This Article Extract Full Text (PDF) Free Letters to the Editor: Submit a response Alert me when this article is cited Alert me when Letters to the Editor are posted Alert me if a correction is posted Services E-mail this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Rights and Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by TRUMBLE, T. E. Articles by BERGER, R. A. Search for Related Content PubMed Articles by TRUMBLE, T. E. Articles by BERGER, R. A. Social Bookmarking                   What's this?

Instructional Course Lectures, The American Academy of Orthopaedic Surgeons - Intra-Articular Fractures of the Distal Aspect of the Radius*

THOMAS E. TRUMBLE, M.D., SEATTLE, RANDALL CULP, M.D., PHILADELPHIA, PENNSYLVANIA, DOUGLAS P. HANEL, M.D.#, SEATTLE, WASHINGTON, WILLIAM B. GEISSLER, M.D.**, JACKSON, MISSISSIPPI and RICHARD A. BERGER, M.D., ROCHESTER, MINNESOTA

An Instructional Course Lecture, The American Academy of Orthopaedic Surgeons

	Introduction

Top Introduction Anatomy of the Articular... Effect of Intra-Articular... Radiographic Studies Classification of Intra... Operative Approaches Associated Fractures of the... Associated Injuries of the... External Fixation Devices Advantages and Disadvantages of... Rehabilitation after Intra... Results of Treatment Overview References

 
High-energy injuries frequently cause shear and impacted fractures of the articular surface of the distal aspect of the radius with displacement of the fracture fragments. Even fractures with a small amount of displacement can result in degeneration of the joint, causing pain and stiffness of the wrist. The fracture pattern, degree of displacement of the fracture fragments, and stability of the fracture determine whether operative treatment rather than immobilization with a cast is needed. The options for operative treatment include open reduction and internal fixation, to realign the articular surface of the radius; external fixation, for fractures with comminution of the metaphysis of the radius, to maintain the length of the radius; and bone-grafting, to provide support for the articular surface of impacted fractures.

	Anatomy of the Articular Interface between the Distal Aspects of the Radius and Ulna and the Carpus

Top Introduction Anatomy of the Articular... Effect of Intra-Articular... Radiographic Studies Classification of Intra... Operative Approaches Associated Fractures of the... Associated Injuries of the... External Fixation Devices Advantages and Disadvantages of... Rehabilitation after Intra... Results of Treatment Overview References

 
The articular surface of the distal aspect of the radius tilts 21 degrees in the anteroposterior plane and 5 to 11 degrees in the lateral plane (Fig. 1). The dorsal cortical surface of the radius thickens to form the Lister tubercle as well as osseous prominences that support the extensors of the wrist in the second dorsal compartment. A central ridge divides the articular surface of the radius into a scaphoid facet and a lunate facet (Fig. 2). The triangular fibrocartilage extends from the rim of the sigmoid notch of the radius to the ulnar styloid process. These areas of thickening of the metaphyseal cortex provide segments of bone that reliably resist fracture and can support internal fixation when indicated. Only the brachioradialis tendon inserts onto the distal aspect of the radius; the other tendons of the wrist pass across the distal aspect of the radius to insert onto the carpal bones or the bases of the metacarpals. In addition to the extrinsic ligaments of the wrist, the scapholunate interosseous and lunotriquetral interosseous ligaments maintain the scaphoid, lunate, and triquetrum in a smooth articular unit that comes into contact with the distal aspect of the radius and the triangular fibrocartilage complex. Because of the different areas of bone thickness and density, the fracture patterns tend to propagate between the scaphoid and lunate facets of the distal aspect of the radius (Fig. 3). The degree, direction, and extent of the applied load may cause coronal or sagittal splits within the lunate or scaphoid facet^26-28.

View larger version (32K): [in this window] [in a new window]   Fig. 1 Schematic drawing showing the method for measurement of palmar tilt, distal radial tilt, and ulnar variance on posteroanterior and lateral radiographs of the distal aspects of the radius and ulna.

View larger version (28K): [in this window] [in a new window]   Fig. 2 Schematic drawing showing the distal articular surface of the radius, which is divided into the lunate and scaphoid facets.

View larger version (29K): [in this window] [in a new window]   Fig. 3 Schematic drawing showing how fracture lines frequently propagate between the scaphoid and lunate facets and extend dorsally adjacent to, but not through, the thicker bone that forms the Lister tubercle.

