Volume 9, Issue 11, November – 2024 International Journal of Innovative Science and Research Technology

ISSN No:-2456-2165 https://doi.org/10.38124/ijisrt/IJISRT24NOV129

Outcomes of Treatment of Intra-Articular

Distal Radius Fractures with Volar Locked
Plates in Patients Above 50 Years
Muhsin Dursun
PhD. Physician, Ortadoğu Private Hospital,
Department of Orthopedics and Traumatology, Adana, Turkey.
https://orcid.org/0000-0002-4024-5059

Abstract:- I. INTRODUCTION

 Objective: Fractures of the distal end of the radius make up one

Outcomes of the treatment of intra-articular distal sixth of the patients presenting with fractures at the
radius fractures seen in patients above 50 years with emergency units.1 When the distribution of age related
volar locked plates were evaluated. fractures are studied, there are two age groups where
incidence is increased. While the first group is made of
 Study design: physically active children between 5 and 10 years of age,
Twenty Eight patients (8 female and 20 male) the second group is made of elderly patients between 50
treated in our clinic with volar locked plates because of and 69 years of age leading less active lives. 2 The
intra-articular distal radius fractures were evaluated mechanism of injury is usually falling on open hand, and
after a 17-month (range 8-30 months) follow-up. Mean this mechanism of injury is particularly valid for
age of the patients was 45.2 (range 50-64) years. osteoporotic patients with reduced bone quality. 3,4 Because
Fractures were classified according to Frykman and AO the young population is open to high energy injuries, there
classifications. According to the Frykman classification, is a high probability of multi-piece and displaced fractures.
2 patients had type 3 (7%), 1 patient had type 4 (5.5%), On the other hand, comminuted intra-articular fractures are
14 patients had type 7 (50%) and 11 patients had type 8 more probable in elderly patients due to the reduced bone
(37.5%) fractures. According to the AO classification, 6 quality. These fractures can be in the form of open
patients had B2 (23.5%), 4 patients had C1 (14%), 11 fractures, but can also be associated with tendon ruptures
patients had C2 (37.5%) and 7 patients had C3 (25%) and neurovascular injuries.5
fractures. All patients were evaluated clinically and
radiologically. Clinical outcomes of the patients were These are important fractures because their treatment
evaluated using Gartland and Werley’s evaluation outcomes affect daily functions of individuals. Fracture
scores and DASH-T scores. Radiologic outcomes were type, age, general status, physical and cognitive capacity,
evaluated according to the radiologic evaluation criteria additional diseases, compliance to treatment and
modified by Steward et al. expectations of the patient should be taken into
consideration in planning the treatment,6
 Results:
According to the evaluation scores of Gartland and The aim of treatment is to obtain anatomic reduction
Werley, 20 patients yielded excellent (72%), 5 patients as well as maintain the achieved reduction while the
good (18%) and 3 patients moderate (10%) results. fracture heals.7 Age related reduction in bone quality leads
Mean DASH-T score of the patients was 34 (range 31 to to implant failure and loss of reduction and iatrogenic non-
40). unions. Use of constant angle volar locked plates is an
important treatment modality to overcome this
 Conclusions: complications.7
Treatment of intra-articular distal radius fractures
seen above 50 years of age with volar locked plates is an In this study, patients with intra-articular distal radius
efficient and safe method. Use of volar locked plates fractures aged above 50 years and treated with constant
reduces the complication risk of reduction loss and need angle volar locked plates were evaluated regarding
for grafts in osteoporotic fractures. anatomic, radiologic and clinical outcomes, and the
influence of treatment outcomes on the daily chores and
Keywords:- Fractures Of The Radius; Forearm Injuries; social lives of the patients were studied.
Colles Fractures.

IJISRT24NOV129 www.ijisrt.com 760

Volume 9, Issue 11, November – 2024 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165 https://doi.org/10.38124/ijisrt/IJISRT24NOV129

