Journal of Orthopedics and Joint Surgery
Volume 2 | Issue 1 | Year 2020

Unstable Intra-articular Fracture Distal Radius Managed by Combined External Fixation and Internal Fixation by Volar Plating

Prabhakar Sekar

Department of Orthopaedics, Government Royapettah Hospital (Attached to Government Kilpauk Medical College), Chennai, Tamil Nadu, India

Corresponding Author: Prabhakar Sekar, Department of Orthopaedics, Government Royapettah Hospital (Attached to Government Kilpauk Medical College), Chennai, Tamil Nadu, India, Phone: +91 8838975484, e-mail:

How to cite this article Sekar P. Unstable Intra-articular Fracture Distal Radius Managed by Combined External Fixation and Internal Fixation by Volar Plating. J Orth Joint Surg 2020;2(1):31–37.

Source of support: Nil

Conflict of interest: None


Background: Combined external fixation and internal fixation of distal radiusfractures is used most commonly to treat injuries with joint surface ormetaphysealcomminution. External fixation aids reduction intraoperatively and facilitates percutaneous or intraoperative manipulation of fracture. Internal fixation maintains precise reduction in critical anatomy, principally the contour and orientation of the articular surface. Postoperatively, the external fixator functions as a neutralization device, preventing fracture collapse and decreasing the biomechanical demands on the internal fixation hardware.

Purpose of study: The aim of this study is to see short-term functional and radiological outcome analysis in patients with unstable intraarticular distal radius fracture treated with combined external fixation and open reduction and internal fixation by volar plating.

Materials and methods: A total of 25 cases of unstable intra-articular distal radius fracture (AO Type C group) were treated by combined transarticular external fixator and internal fixation by volar plating with supplementary procedures such as primary bone grafting and K-wire fixation if necessary. The abovementioned study was conducted in Government Royapettah Hospital, Chennai-14, from June 2010 to May 2012. The Modified Gartland and Werley Demerit Scoring system was used to evaluate the functional outcome. In most cases, external fixator was left for a period of 6 weeks.

Results: There were 25 patients ranging from 20 to 70 years with 16 males and 9 females. The follow-up period was from 12 to 18 months. Accordingly, there were 14 (56%) excellent, 8 (32%) good, 2 (8%) fair, and 1 (4%) poor results. There were very few complications such as one malunion, two superficial radial nerve palsy, and two secondary fracture collapse noted in our series.

Conclusion: We conclude that unstable intra-articular fractures of distal radius treated by combined external fixation and internal fixation by volar plating provides high rate of fracture union and high level of patient satisfaction with early return to work.

Keywords: Bone grafting, Distal radius, External fixator, Intra-articular, Metacarpal K wire, Stainless steel (SS) wire, Unstable, Volar plating.


Communited fractures, which include the intra-articular surface of the distal radius, can imperil the kinematics as well as the congruency of wrist joint. Thus, anatomical intra-articular reduction may decrease enormously the occurrence of posttraumatic osteoarthrosis1 and the ultimate result is legitimately identified with nature of reduction. Many methods of fixations have been portrayed including pin-plaster fixation,2 percutaneous pinning,3 intramedullary pinning,4 outside fixation,5 bridging,6 or non-bridging7 (static or dynamic) and different types of internal fixation810 with modified implants. Although communited fractures commonly require aggressive treatment, the perfect management for the distal radius does not exist till now. Both internal and external fixation methods when utilized alone prompt treatment failures in communited distal radius fracture group. Hence, vigorous search over mixed methods of fixations have been attempted. It incorporates external fixator with different methods of internal fixation running from K wire to volar plating and dorsal plating or dual plates.


To analyze the role and effectiveness of combination of ligamentotaxis by external fixator and open reduction by volar plating in the management of unstable distal radius fracture.

Principles behind the Combined Ligamentotaxis and Internal Fixation by Volar Plating

  • External fixation aids reduction intraoperatively and facilitates percutaneous or open manipulation of articular fragments while volar plate application.
  • Internal fixation maintains precise reduction of critical anatomy, principally the contour and orientation of the articular surface.
  • Postoperatively, the fixator functions as a neutralization device, preventing fracture collapse and reducing the biomechanical demands on the internal fixation hardware.


This prospective study was conducted in our Government Royapettah Hospital from June 2010 to May 2012. Patients with unstable comminuted intra-articular distal radius fractures were selected for study and treated by combined ligamentotaxis through external fixator and internal fixation by volar plating.

Inclusion Criteria

  • All comminuted distal radius fractures classified as type C in AO/OTA classification.
  • Age between 20 years and 70 years.
  • Fractures upto 2 weeks old.

Exclusion Criteria

  • Open distal radius fractures excluding grade I compound.
  • Surgically unfit medical comorbid conditions.
  • Pathological fractures.