	Effect of Intra-Articular Fracture-Healing on Articular Congruity

Top Introduction Anatomy of the Articular... Effect of Intra-Articular... Radiographic Studies Classification of Intra... Operative Approaches Associated Fractures of the... Associated Injuries of the... External Fixation Devices Advantages and Disadvantages of... Rehabilitation after Intra... Results of Treatment Overview References

 
Knirk and Jupiter¹⁹ reported that 2.0 millimeters or more of displacement of the distal radial articular fragments resulted in traumatic osteoarthrosis; however, other investigators^9,34,35 found that displacement of even 1.0 millimeter resulted in pain and stiffness of the wrist. In animal models of articular fractures, the cartilage remodeled to provide a congruent articular surface when displacement of the articular surface was less than 1.0 millimeter, whereas a step-off of 1.0 millimeter or more did not cause appreciable remodeling^24,36. In one of these animal models—an articular fracture of the tibial plateau in sheep, in which the dimensions of the cartilage and bone are similar to those of the human wrist—the cartilage on the depressed segment of the tibial plateau expanded over time, whereas the cartilage on the non-depressed segment of the fracture (the so-called high side of the tibial plateau) became compressed with resultant bending of the unloaded collagen fibers (Figs. 4 and 5)³⁶. The cartilage on the high side of the fracture formed a shelf, which overlapped with the low side (Fig. 6).

View larger version (175K): [in this window] [in a new window]   Figs. 4, 5, and 6: Undecalcified specimen obtained from a sheep twelve weeks after a tibial osteotomy. Fig. 4: The fracture is still evident, with ongoing bone-remodeling. The low side (the depressed segment of the fracture), which has been unloaded by the osteotomy, demonstrates chondrocyte hypertrophy and expansion of the cartilage surface. Compared with sites distant to the osteotomy, the cartilage on the high side (the non-depressed segment of the fracture) is reduced in overall thickness by approximately 20 per cent (Masson trichrome, x 200).

View larger version (122K): [in this window] [in a new window]   Fig. 5 High-power scanning electron micrograph showing the collagen fibrils on the high side of the tibial osteotomy. The arrows highlight the bending of the collagen fibrils. Bar = 100 micrometers.

View larger version (111K): [in this window] [in a new window]   Fig. 6 Low-power scanning electron micrograph showing an overview of the cartilage flap produced by the response of the articular surface to the osteotomy. The lower arrow demonstrates the fracture line (FX). Bar = one millimeter.

	Radiographic Studies

Top Introduction Anatomy of the Articular... Effect of Intra-Articular... Radiographic Studies Classification of Intra... Operative Approaches Associated Fractures of the... Associated Injuries of the... External Fixation Devices Advantages and Disadvantages of... Rehabilitation after Intra... Results of Treatment Overview References

 
The initial standard posteroanterior, lateral, and oblique radiographs of the distal radial injury are very important because they show the extent and direction of the initial displacement. Traction radiographs assist the surgeon in determining whether the fracture is intra-articular or extra-articular. Repeat radiographs should be made after the reduction in order to help identify the residual deformity and the degree of comminution.

Plain and computerized tomographic scans, made in the sagittal and coronal planes oriented along lines parallel to the shaft of the radius, are extremely useful in helping to determine if an operation is needed when the amount of displacement is unclear or when the fracture pattern is difficult to visualize on plain radiographs (Figs. 7 and 8). Computerized tomography is strongly recommended to help define the intra-articular fracture pattern, especially in association with die-punch fractures (those with a central depression of the articular surface), volar rim fractures, and fractures involving the scaphoid facet, which can be more difficult to visualize. Computerized tomography also is helpful in determining the operative approach; fractures of the lunate facet and the radial styloid process may have volar or dorsal displacement that is not evident on plain radiographs, especially if the wrist is in a cast. Radiographs made at the time of the initial injury are important in helping to determine the direction of displacement of the fracture. Traction radiographs are useful in determining the accuracy of reduction. Final displacement is measured on radiographs or computerized tomographic scans made after the reduction.

View larger version (175K): [in this window] [in a new window]   Fig. 7 A die-punch fracture (arrow) of the scaphoid facet is barely visible on this posteroanterior radiograph.

View larger version (95K): [in this window] [in a new window]   Fig. 8 Computerized tomographic scan, made in the sagittal plane, clearly showing the die-punch fracture (arrow) of the scaphoid facet with three millimeters of depression that would have been easy to overlook on plain radiographs.