II. MATERIALS AND METHODS carpi radialis tandon. The pronator quadratus muscle was
dissected from the radial insertion site. The fracture was
Twenty-eight distal radius fractures of 28 patients exposed. İntra-articular fractures were indirectly reduced
aged above 50 years presenting with intra-articular distal and a volar constant angle plate was adapted. First, one
radius fractures at the emergency service of our clinic unlocked cortical screw was screwed to the proximal
between February 2006 and April 2008 were fragment by keeping the fracture at the reduced position
retrospectively evaluated. Eight patients (29%) were female and the plate was aimed to have a supporting effect on the
and 20 (71%) were male. Female: male ratio was 1:2.5. distal fragment. Then a constant angle locked screw was
Mean age was 54.2 years (range 50 to 64 years). Twenty- placed at the part compatible with the subchondral region
two (78%) fractures were on the right extremity and 6 with the fracture in the reduced position. A fluoroscopic
(22%) were on the left extremity. Four (14%) of the control was carried out and the reduction of the fracture,
fractures were type I open fractures according to the position of the plate and the relationship of subchondral
Gustilo-Anderson classification. screws with the joint were assessed. Following this,
proximal metaphysis screws were sent as to hold the dorsal
In addition to distal radius fractures, there were pieces for supplemental stability. At least 2 locked cortical
intertrochanteric femur fractures in 2 patients and an screws were added to the proximal fragment and a repeat
olecranon fracture in 1 patient. fluoroscopic control was made. The tourniquet was opened
and bleeding control was made. The pronator quadratus
Histories were taken primarily from patients muscle was sutured so as to cover the plate. Subcutaneous
presenting with distal radius fractures at the emergency tissue was sutured with a 4/0 absorbable suture. The skin
service. Patients underwent physical examination and was closed with a 4/0 nonabsorbable suture and an elastic
antero-posterior and lateral X-rays of the wrists were bandage was applied (Figure 1 and 2).
routinely taken. In patients thought to have additional
pathologies, examinations directed at these pathologies On the first postoperative day, all patients were started
were added. on finger movement aperture exercises and fore arm
pronation-supination exercises at tolerable levels. At the
Distal radius fractures of all patients underwent closed end of the first week, the patients started wrist exercises.
reduction and fixation with circular casts and control X-
rays were taken. X-rays were evaluated for radial heights, Sutures of all patients were taken on day 15. Until the
radial inclination, palmar slope and articular discordance end of the eighth week finger, wrist and fore arm
before and after reduction. Taking into consideration the movements were progressively increased with weekly
stability criteria determined by La fontaine et al.8, surgical controls.
treatment was decided for unstable fractures and the
patients were included in the study group. Patients were followed clinically and radiologically.
Patients with adequate follow-up were called for their last
Frykman9 and AO10 classifications were used in the controls. Mean follow-up at last controls was 17 months
evaluation of fractures. Patients included in the study had 2 (range 8 months to 30 months). Clinical outcomes were
type 3 fractures (7%), 1 type 4 fracture (5.5%), 14 type 7 evaluated with the evaluation score of Gartland and
fractures (50%) and 11 type 8 fractures (37.5%) according Werley11 (Table 1) and DASH-T score12 (Table 2).
to the Frykman classification, and 6 type B2 fractures Radiologic outcomes were evaluated according to the
(23.5%), 4 type C1 fractures (14%), 11 type C2 fractures radiologic evaluation criteria modified by Steward et al.13
(37.5%) and 7 type C3 fractures (25%) according to the AO (Table 3).
classification.

Among the patients presenting at our clinic with distal

radius fractures, 8 were operated on during the first 3 days,
14 between days 3 and 7, and 6 between days 7 and 16. The
mean interval between the fracture and surgery was 5.3
days (range 2 to 41 days). Surgical Technique:

 Surgical Technique
General anesthesia was applied to 6 patients,
supraclavicular block to 8 patients and axillary block to 14
patients. Distal radii of all patients were operated on under
a tourniquet. The patients were taken to the operating room
and laid in a supine position. Following anesthesia,
prophylactic 1 gr Cefazolin sodium was administered
intravenously before the tourniquet. Following appropriate
Fig 1: Anteroposterior and Lateral View of 58 Years Old
cleaning and draping, the fore arm was placed on the hand
Male Patient’s Distal Radial Fracture
table with the wrist at a 90 degree flexion. With a volar
longitudinal incision, an entrance was made over the flexor

IJISRT24NOV129 www.ijisrt.com 761

Volume 9, Issue 11, November – 2024 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165 https://doi.org/10.38124/ijisrt/IJISRT24NOV129

wound debridement on day 12 and use of oral antibiotics.

In one patient operated on day 41 following fracture and
healing with shortening, there were findings of pressure on
the median nerve during follow-up and the implant was
removed at the end of the 8th month. The symptoms
improved following removal of the implant. Reflex
sympathetic dystrophy developed in 5 patients. Significant
improvement was obtained with physical therapy together
with opposite bath applications and use of Calcitonin 200
IU as a nasal spray for 2 months. No complications like
tendon ruptures and tenosynovitis were seen in any patient.
Postoperative arthritis was not encountered clinically or
radiologically, but the follow-up was short.

