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Fractures of the distal radius show a wide spectrum of different fracture patterns. Although standard X‑ray images are sufficient for extra-articular fractures, the exact analysis of intra-articular fractures requires the use of computed tomography (CT) with coronal, sagittal and axial sectional images. The classification is based on the Working Group for Osteosynthesis Questions (AO) criteria. The treatment strategy can be more precisely defined by a CT-based classification. Special attention must be paid to the presence of the key corners, as they have a high risk for primary or secondary dislocation if they not adequately stabilized., (© 2024. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Posttraumatic malunion or secondary dislocation can cause wrist joint incongruency. Uncorrected malalignment increases the risk of secondary degenerative changes and chronic pain. Therefore, early correction using the available fixed-angle devices, cancellous bone grafting only becomes necessary in larger bony defects. Premounting the plate through a palmar approach with regard to the desired correction angles leads to predictable results by precise correction. In case of posttraumatic growth arrest with larger discrepancy of the radius and the ulna, a two-staged procedure is advisable.

A wide range of different classifications exist for distal radius fractures (DRF). Most of them are based on plane X-rays and do not give us any information on how to treat these fractures. A biomechanical understanding of the mechanical forces underlying each fracture type is important to treat each injury specifically and ensure the optimal choice for stabilization. The main cause of DRFs are forces acting on the carpus and the radius as well as the position of the wrist in relation to the radius. Reconstructing the mechanism of the injury gives insight into which structures are involved, such as ruptured ligaments, bone fragments as well as the dislocated osteoligamentous units. This article attempts to define certain key fragments, which seem crucial to reduce and stabilize each type of DRF. Once the definition is established, an ideal implant can be selected to sufficiently maintain reduction of these key fragments. Additionally, the perfect approach is selected. By applying the following principles, the surgeon may be assisted in choosing the ideal form of treatment approach and implant selection.

Fractures of the distal radius are very common. The majority of patients are elderly females. High impact trauma are often responsible for fractures in young men. Clinical and radiological diagnostics, including computer-assisted tomography (CAT) scan, are generally sufficient. The indication for conservative treatment is still recommended for specific fracture patterns. Application of palmar locking plates after open reduction proved to be efficacious for the majority of fracture patterns. Furthermore, precise detection and treatment of concomitant lesions are mandatory in order to prevent complications.

Background: The conservative as well as the operative treatment of distal radius fractures poses a risk of inadequate reduction or secondary dislocation. The consequences may be limited use of the hand with pain and restricted movement., Materials and Methods: Out of 21 patients with malunited fractures of the distal radius which were corrected operatively through a palmar approach, 19 have been assessed clinically as well as radiologically. The mean age was 60 years (range 45-84 years) and the mean follow-up period was 342 days. In 10 cases no autologous bone graft was inserted into the osteotomy gap., Results: Postoperatively the average extension was 51.8° (±14.9°) and flexion 53.5° (±14°) as well as a supination of 83.8° (±11.2°) and pronation of 84.7° (±12°). The wrist score averaged 85 points, the disabilities of the arm, shoulder and hand (DASH) functional value averaged 17 points. A mean preoperative palmar inclination of -20.9° (±10.1°) improved to 5.4° (±3.8°) after surgery and the ulnar inclination from 9° (±8.5°) to 18.1° (±6.2°)., Discussion: The correction of malunited distal radius fractures led to an improvement in function with less pain. Our data indicate that under certain circumstances interposition of an autologous bone graft does not need to be performed.

Purpose/background: Open reduction and internal fixation with plates is a valid treatment of displaced extra- and intra-articular distal radius fractures. This report presents our experience treating unstable distal radius fractures by using a multidirectional palmar fixed-angle plate system (Aptus(R) Radius 2.5 by Medartis). The subchondral support of the articular surface by fixed angle screws prevents secondary dislocation allowing early mobilisation., Patients and Method: 61 patients with distal radius fractures were treated during 6/2003 and 10/2004 using this palmar fixed-angle plate fixation without bonegraft. Postoperative X-rays showed anatomical reduction in all cases. 55 patients could be evaluated postoperatively. The follow-up examination included the patient's history, physical and radiographic examination as well as the DASH questionnaire and the Krimmer's modified Cooney wrist score., Results: The average follow-up time was 9.6 +/- 5.2 months. The mean age of the examined patients was 53.9 +/- 17.8 years. The fractures were classified according to AO. There were eleven A3, four B2 and five B3 fractures, ten C1, 16 C2 and nine C3 fractures. All fractures united without complications. Just two cases showed a loss of length. At follow-up the average palmar angulation was 8 degrees , ulnar inclination 21 degrees and ulnar variance + 0.2 mm. Wrist motion averaged a decrease for extension and flexion of 12 %, for ulnar and radial deviation of 9 % and for pronation and supination only of 2 % in comparison to the uninjured side. Grip strength reached an average of 85 % of the contralateral side. Patients regained good function as represented in a mean DASH score of 14 points and a Krimmer score of 82 points., Conclusions: The treatment of unstable distal radius fractures with this plate fixation provided stable internal fixation and allowed early function. Due to multidirectional angle fixation and two lines of cortical screws it is possible to achieve an optimal restoration. The fixation of the central articular surface is guaranteed by the distal line, the dorsal subchondral support by the proximal line.

In addition to conventional radiological C-arm image amplifiers used for intraoperative imaging, now a new mobile C-arm image amplifier with an option for three dimensional imaging (Iso-C 3D) is available to visualize reduction of fractures and position of implants. In a wrist-model three titanium pins were placed and three holes of different length were drilled. Distances between the pins and the depths of the drilled holes were calculated in conventional computer tomographic scans and Iso-C 3D scans in perpendicular, 30 degree and 90 degree position of the gantry and compared to actual distances and depths. There were no significant differences between the actual measured distances and those measured by CT scans and Iso-C 3D scans. Furthermore, gantry position had no significant effect upon the results. Iso-C 3D scans are as reliable as conventional CT scans for intraoperative controlling of implant positioning.

Internal fixation of distal radius fractures often shows the problem of secondary dislocation due to dorsal comminution and osteoporosis. Although dorsal plating systems provide good stabilization, the intraoperative control of reduction is difficult in the comminuted area with high incidence for the need of cancellous bone graft. Occurrence of extensor tendon complications including tendonitis and rupture is not uncommon. The use of fixed angle devices by a palmar approach has demonstrated the advantage of better visualization and control at the fracture side. The subchondrale support of the articular surface by fixed angle pegs or screws prevents secondary dislocation allowing early mobilization. Better soft tissue coverage is associated with a low complication rate. 62 patients (average age 55 years) were treated with different fixed angel devices according to the fracture type and underwent retrospective evaluation with mean follow-up of 11 months (6-23 months). According to the AO Classification there were 3 A2, 24 A3, 7 B3, 14 C1, 9 C2 und 5 C3 fractures. The majority beside the B3 types and one C3 fracture were dorsally displaced. All of them showed healing without relevant secondary loss of reduction. Mean DASH score reached 19 points.

The ulnar impaction syndrome is proven to be a common source of ulnar sided wrist pain. Ulna-shortening osteotomy represents a successful therapy for this kind of problem, both congenital or posttraumatic positive ulnar variance. Positive variance resulting from a distal radius fracture needs correct dorsal and radial angulation of the radius. In case of congenital positive variance arthroscopic debridement for decompression of the TFCC should be performed first. The adequate correction of the length is the major problem. Disorders of the distal radioulnar joint may result due to overcorrection. Oblique osteotomy using 7-hole-plates is our preferred treatment.