	Classification of Intra-Articular Fractures of the Distal Aspect of the Radius

Top Introduction Anatomy of the Articular... Effect of Intra-Articular... Radiographic Studies Classification of Intra... Operative Approaches Associated Fractures of the... Associated Injuries of the... External Fixation Devices Advantages and Disadvantages of... Rehabilitation after Intra... Results of Treatment Overview References

 
A number of authors have proposed systems for the classification of fractures of the distal aspect of the radius. Many of these systems combine intra-articular and extra-articular fractures^{4-6,10,15,17,23,25,26,29,30,33}; however, studies have not revealed substantial interobserver agreement among fracture types determined with use of the Frykman¹⁰, Mayo^4-6, Melone^26-28, or AO^23,29,30 classification system. Significant agreement (p < 0.05) among physicians' classifications with use of the AO system, based on reviews of the radiographs, was achieved only after the classification was reduced from twenty-seven detailed descriptions of fractures to three major fracture types (extra-articular, intra-articular with part of the metaphysis intact, and intra-articular fractures with complete disruption of the metaphysis); this simplification of the system limited its usefulness^1,23. Interobserver agreement for the other classification systems was poor¹.

Frykman Classification¹⁰
This classification focuses on the intra-articular extension of the fracture and the involvement of the ulnar styloid process, implying that the involvement of these structures contributes to the seriousness of the fracture (Fig. 9). However, it appears to be particularly difficult to determine exactly what fracture line extends where. Many fracture lines extend near the corner of a joint surface, and the decision regarding whether such a line involves the joint is often arbitrary. As one of the earliest systems for the classification of fractures of the distal aspect of the radius, this system drew attention to the distal radioulnar joint. Because displaced and non-displaced fractures are considered equally important, this system cannot be used to predict outcome as accurately as other systems.

View larger version (19K): [in this window] [in a new window]   Fig. 9 The Frykman classification system10. The fractures are divided into eight categories according to whether they extend into the articular surface and whether there is an associated fracture of the distal aspect of the ulna.

Mayo Classification^4-6
This classification system resembles that of Frykman in that the emphasis is on the extent of articular involvement (Fig. 10), but it introduces an additional variable: that of distinguishing the extension of the fracture into either the radioscaphoid or the radiolunate joint. The expected increase in variability that this might cause is offset by the fewer general categories, as the ulnar styloid process is ignored in the Mayo system.

Fig. 10 The Mayo classification system4-6. The fractures are divided into groups according to whether they are extra-articular or intra-articular. Intra-articular fractures are divided further according to the extent of fragmentation. S = scaphoid, L = lunate, RS = radial styloid fragment, D = dorsal, and V = volar. (Reproduced, with modification, from: Missakian, M. L.; Cooney, W. P.; Amadio, P. C.; and Glidewell, H. L.: Open reduction and internal fixation for distal radius fractures. J. Hand Surg., 17A: 745–755, 1992. Reprinted with permission.)

Melone Classification²⁸
This classification system is based on the belief that the condition of the medial portion of the articular column of the distal aspect of the radius is important for determining the prognosis and the options for treatment (Fig. 11). This system was one of the first to provide an accurate description of the way in which most fractures propagate through the articular surface of the radius. By definition, this classification is relevant only to intra-articular fractures. The difficulty involved with the use of this system lies in the fact that observers often disagree about whether or not the fracture extends into the radiocarpal joint. The importance of the medial articular facet in this system resulted in forty-four (88 per cent) of fifty fractures in one study¹ being placed into class I or II; fractures that extended into the scaphoid facet were impossible to classify.

Fig. 11 The Melone classification system28. The fractures are divided into groups according to the amount of displacement, the pattern of the fracture, the degree of volar metaphyseal comminution, and the extension of the fracture into the diaphysis. 1 = radial shaft, 2 = radial styloid fragment, 3 = volar ulnar fragment, and 4 = dorsal ulnar fragment. (Reprinted, with permission, from: Melone, C. P., Jr.: Distal radius fractures: patterns of articular fragmentation. Orthop. Clin. North America, 24: 241, 1993.)

Jupiter and Fernandez Classification¹⁷
This classification system is a modification of the AO system that takes into account the mechanism of injury, including bending, shear, compression, and avulsion (traction). It also includes complex fractures that result from a combination of at least two of these mechanisms of injury. Jupiter and Fernandez expanded the AO classification to include avulsion fractures caused by radiocarpal dislocation and high-velocity combined injuries. This is an excellent system that includes information on fracture displacement and the number of fracture fragments. On the basis of the main fracture type and the direction of displacement, the classification consists of approximately twenty-five subtypes. Because this is a newer system, scant data are available for comparing the ease and accuracy of its use with those of other classification systems.