Fig 2: Postoperative Sixth Months Anteroposterior and IV. DISCUSSION

Lateral View of the Same Patient’s Wrist
The incidence of distal radius fractures has increased
III. RESULTS due to the widespread use of motor vehicles, regular sports
activities and increased life expectancy. The aims in the
Finally, complete content and organizational editing treatment of intra-articular distal radius fractures are
before formatting. Please take note of the following items achievement of maximal function, maintenance of
when proofreading spelling and grammar: According to the movement aperture, limitation of posttraumatic arthritis and
clinical evaluation criteria of Garland and Werley, excellent prevention of complications.12 In order to achieve these
results were obtained in 20 (72%) of 28 distal radii, good therapeutic aims, an appropriate reduction should be
results in 5 (18%) and moderate results in 2 (10%). Mean obtained and preserved until the fracture heals and a good
DASH-T value of the patients evaluated with the DASH-T rehabilitation program should be carried out for the
score was 34 (range 31 to 40). restoration of movement and strength.

At the last follow-up, wrist and fore arm movement In addition to the necessary criteria for an acceptable
aperture values were as follows: 70º (range 50º to 90º) reduction in intra-articular distal radius fractures, there is
dorsiflexion, 60º (range 40º to 90º) palmar flexion, 28º still controversy about the optimal techniques to be applied
(range 20º to 45º) unlar deviation, 20º (range 10º to 35º) in order to obtain this reduction and maintain its continuity.
radial deviation, 75º (range 60º to 90º) pronation and 80º Gartland and Werley have shown that four components of
(range 75º to 90º) supination. distal radius fractures should be corrected in order to obtain
good functional results; 1) radial shortening, 2) radial
With the Steward’s scoring system carried out for inclination, 3) dorsal slope and 4) discordance of distal
radiologic evaluation, excellent results were obtained in 19 radioulnar joint.14 The generally accepted opinion is that
fractures (68%), good results in 7 (25%) and moderate good functional results can be obtained by restoring the
results in 2 fractures (7%). neutral length of the radius, and by achieving a radial
inclination of more than 0 degree, a volar slope between 0
In the radiologic evaluation of the fractures, mean and 5 degrees, an articular stepping of less than 2 mm,
preoperative radial height was 0 mm [range (-16) to 6], stable relationships between carpal joints and decreased
mean postoperative radial height was 14 mm [range 6 to distal radioulnar joint instability. Although basic
25], mean preoperative radial inclination was 4º [range (-8º) extraarticular criteria (radial height, radial inclination, volar
to 10º], mean postoperative radial inclination was 22º slope) are important, the most important criterion required
[range 10º to 28º], mean preoperative palmar slope was -10º for successful results has been accepted to be intra-articular
[range (-20º) to 5º] and mean postoperative palmar slope reconstruction, that is correct restoration of the joint
was 4º [range (-5º) to 10º]. İntra-articular stepping and surface.4,14,15
gapings were anatomically restored with the exception of 1
patient. There was a 3-mm intra-articular stepping only in 1 Currently, the treatment of fractures of the distal end
patient. of the radius is planned regarding the stability of the
fracture. La Fontaine et al. have identified criteria for
Mean time needed for the patients to perform their determining the stability the fracture. According to the
normal daily functions was found to be 65 days (range 42 criteria of La Fontaine et al., stable fractures are non-
to 105 days). displaced or mildly displaced fractures without dorsal
fragmentation and seen in young patients. 8 In these patients
During surgery no radial artery injury, median nerve treatment with a cast is usually sufficient. On the other
injury or complications related with the tendinous hand, different treatment modalities should be tried in
structures dissected during exploration were encountered in unstable fractures of the distal end of the radius. An
any patient. There was a wound site infection in one patient unstable fracture should have at least three of the following
during the early postoperative period and was treated with criteria: a dorsal inclination of more than 20 degrees during

IJISRT24NOV129 www.ijisrt.com 762

Volume 9, Issue 11, November – 2024 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165 https://doi.org/10.38124/ijisrt/IJISRT24NOV129

fracture formation, fragmentation of dorsal metaphysis, additional casts in the postoperative period and started
radiocarpal intra-articular spreading, presence of an unlar active movement aperture exercises of the wrist and elbow
styloid fracture and patient age above 60 years.8 on the seventh postoperative day.