Surgical Technique

For the placement of the external fixator, pins open method was utilized. This fixator will engage only four metacarpal cortices. Predrilling is done for both metacarpal and radial pins. Metacarpal Schanz pins (2.5 mm) were inserted in the order of proximal followed by distal in 30°–45° to coronal plane to the second metacarpal base and shaft. Then, radial Schanz pins (3.5 mm) were applied in same plane with distal pin insertion at least 2 cm away from the fracture site. Longitudinal traction was given along forearm axis and followed by attaching C–D unit interconnecting rod after radiological check (Mobile X-ray/C-arm) to assess restoration of radial length. Further, the index finger flexed up to 90° to rule out overdistraction. Usually, intra-articular volar fragments may be aligned properly, so in all cases augmented volar plating was done in our study.

Many volar approaches for distal radius fracture were described. We followed Elly’s approach in most of the cases mainly to elevate the articular step up and to stabilize medial column of distal radius fracture. In some cases, Henry approach is used to stabilize the comminuted lateral column. Pt in supine position by Volar Ellis approach, plane between FCR and Palmaris longus entered. Median nerve is isolated, and its sensory branch is protected. Then the arm is kept in mid-prone position and pronator quadratus muscle is erased proximal to distal from the volar aspect of the distal end of the radius, exposing the fracture. In our study, volar capsule is not dissected off, the volar aspect of the radius, in order to maintain the strong ligamentous support by external fixator. Carpal tunnel was released in some cases, but it is not mandatory. Limited soft tissue release is done to visualize the volar articular fragments and its anatomic reduction attempted. Also, if there is radial shortening and malalignment, the articular surface should be elevated as a unit to the level of the scaphoid and lunate and then reduced. After the articular fragments had been anatomically reduced, all fractures required stabilization with volar plate with or without additional K-wire fixation depending on fragment size. Eight fractures with DRUJ instability were transfixed with 1.8-mm Kirschner wires. Defects in five fractures with type AO type C3 with extensive comminution were filled with bone graft to prevent collapse by early incorporation. Ipsilateral corticocancellous crest bone graft was used for all fractures with larger defects. By dorsal approach, the graft was placed in the defect with the both cortices positioned so that it offered optimal resistance to displacement or collapse of the articular fragments (Figs 1 to 6).

Postoperative Protocol

  • Limb elevation to reduce edema/daily pin tract dressing.
  • Drain removal 48 hours after surgery.
  • Parenteral antibiotics for first 5 days followed by oral antibiotics.
  • Sutures removed on 14th day, active and passive mobilization of adjacent joints started immediately, and wrist mobilization after ex-fix removal.

Duration of External Fixator

In most cases, external fixator was left for a period of 6 weeks. Bone healing was determined radiographically by the appearance of bridging trabeculae across the fracture site and clinically by the fracture site being nontender to palpation. Additional k-wires were also removed. In highly comminuted fractures, external fixator was left up to eight weeks.


In this study, there were 25 patients treated with combined external fixation and open reduction with plate fixation. Sixteen males and nine females were followed up for a period of 12–18 months. The dominant extremity was involved in 17 patients. All patients were in group C according to the AO/OTA classification, but majority had C1 type of fractures, where the comminution did not extend to the diaphysis. There was no correlation between gender and the functional outcome. There were very few complications reported.

Functional, radiological outcome measures, paired t tests and comparative studies were tabulated (Tables 1 to 5).


Our outcomes demonstrate that the useful result is directly related to the nature of anatomical reduction in the articular surface and extra-articular arrangement in comminuted intra-articular fractures of the distal radius as in other studies.11 Inability to accomplish appropriate reduction and length of distal radius comparative with ulna can bring about difficulties in torment pain and instability that may require corrective osteotomy. Regarding treatment of communited distal radius fractures, external fixation alone or with percutaneous pinning has delivered great or excellent outcomes.12 Anyway, there are still some articular fractures in which articular restoration cannot be accomplished and the length alone looked after through ligamentotaxis. Henceforth, further volar plate is expected to reestablish these articular pieces. Volar plating of dorsally angulated distal radius fractures, including AO type C3, has become an inexorably basic treatment option in later years13). We concur with Rogachefsky et al. that the increase in fracture fixation by external fixator at full mode of distraction before the surgical approach aided in fracture reduction and improved radial length and alignment. The fixator normalizes the compressive forces over the joints, decreasing collapse of the fracture during the first 2 or 4 weeks of healing, when bony resorption and early new bone arrangement are maximal.

Kömürcü et al.14 evaluated the consequences of combined treatment modality with closed reduction, K-wires, bone grafting, and external fixator in patients with distal radius fractures. T1hat treatment of the distal end fractures of the range (AO type C2–C3) with a mix of external fixator, primary bone grafting, and percutaneous K-wires gives practically close normal radiologic and clinical findings. In any case, when Dicpinigaitis et al.15 assessed the effectiveness of mixed external fixator and percutaneous pinning and found that loss of volar tilt reduction was seen for a time of up to 6 months after surgical fixation. In our case series, after restoration of radial height, radial inclination, volar tilt edge, and congruous intra-articular surface by good reduction, a volar buttress plate was applied first to help the volar cortex and get a volar support. This not just maintains the volar tilt edge but also prevents volar displacements of fractures, however, could likewise give a volar support to the dorsal external fixator.