AO Classification^23,29,30
The AO classification system, which comprises twenty-seven categories, is the most detailed. It also is the most inclusive, making it useful for broad anatomical categorization of large numbers of fractures for trauma registries even though it is cumbersome and lacks sufficient focus for use in clinical decision-making. Andersen et al.¹ found significant (p < 0.05) agreement between reviewers when this system was reduced to three classifications: extra-articular, partial articular, and complex articular. We surveyed a group of six orthopaedic surgeons and residents with regard to their ability to categorize only intra-articular fractures of the distal aspect of the radius with use of a slightly modified version of the AO classification. Type B1 comprised fractures of the radial styloid process; type B2, fractures of the dorsal rim; type B3, fractures of the volar rim; type B4, die-punch fractures; and type C, complex fractures as a combined group. We added type B4 as there was no convenient way, with use of the original AO system, to classify die-punch fractures (Fig. 12). Because fractures with at least three fragments that involve the entire articular surface necessitate such individualized treatment, we included these fractures together as a class, separated only into those with predominantly dorsal displacement and those with predominantly volar displacement as seen on the initial radiographs. We considered only displaced intra-articular fractures because non-displaced fractures generally remain as a unit, similar to extra-articular fractures. With the addition of computerized tomographic scans and the instruction that only fractures with displacement of 1.0 millimeter or more should be included, the six physicians accurately classified eighteen of twenty intra-articular fractures of the distal aspect of the radius.

View larger version (39K): [in this window] [in a new window]   Fig. 12 Modification of the AO classification of partial articular fractures of the distal aspect of the radius to include die-punch fractures of the scaphoid and lunate facets (subtype B4). With these fractures, a portion of the articular surface remains in continuity with the metaphysis, providing some stability even if there is loss of congruity.

Partial Intra-Articular Fractures (AO Type B)
Shear injuries cause fractures of the volar and dorsal rims, fractures of the radial styloid process, and medial corner fractures, whereas impaction injuries cause die-punch fractures (Fig. 12). These injuries may include additional, smaller fractures or non-displaced fractures that do not necessitate separate treatment, but the feature that is common to all is sparing of a portion of the articular surface that remains in continuity with the metaphysis; this adds greatly to the stability of the fracture. This simplified classification system provides guidelines for treatment (Table I).

Complex Articular Fractures
These injuries, which generally are higher-energy fractures than type-B fractures, often involve a combination of shear and impaction (Fig. 13). None of the articular surface remains in continuity with the metaphysis. The fractures can be classified simply as those with a dorsal pattern, those with a volar pattern, or direct impaction fractures with or without comminution. Although the fracture pattern can involve the so-called T or Y-split of the articular surface in primarily the sagittal or coronal plane, most of these complex fractures involve a component of both (Table II).

View larger version (40K): [in this window] [in a new window]   Fig. 13 Complex (type-C) fractures, described in the AO classification, have been combined into a single group. The notations indicate whether the displacement was dorsal or volar or whether the fracture was severely impacted from an axial load that caused comminution of both the dorsal and volar portions of the metaphysis or diaphysis, or both. All of these fractures involve complete separation of the metaphysis from the articular surface, making them highly unstable. MC = metacarpal and R = radius.

Limits of Classification Systems
Some orthopaedists, especially those in training programs, have expressed concern that more time is spent in trying to memorize classification systems than in attempting to truly understand the fracture mechanics or the factors that have a major bearing on prognosis and treatment. A classification system, like any tool, has limitations. These systems are important when the diagnosis and treatment alternatives are being considered. A system will be sustained if it can be used to communicate the relative severity of the fracture and to describe the corresponding treatment options.

In fairness to the authors of the classification systems, it should be noted that the original systems were developed and the subsequent comparisons between them were performed without the use of computerized tomography, which has become particularly important for the diagnosis of intra-articular fractures. None of these authors expected their systems to provide answers to all of the questions regarding treatment and prognosis, and each system has added to our knowledge of these troublesome injuries. Most of the systems focus on the mechanism of injury or the geometry of the fracture. Unfortunately, most of the classifications do not correspond directly to the fracture stability³⁸.