Intra-articular distal radius fractures which usually Another important point is that constant angle volar
occur following high energy trauma in young adults occur locked plates provide indirect reduction. In our technique, it
as a result of low energy trauma due to decreased bone is possible to provide reduction between the proximal and
quality in patients above 50 years of age. Distal radius distal fragments by using the buttress effect of the plate
fractures occurring as a result of a simple fall on open hand after the adaptation of the anatomically compatible constant
can be treated with closed reduction and cast angle volar locked plate to the proximal fragment with one
immobilization most of the time. Although numerous unlocked cortical screw following indirect reduction of
fixation methods have been described for patients that intaarticular fragments with the aid of carpal bones and
cannot undergo closed reduction or are decided to be carpal ligaments and consequently stabilization of the
unstable following closed reduction, there is still no fracture by placing locked screws to the screw holes
consensus about the appropriate treatment. Many treatment matching the subchondral region of the distal fragment with
and fixation methods have been described in the literature the use of these plates.
ranging from percutaneous pinning together with closed
reduction to arthroscopically supported open reduction and Because previous plates did not have these
internal fixation technique with multiple plates (fragment qualifications, the use of plate screw was not recommended
specific fixation). Successful results can be obtained with in osteoporotic elderly patients. 24 According to our current
the defined techniques in many distal radius fractures. knowledge, osteoporosis of the fracture is among the
Nevertheless, treatment of patients with reduced bone indications for the use of plate screws. The study by Orbay
quality is important. Particularly, the treatment method to and Fernandez confirming this observation of ours has also
be chosen in intra-articular distal radius fractures in patients reported success with the treatment performed by the volar
above 50 years should allow a more rigid fixation. constant angle locked plate system in radius fractures
occurring in the setting of osteoporosis in patients aged 75
There are reports recommending avoidance of open years or above.24
reduction internal fixation in the presence of intra-articular
fractures with severe osteoporosis in the elderly. This was Clinical evaluation of our patients at the end of the
concluded due to the frequent complications like implant study has revealed excellent results in 20 of 28 distal radii
failure, iatrogenic non-union and reflex sympathetic (72%), good results in 5 (18%) and moderate results in 3
dystrophy in these patients.16,17,18 (10%), according to the clinical evaluation criteria of
Gartland and Werley. Mean DASH-T value of the patients
Lauber and Pfeiffer have published the results of 117 evaluated with the DASH-T scoring system was 34 (range
cases with distal radius fractures they treated in 1984, and 31 to 40). These results are similar to those in the literature.
have reported loss of reduction in 12% of cases, permanent Radiologic evaluation of the patients according to
intra-articular stepping or gaping in 50% of cases and Steward’s radiologic scoring system has revealed excellent
failure to restore extra-articular anatomy in approximately results in 19 fractures (68%), good results in 7 (25%) and
2/3 of cases and permanent joint pain in 60% of cases. 19 moderate results in 2 (7%). Thus, clinical and radiologic
Again in 1984, Letsch et al. have evaluated 124 cases scores were found to show compatibility.
treated with a 3.5-mm T plate through dorsal and volar
interventions, and have concluded that these implants are V. CONCLUSIONS
not suitable fixation devices in osteoporotic fractures and in
fractures with large defects due to induction of secondary The aims in the treatment of distal radius fractures are
reduction losses.20 providing anatomic restoration, maintenance of the
restoration until the fracture heals and allowing movement
Successful results have been reported with the use of aperture and function by starting early rehabilitation. Rigid
constant angle volar locked plates in the last decade.21,22,23 fixation is required particularly in patients with intaarticular
It was aimed to reduce radial shortness and prevent distal radius fractures aged 50 years and above because of
secondary reduction losses, maintain palmar tilt by reduced bone quality. Constant angle volar locked plates
restoration and reduce the need for grafting by supporting are suitable materials for the fixation of these fractures. The
the subchondral region with distal locked screws and pegs use of constant angle volar locked plates is associated with
located in the design of volar constant angle plates and by low complication rates.
placing a locked screw in the proximal of the fracture. With
the exception of our patient with a residual 3-mm stepping As a result of our study, the use of constant angle
in the joint, anatomic joint restoration was realized in all volar locked plates in the treatment of intra-articular distal
patients by relieving radial shortening and correcting radius fractures with low bone quality was shown to be an
palmar tilt, and none of our patients developed secondary effective treatment method. Reliability of this method was
reduction loss. Also, none our patients required grafting. supported by the absence of secondary reduction losses and
Another important point is that this plate system allows favorable joint movements and good clinical and radiologic
earlier movement. We monitored our patients without outcomes. We think that this method can be used as a

