpal dislocations. The anatomy surrounding the radial styloid is complex, and complications related to surgical approach, treatments, and symptomatic hardware can occur. Operative treatments vary according to the injury pattern present, and pattern recognition is the key to optimizing treatment of these injuries. Outcomes are related to the precision of the reconstruction as well as the magnitude of the injury; better results are associated with lower-energy patterns.

Palmar multidirectional fixed-angle plate fixation in distal radius fractures: do intraarticular fractures have a worse outcome than extraarticular fractures?

The results and complications using a palmar plate system with the possibility of multidirectional fixed-angle screw fixation (Aptus® Radius 2.5 mm by Medartis®) for the treatment of unstable distal radius fractures were evaluated in a single cohort study including 62 patients. Patients with extra- and intraarticular fractures were evaluated separately. The mean follow-up was 14.7 months. Active wrist motion averaged 60.1° extension, 52.0° flexion, 86.3° pronation, and 84.6° supination. Grip strength averaged 89% of the contralateral wrist. There was no loss of the initial reduction with bony union in all cases. The mean DASH-score was 12.6 points. Postoperative complications included two extensor pollicis longus tendon ruptures, two median nerve compression syndromes, one complex regional pain syndrome, and one postoperative haematoma. In our series the results of the intraarticular fracture group were similar to the extraarticular fracture group. The complication rate, however, was substantially higher in the intraarticular fracture group. We conclude that palmar plating with multidirectional fixed-angle screw insertion is an effective and useful treatment option, especially for complex intraarticular distal radius fractures.

Clinical and radiological outcomes after stabilisation of complex intra-articular fractures of the distal radius with the volar 2.4 mm LCP

The purpose of the present study is to evaluate the results of the treatment of intra-articular fractures with the volar 2.4 mm LCP with regard to loss of reduction, clinical outcome and complications. Patients treated with a volar 2.4 mm LCP following a complex intra-articular distal radius fracture were assessed by clinical and radiological examination of both wrists, the Disability of Arm, Shoulder and Hand (DASH) outcome instrument, Martini score and the pain Visual Analogue Scale score. Forty patients (40 fractures: 5 type C1, 11 type C2, and 24 type C3 according to AO/OTA classification) were followed at a mean 18 months from the injury. Of the initial 40 fractures, 4 fractures required surgical revision (1 because of loss of reduction, 2 due to fracture incongruity as seen on the postoperative computer tomogram and 1 case of screw displacement in the radial shaft). Radiographs in the immediate postoperative period showed a radial inclination of 22.1 degrees, volar tilt of 7.2 degrees, and ulnar deviation of 0.2 mm (means). At follow-up examination, radial inclination was 23.8 degrees, volar tilt was 6.2 degrees and ulnar deviation was 0.9 mm (means). Average final wrist range of motion was significantly (p < 0.05) decreased in comparison to contralateral wrist. Average DASH and Martini scores were 18 and 27, respectively, with no significant differences between C1-, C2- and C3-type fractures. Patients who underwent a surgical revision had poorer Martini score. Complications were an EPL tendon rupture, a tendon irritation and a complex regional pain syndrome in a patient who underwent revision. The treatment of complex intra-articular distal radius fractures with the volar 2.4 mm LCP provides sufficient fixation to prevent clinically significant loss of articular reduction, acceptable patient outcomes and minimal soft tissue complications.

Comparison of efficacies of two fixation methods in treatment of complex intra-articular fracture of the distal radius

Objective To compare the efficacies and indications of locking compression plate (LCP) and external fixator plus Kirschner wires in treatment of complex intra-articular fracture of the dis-tal radius. Methods Ninety-eight patients with complex intra-articular fractures of the distal radius were treated with volar LCP or external fixator plus Kirschner wires, the efficacies of which were evaluated by comparing the grasping force and wrist function of the patients. Results All the patients were fol-lowed up for an average of 12.4 months, which showed fracture healing in all the patients. According to the wrist function assessment system of New York Orthopedic Hospital (1990), there was no statistical difference in the efficacy of LCP and external f'lxator plus Kirschner wires in treatment of types C1 or C2 fractures (P > 0.05), while the efficacy of external fixator plus Kirschner wires was significantly superior to that of LCP in treating type C3 fracture (P < 0.05). Conclusions For types C1 or C2 intra-articu-lar fractures of the distal radius, the efficacies of LCP and external fixator plus Kirschner wires are simi-lar, while the efficacy of external fixator plus Kirschner wires is superior to that of LCP in treating type C3 intra-articular fracture of the distal radius. Key words: Radius fractures; Fracture fixation, internal; External fixators; Locking compres-sion plate