	Operative Approaches

Top Introduction Anatomy of the Articular... Effect of Intra-Articular... Radiographic Studies Classification of Intra... Operative Approaches Associated Fractures of the... Associated Injuries of the... External Fixation Devices Advantages and Disadvantages of... Rehabilitation after Intra... Results of Treatment Overview References

 
Although there are many different operative approaches to the distal aspect of the radius, often based on the different intervals between the tendons, more than 90 per cent of the time we have relied on three main approaches for open reduction and internal fixation of a fracture of the distal aspect of the radius.

Dorsal Approach
A longitudinal midline incision over the dorsum of the wrist provides a useful and practical exposure of the dorsum of the radius (Figs. 14 and 15)³⁵. The extensor pollicis longus is identified distally and traced to the third dorsal compartment. This compartment usually is distended with fracture hematoma, as most fractures that split the scaphoid and lunate facets extend into the floor of the third compartment, avoiding the stronger and thicker Lister tubercle. The third and fourth compartments are sharply elevated off the dorsal aspect of the capsule, with both the tendon compartments and the dorsal capsular ligaments, including the dorsal radiotriquetral ligament, kept intact. This avoids the need to repair the extensor retinaculum and related compartments later, which can be difficult in the presence of swelling of the tendons and the joint capsule. If the dorsal retinaculum is divided and not repaired, the tendons of the fingers and wrist will bowstring with extension of the wrist.

View larger version (42K): [in this window] [in a new window]   Figs. 14 and 15: The dorsal midline approach. EPL = extensor pollicis longus, ECRB = extensor carpi radialis brevis, and ECRL = extensor carpi radialis longus. Fig. 14: The third dorsal compartment is released, and the fourth dorsal compartment is elevated off of the wrist capsule.

View larger version (39K): [in this window] [in a new window]   Fig. 15 The capsule, including the dorsal radiotriquetral ligament (DRT), is incised near its insertion onto the dorsal rim of the radius and then is reflected distally to expose the radiocarpal joint. EPL = extensor pollicis longus.

After bone-grafting and placement of the Kirschner wires, the reduction is confirmed with fluoroscopy. The Kirschner wires are cut flush with the metaphyseal surface to avoid irritating the extensor tendons. The capsule is sutured carefully to avoid any tightening that might decrease flexion of the wrist. The second and fourth extensor compartments are loosely reapproximated, but the extensor pollicis longus is left out of its compartment. The oblique course of the extensor pollicis longus prevents it from bowstringing even though the sheath of the third compartment is not repaired.

Limited Dorsal Approach (without Arthrotomy)
The limited approach does not involve an arthrotomy and requires a skin incision of 3.0 centimeters or less. This approach is practical for patients who have an isolated die-punch fracture and for those in whom the articular fracture can be completely reduced in a closed manner or with manipulation with use of Kirschner wires or small elevators as joysticks to impale or lever the fracture fragments into position¹². The decision to perform a limited open reduction rather than an open reduction with an arthrotomy is based on the surgeon's evaluation of the reduction under fluoroscopy. Because the approach can easily be extended and an arthrotomy can subsequently be performed, little is lost by choosing the limited approach initially.

The radial styloid process is stabilized to the distal part of the diaphysis with 0.045-inch (1.143-millimeter) smooth Kirschner wires, placed percutaneously through the dorsal aspect of the radial styloid process through a soft-tissue protector sleeve that minimizes injury to the branches of the radial sensory nerve as well as the radial artery. The radial styloid fragment becomes the landmark for the subsequent realignment of the remaining displaced articular fragments. Under fluoroscopy, impacted fragments can be elevated with use of Freer elevators, dental probes, or Kirschner wires as joysticks. After the fragment has been restored to its anatomical position, it can be secured with 0.035-inch (0.889-millimeter) or 0.045-inch (1.143-millimeter) smooth Kirschner wires that have been introduced through the radial styloid process horizontally and dorsally, directly entering the subchondral bone of the fragment of the lunate facet. Similarly, depressed segments of the scaphoid facet can be stabilized after reduction with use of smooth Kirschner wires, placed from the dorsal medial corner of the radius into the subchondral bone of the distal fragment.

This approach allows for the placement of a small (2.7 or 3.5-millimeter) buttress plate to provide support to the reconstructed dorsal rim. Supplemental cancellous bone-grafting is added when a metaphyseal defect is present.