IJISRT24NOV129 www.ijisrt.com 763

Volume 9, Issue 11, November – 2024 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165 https://doi.org/10.38124/ijisrt/IJISRT24NOV129

reliable method in patients with low bone quality planned [16]. Hastings H 2nd, Leibovic SJ: Indications and
for surgery. techniques of open reduction. İnternal fixation of
distal radius fractures. Orthop Clin North Am
REFERENCES 1993,24(2):309-26.
[17]. Jupiter JB, Lipton H: The operatif treatment of
[1]. Jupiter JB. Fractures Of The Distal End Of The Intraarticular fractures of the distal radius. Clin
Radius. J Bone Joint Surg. Am. 1991; 73(A): 461- Orthop 1993,292:48-61.
469.. [18]. Arora R, Roth T, Kralinger F,Blauth M: A
[2]. Bradway JK, Amadio PC. Open reduction and Representative Case of Osteoporotic Distal Radius
internal fixation of displaced, comminuted Fracture. J Orthop Trauma 2008; 22: 116-120.
intraarticular fractures of the distal end of the radius. [19]. Lauber P, Pfeiffer KM: Open osteosynthesis of
J Bone Joint Surg 1989; 71(A): 839. distal radius fractures. Results and long-term follow-
[3]. Cooney WP,Linscheid RL, Dobyns JH: Fractures up. Unfallheilkunde 1984, 87(5):185-95.
and dislocation in wrist: Rockwood and Green’s [20]. Letsch R, Schmit-Neuerburg KP, Towfigh H:
Fractures in adults. 3 th edt. Rockwood CA, Green Indications and results of plate osteosynthesis of the
DP, Bucholz RW (Eds). JB Lippincott co. distal radius. Langenbecks Arch Chir 1984,
Newyork., Volume-I, Chapter 8. P:563-638. 364:363-8.
[4]. Knirk JL, Jupiter JB. Intra-articular fractures of the [21]. Willis AA, Kutsumi K, Zobitz ME, Cooney WP:
distal end of the radius in young adults. J Bone Joint Internal Fixation of Dorsally Displaced Fractures of
Surg 1986; 68-A(5): 647-59. the Distal Part of the Radius. A Biomechanical
[5]. Kozin S.H, Wood M.B. Early soft tissue Analysis of Volar Plate Fracture Stability. J Bone
complications after fractures of the distal part of the Joint Surg Am 2006, 88: 2411-2417.
radius. J Bone Joint Surg 1993 ; 75A: 144-153. [22]. Chung KC, Watt AJ, Kotsis SV, Margaliot Z:
[6]. Short WH, Palmer AK, Wernwr FW: A Treatment of Unstable Distal Radial Fractures with
biomechanical study of distal radial fractures. J the Volar Locking Plating System. J Bone Joint Surg
Hand Surg 1987; 12A: 529-534. Am 2006, 88: 2687-94.
[7]. Palmer AK. Fractures of the distal radius. Operative [23]. Taylor KF, Parks BG, Segalman KA:
Hand Surgery ; 3th edition. Churchill Livingstone, Biomechanical Stability of a Fixed-Angle Volar
1991;929-941. Plate Versus Fragment-Specific Fixation System:
[8]. La Fontaine M, Hardy D, Delience P.H. Stability Cyclic Testing in a C2-Type Distal Radius Cadaver
assessment of distal radius fractures. Injury 1989; Fracture Model. J Hand Surg 2006; 31A: 373-378.
20: 208-210. [24]. Orbay JL, Fernandez DL: Volar fixed-angle plate
[9]. Frykman G, Tooma GS, Boyka K, Henderson R. fixation for unstable distal radius fractures in the
Comparison of eleven external fixators for treatment elderly patient. J Hand Surg 2004; 29-A(1):96-102.
of unstable wrist fractures. J Hand Surg 1989; 14A :
247-254.
[10]. Fernandez DL: Geissler WB: Treatment of displaced
articuler fractures of the radius. J Hand
Surg1991,16-a(3):375-84.
[11]. Gartland JJ Jr, Werley WC. Evaluation of healed
Colles’ fractures. J Bone Joint Surg 1951; 33-A:
895-907.
[12]. Hanel DP. Treatment of intraartiküler fractures. In
Trumble TE (Ed) Hand Surgery Update. Hand,
Elbow and Shoulder 3rd ed. American Society for
Surgery of the Hand, Rosemont,2002; pp : 105-121.
[13]. Herrera M, Chapman CB, Roh M, Strauch RJ,
Rosenwasser MP: Treatment of unstable distal
radius fractures with cancellous allograft and
external fixation. J Hand Surg 1999, 24-A(6):1269-
78.
[14]. Jones KG: Colles’ fracture. J Arkansas Med Soc
1976; 73: 244-247
[15]. Weber S.C, Szabo R.M. Severely comminuted distal
radial fracture as an unsolved problem:
Complications associated with external fixation and
pins and plaster techniques. J Hand Surg 1986; 11A:
157-165.

IJISRT24NOV129 www.ijisrt.com 764