Figs 1A to F: External fixator application (first fixation)

The external fixator was utilized in a static mode for 5 to 7 weeks after surgery, which could keep up distal radius height and volar tilt edge through a volar support, and also stops the redisplacement brought about by the conflict of the lunate and scaphoid on the distal radial articular surface. In this way, a stable mechanical background could be made for fracture healing. Rather than external fixator alone, the addition of volar support plate will normalize the Z’orientation impact of dorsal wrist ligaments. In this way, it gives a background to early rise in hard callus and shirking of scapho-lunate conflict by satisfactory maintenance of volar tilt edge, which was additionally helpful for the redemption of intra-articular congruence. What’s more, different procedures, for example, Kirschner wire application as a joystick maneuver and bone grafting were included as important to additionally balance out the fragments and stop the secondary collapse of the articular surface. Bass et al.16 introduced the consequences of the consolidated two-incision technique in a gathering of AO type C3 fractures of the distal radius. Results were accomplished, with a full range of wrist movement and grip strength that were 80% and 83% of the qualities for the healthy side, respectively, despite the external fixator having been kept up for a mean of 12 weeks. The poor result in one patient was because of serious comminution at the fracture site (AO type C3). We presently accept that on the off chance that if bone grafting had been done, at that point, we could have maintained fracture reduction thereby preventing secondary collapse.

Figs 2A and B: Volar Ellis approach (carpal tunnel released)

Fig. 3: Median nerve and its branch isolated

Fig. 4: Volar plating (2nd fixation)

Fig. 5: Complications

Confinements of our case series study incorporate its absence of controls and generally modest number of cases. A randomized, prospective study of a group treated with combined fixation and a control group managed by internal fixation alone would have been important to evaluate the need of supplemental external fixation.


In this study of combined external fixation and internal fixation by volar plating, we were able to achieve the near-normal anatomy of wrist with restoration of articular surface as well as radial length, correction of palmar tilt, and radial inclination. The importance of proper pin site care is emphasized and primary bone grafting as and when needed must be done. Hence, we conclude that the combined fixation method provides high rate of fracture union andhigh level of patient satisfaction with early return to work.

Figs 6A to D: Mr RM, 68 years/male, AO type C1: (A) Preoperative; (B) Immediate postoperative; (C and D) 24 months follow-up

Table 1: Gartland and Werley demerit scoring system
Gartland and Werley score (demerit system)-components are:
I. Subjective evaluation—6
  • Excellent: no pain, disability, or limitation of motion (0)
  • Good: occasional pain, slight limitation of motion, and no disability(2)
  • Fair: occasional pain, some limitation of motion, feeling of weakness in wrist, no particular disability if careful and activities slightly restricted (4)
  • Poor: pain, limitation of motions, disability, and activities more or less markedly restricted (6)
II. Objective evaluation—5
  • Loss of dorsiflexion (5)
    • Ulnar deviation (3)
    • Supination (2)
    • Palmar flexion (1)
    • Radial deviation (1)
    • Circumduction (1)
    • Distal radioulnar joint (1)
III. Residual deformity—3
  • Prominent ulnar styloid (1)
  • Residual dorsal tilt (2)
  • Radial deviation of hand (2–3)
IV. Complications—5
  • Arthritic changes minimal (1)
    • Minimal with pain (3)
    • Moderate (2)
    • Moderate with pain (4)
    • Severe (3)
    • Severe with pain (5)
      • Nerve complications (median) (1–3)
      • Poor finger function due to cast (1–2)
        • Final result
        • 0–2 Excellent
        • 3–8 Good
        • 9–20 Fair
        • ≥21 Poor
Combined fixation
Table 2: Radiological evaluation
Affected wristNormal wrist6 months12 months18 months
Radial length (mm)    3.1412.6111.9611.8611.86
Radial inclination (°)  11.1522.2020.5320.4020.40
Palmar tilt (°)−22.89  7.75  6.78  6.72  6.72
Intra-articular step (mm)    2.22  1.336  1.31  1.331
Table 3: Paired sample t test (1)
VariableProcedureMean differencep value
Radial length (mm)Combined fixation  8.17<0.0001
Palmar tilt (°)Combined fixation30.50<0.0001
Radial inclination (°)Combined fixation  9.25<0.0001
Intra-articular step (mm)Combined fixation−0.896<0.0001

Mean difference is between prereduction and 18 months follow-up

Table 4: Paired sample t test (2)–combined fixation
Test valueTestdfSig (2–tailed)Mean difference95% confidence interval of the difference
RL101.08Paired t test240.000  8.1720  8.8898  8.5341
PT162.54Paired t test240.00030.496030.883230.1088
RI  63.01Paired t test240.000  9.2500  9.5529  8.9470
IS−15.55Paired t test240.000−0.8964−0.7774−1.0153

RL, radial length; PT, palmar tilt; RI, radial inclination; IS, intra-articular step

Table 5: Comparative studies
StudyNumber of ptsFollow upExcel/good
Vaughan et al.55920–22 months29/60
Pradhan et al.172214–46 months50/31
Zhang et al.182712–29 months30/60
Rogachefsky et al.191730 months59
Our study2518–24 months56/32


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