Volar Radial Approach
The most commonly used volar approach is between the radial artery and the flexor carpi radialis (Fig. 16). By extending the incision distally along the border of the thenar eminence, the flexor carpi radialis can be exposed distal to the flexion crease of the distal aspect of the wrist. The flexor carpi radialis is released from its attachments to the trapezium; this allows it to be retracted, along with all of the flexor tendons to the digits, to expose the entire volar rim, the sigmoid notch, and the distal radioulnar joint. Elevation of the pronator quadratus from the distal aspect of the radius provides the necessary exposure for the placement of a buttress plate. Large volar rim fragments can be stabilized with a buttress plate, but smaller fragments must be stabilized separately with small Kirschner wires before application of the buttress plate (Fig. 17).

View larger version (43K): [in this window] [in a new window]   Figs. 16 and 17: The volar radial approach. Fig. 16: The approach is through the interval between the flexor carpi radialis (FCR) and the radial artery. R = radius and U = ulna.

View larger version (34K): [in this window] [in a new window]   Fig. 17 Fractures of the volar rim can be stabilized with use of a contoured buttress plate.

Volar Ulnar Approach for Fractures of the Volar Ulnar Corner
A longitudinal incision along the radial border of the flexor carpi ulnaris is an excellent approach for fractures of the volar ulnar corner of the distal aspect of the radius (Fig. 18). The incision can be extended distally with a release of the carpal tunnel. The ulnar nerve and artery are identified deep to the flexor carpi ulnaris tendon. The flexor tendons can be retracted radially to expose the volar rim of the distal aspect of the radius and the distal radioulnar joint. The origin of the pronator quadratus on the ulna is incised and is reflected radially to expose the displaced fracture of the rim. The fragment is reduced with use of the fracture interdigitations to correct alignment because neither the radial nor the ulnar operative approach to the volar aspect of the radius allows visualization of the articular surface. A small 2.7-millimeter buttress plate frequently provides adequate stabilization.

View larger version (50K): [in this window] [in a new window]   Fig. 18 The volar ulnar approach, which is through the interval between the flexor tendons to the fingers and the ulnar nerve and artery. R = radius and U = ulna.

Combined Volar and Dorsal Approach
The combined approach is utilized for only approximately 10 per cent of high-energy complex intra-articular fractures—for example, for a displaced fracture of the volar rim combined with a dorsal die-punch injury and an impacted scaphoid or lunate facet. We recommend that the volar rim be stabilized first, as described earlier, followed by use of a dorsal open or arthroscopic approach to elevate the depressed fragments. Bone-grafting and internal fixation with Kirschner wires or a dorsal buttress plate are added to stabilize articular fractures that have been elevated.

These high-energy injuries often are associated with extensive swelling, and the operation should be performed after the swelling has decreased, several days after the initial injury. Closure of the volar incision before the incision for the dorsal approach is made helps to minimize the tissue-swelling and wound separation that render wound closure without excessive tension difficult.

Arthroscopically Guided Reduction
In order to minimize bleeding from the fracture sites, which obscures the arthroscopic field, the operation is performed at least three days after the injury. A compressive elastic bandage is wrapped around the forearm to retard extravasation of fluid into the muscle compartments during arthroscopy. The wrist is suspended in a traction tower, and ten pounds (4.5 kilograms) of traction is applied to the index and long fingers through finger-traps. An inflow cannula is inserted through a portal located ulnar to the extensor carpi ulnaris tendon (the 6U portal), and the joint is distended. A 20-gauge needle is inserted between the extensor pollicis longus tendon and the extensor digitorum communis tendons (the dorsal 3,4 portal). The needle should pass easily into the joint without impinging on either the carpal bones or the distal end of the radius, to ensure that the arthroscopic cannula will not be inserted into a fracture plane or an intercarpal joint, such as the scapholunate or lunotriquetral joint. The skin then is incised over the dorsal 3,4 portal by pulling it against the tip of a number-11 scalpel blade, and a blunt arthroscopic cannula is inserted to prevent injury of the cutaneous nerves and dorsal veins. A small-joint arthroscope, 2.7 millimeters in diameter, is inserted through the cannula into the dorsal 3,4 portal (Fig. 19).

View larger version (38K): [in this window] [in a new window]   Fig. 19 The method for an arthroscopically guided reduction. The arthroscope is placed in the dorsal 3,4 portal, and a probe is inserted in the dorsal 4,5 portal. The radial styloid fragment is stabilized with percutaneous Kirschner wires.