La prothèse de remplacement et resurfaçage du radius distal : un nouveau concept thérapeutique

Complex intra-articular distal radius fractures represent a challenging therapeutic problem. We propose in these difficult cases to replace and to resurface the distal radius by a prosthesis, especially in fractures related to aging and osteoporosis. We have designed an anatomic prosthesis to replace and resurface the distal radius. The design was obtained from radiographs, tomograms and anatomical specimens. The prosthesis is composed of a radial stem and an epiphyseal-metaphyseal bloc articulating both with the carpal condyle and the ulnar head. The epiphyseal-metaphyseal bloc can rotate 10 degrees on the longitudinal axis of the stem. From March 2005 to February 2007, six patients were operated on: five women and one man, the mean age was 73 years (38-87). Five cases were elderly and osteoporotic patients: four had complex intra-articular fractures and one had a malunion complicated by extensor tendon ruptures. In one case, the procedure was performed on a young man with a pathologic fracture (giant cell tumor). The patients were reviewed with a mean follow-up of 27 months (13-36 months). Five patients are satisfied or very satisfied but one patient is dissatisfied due to a stiff wrist after an algodystrophic syndrome. The mean mobilities are: extension 65 degrees, flexion 30 degrees, ulnar inclination 20 degrees, radial inclination 20 degrees, pronation 60 degrees, supination 50 degrees. The mean strength was 80% of the contralateral side. The implants are perfectly stable on the radiographs. Replacement and resurfacing of the distal radius by a prosthesis articulating both with the carpal condyle and ulnar head is possible. The preliminary clinical results are good. This prosthesis takes into account the transmission of the pronosupinator couples through the wrist. The longitudinal rotation between the stem and the epiphyseal-metaphyseal bloc has three goals: the first is to decrease the constraints born from the pronosupination torques, the second is to improve the congruence with the carpal condyle, the third is to increase radio-ulnocarpal stability. The treatment of complex intra-articular distal radius fractures by replacement and resurfacing prosthesis is a solution we can now consider in elderly patients with osteoporosis. This solution seems ideal for distal radius tumors.

Kombinierte dorsale und palmare Plattenosteosynthese bei distalen intraartikulären Radiusfrakturen

Complex comminuted intraarticular fractures of the distal radius require anatomic restoration. In rare cases, this aim can only be achieved by a combined dorsal and volar plate fixation despite increasing experience with volar locking compression implants. This retrospective quality control study investigated functional, radiological and subjective outcomes of patients treated with this technique. Between March 1999 and January 2003, 30 out of 360 patients who were operated on for an unstable distal radius fracture with complex C2/C3 type distal radius fractures at the Division of Trauma Surgery of the University Hospital Zurich, had been treated with a combined dorso-palmar plate fixation (dorsal two 1/4 tubular plates, volar 3.5 mm T-plate) and were included in this study (9 female, 21 male, mean age 52 years). Of the 30 patients 25 could be evaluated at an average of 29 months after injury. Anatomic reconstruction could not be achieved in all cases, 56% showed mild and 28% explicit signs of arthrosis. Flexion reached 66% and extension 75% of the contralateral wrist, whereas pronation reached 98% and supination 91%, respectively. Grip strength achieved 75% of that of the contralateral side and 10 patients (40%) developed a complex regional pain syndrome (CRPS). Return to work was possible 120 days after the injury. With the dorso-palmar plate fixation joint reconstruction in complex intraarticular distal radius fractures can be achieved with a satisfactory subjective, functional, and radiologic result, although additional soft tissue injury was caused by the bilateral approach. The patient has to be informed of the high rate of CRPS and the long period of disability.

Combined Internal and External Fixation of Complex Intra-articular Distal Radius Fractures Using Dorsal and Volar Approaches

Elbow, Hand and Microsurgery Service, Orthopedic Surgery Section, University of Michigan Medical Center, Ann Arbor, Michigan, U.S.A. (JEBSON) Steindler Orthopedic Clinic, Iowa City, Iowa, U.S.A. (BLAIR) Address correspondence and reprint requests to Dr. Peter J.L. Jebson, Orthopedic Surgery Section TC 291Y0328, University of Michigan Medical Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109, U.S.A.; e-mail: [email protected]