The fracture is reduced in a manner similar to the limited open approach. Smooth Kirschner wires are inserted percutaneously through the radial styloid process into the distal aspect of the diaphysis to provide the stable framework necessary for securing the remaining articular fragments. A small fragment can be elevated by means of a blunt trocar beneath the fracture fragment with use of the dorsal 4,5 portal or by means of a large (0.11-inch [2.79-millimeter]) Kirschner wire placed percutaneously into the metaphyseal bone proximal to the articular surface of the fragment. The Kirschner wire can be used as a joystick to elevate and reduce the fracture fragment under arthroscopic control. Volar or dorsal rim fractures initially are stabilized with a limited approach with use of a buttress plate. Without visualization of the joint surface, the fracture is reduced with use of only the osseous landmarks of the interdigitating fracture lines. The accuracy of the reduction is confirmed with arthroscopy and is adjusted as necessary.

	Associated Fractures of the Ulnar Styloid Process

Top Introduction Anatomy of the Articular... Effect of Intra-Articular... Radiographic Studies Classification of Intra... Operative Approaches Associated Fractures of the... Associated Injuries of the... External Fixation Devices Advantages and Disadvantages of... Rehabilitation after Intra... Results of Treatment Overview References

 
Small avulsion fractures of the ulnar styloid process (type 2A¹⁶) do not necessitate additional treatment. The AO classification system includes six different types of fractures of the ulnar styloid process that are associated with fractures of the distal aspect of the radius (Fig. 20). Fractures near the base of the ulnar styloid process (type 2B¹⁶) include the entire insertion of the ulnar border of the triangular fibrocartilage complex; these fractures may cause instability of the distal radioulnar joint, necessitating some form of reduction and internal fixation. Injuries involving the triangular fibrocartilage (type 1¹⁶) and complex fractures of the ulnar diaphysis or the distal articular surface of the ulna (types 3, 4, and 5¹⁶) are beyond the scope of this Instructional Course Lecture. Displaced fractures near the base of the ulnar styloid process (type 2B¹⁶) and fractures involving the entire distal articular surface of the ulna (type 5¹⁶) cause displacement and deformity of the triangular fibrocartilage complex. Arthroscopy has demonstrated a high rate of involvement of the triangular fibrocartilage complex in association with intra-articular fractures of the distal aspect of the radius¹⁴.

View larger version (29K): [in this window] [in a new window]   Fig. 20 Modification of the AO classification of fractures of the distal aspect of the ulna. Type-2 fractures are divided into small avulsion fractures (type 2A) and fractures near the base of the ulnar styloid process (type 2B) that cause instability of the triangular fibrocartilage complex and, consequently, the distal radioulnar joint.

View larger version (36K): [in this window] [in a new window]   Fig. 21 The screw-fixation and tension-band-wire techniques can be used to stabilize fractures of the ulnar styloid process.

	Associated Injuries of the Intercarpal Ligaments or the Triangular Fibrocartilage Complex

Top Introduction Anatomy of the Articular... Effect of Intra-Articular... Radiographic Studies Classification of Intra... Operative Approaches Associated Fractures of the... Associated Injuries of the... External Fixation Devices Advantages and Disadvantages of... Rehabilitation after Intra... Results of Treatment Overview References

 
Recent advances in arthroscopically assisted reduction of intra-articular fractures have made it possible to categorize soft-tissue injuries of the wrist joint that are associated with these fractures^13,22,39,41. In previous studies, forty-one (68 per cent) of sixty patients had soft-tissue injuries that included the triangular fibrocartilage complex in twenty-six, the scapholunate interosseous ligament in nineteen, and the lunotriquetral interosseous ligament in nine^11,13,14. (Thirteen patients had two injuries each.) Intercarpal injuries were identified most frequently in association with fractures involving the lunate facet of the distal articular surface of the radius.

Tears of the intercarpal ligaments were classified by Geissler et al.^13,14. Grade-I tears involve attenuation or hemorrhage of an interosseous ligament as seen from the radiocarpal space, with no incongruency of the carpal alignment in the mid-carpal space. Grade-II tears involve attenuation or hemorrhage of an interosseous ligament as seen from the radiocarpal space, with incongruency or step-off between the scaphoid and the lunate as seen from the mid-carpal space. There may be a slight gap, less than the width of a probe, between the carpal bones. Grade-III tears are associated with incongruency or step-off of the carpal alignment as seen from both the radiocarpal and the mid-carpal space. A probe can be placed through a gap between the carpal bones. Grade-IV tears are associated with incongruency or step-off of the carpal alignment as seen from both the radiocarpal and the mid-carpal space as well as with gross instability on manipulation. A 2.7-millimeter arthroscope can be passed through the gap between the carpal bones.

Of the nineteen patients who had an injury of the scapholunate ligament in the series of Geissler et al.¹⁴, ten had a grade-II injury; seven, a grade-III injury; and two, a grade-IV injury. Twenty-five patients had a fracture of the ulnar styloid process. Sixteen of them had a lesion of the triangular fibrocartilage complex; the lesion was ulnar type B or radial type D in fourteen^14,31.

	External Fixation Devices

Top Introduction Anatomy of the Articular... Effect of Intra-Articular... Radiographic Studies Classification of Intra... Operative Approaches Associated Fractures of the... Associated Injuries of the... External Fixation Devices Advantages and Disadvantages of... Rehabilitation after Intra... Results of Treatment Overview References

 
The use of an external fixation device is the only practical means of overcoming the force of the muscles of the forearm that pull comminuted distal radial fractures into a collapsed, shortened position. Because the loss of radial length is associated with a poorer functional outcome, an external fixation device can often be an important part of the treatment of intra-articular fractures of the distal aspect of the radius^34,35. In many instances of severe comminution of the metaphysis, the surgeon can reconstruct the articular surface but cannot stabilize it to the shaft of the radius. An external fixation device can allow alignment of the articular surface with the shaft without reliance on support from the metaphysis.

A large variety of devices are available for external fixation of fractures of the distal aspect of the radius. All involve distraction across the wrist joint with placement of pins in the radius and the metacarpals (Fig. 22). The proximal pins are placed into the junction of the distal and middle thirds of the radius, near the insertion of the pronator teres muscle. Small incisions are made along the radial border of the forearm. The drill-guide is placed between the extensor carpi radialis longus and the extensor carpi radialis brevis so that the sensory branch of the radial nerve will be protected as it exits between the extensor carpi radialis longus and the brachioradialis. The partially threaded pins can be inserted perpendicular to the shaft of the radius, unlike the smooth pins used with older external fixation devices, which had to be placed at oblique angles to one another. Placement of the pins at right angles to the radius and the metacarpals decreases skin tension and irritation. Predrilling of the pin sites (with use of a 2.0-millimeter drill-bit for a 2.5-millimeter pin, for example) facilitates placement of the pins in hard cortical bone. The metacarpal pins also are inserted at right angles to the bone after the soft tissues have been spread to avoid injury to the smaller branches of the radial sensory nerve and the first dorsal interosseous muscle. The first pin is placed at the junction of the base and shaft of the index metacarpal. The second pin is placed near the middle or distal metaphyseal flare of the index metacarpal.

View larger version (50K): [in this window] [in a new window]   Fig. 22 The partially threaded pins for the external fixation device are inserted in the interval between the extensor carpi radialis longus (ECRL) and the extensor carpi radialis brevis (ECRB) in order to protect the sensory branch of the radial nerve. MC II = second metacarpal.

	Advantages and Disadvantages of Open Reduction, Arthroscopically Aided Reduction, and Limited Open Reduction

Top Introduction Anatomy of the Articular... Effect of Intra-Articular... Radiographic Studies Classification of Intra... Operative Approaches Associated Fractures of the... Associated Injuries of the... External Fixation Devices Advantages and Disadvantages of... Rehabilitation after Intra... Results of Treatment Overview References

 
Internal fixation accompanied by arthroscopically aided reduction and limited open reduction has the advantage of minimizing capsular scarring, thereby reducing stiffness of the wrist after fracture-healing. To our knowledge, there are no data, retrospective or prospective, demonstrating that arthroscopically assisted reduction improves patient outcome. Arthroscopy does offer better visualization of soft-tissue injuries and the potential for treatment with repair or débridement of the triangular fibrocartilage complex. However, arthroscopic repair of the interosseous ligaments is limited to percutaneous pinning to stabilize the carpal bones, whereas an open approach provides an opportunity to suture detached ligaments to the carpal bones.

In a prospective trial of 240 patients who were randomized to treatment with either limited or standard open reduction and internal fixation, limited open reduction resulted in an average of 20 degrees (15 per cent) more motion²⁰. However, in 20 per cent of the 120 patients who had limited open reduction, the procedure failed to restore a congruent articular surface and the surgeon had to perform an open reduction. Although limited open reduction does not provide an opportunity to assess soft-tissue injury within the wrist because the reduction is guided by fluoroscopy, the data suggest that limited open reduction and internal fixation, when used successfully, improves patient outcome.

	Rehabilitation after Intra-Articular Fractures of the Distal Aspect of the Radius

Top Introduction Anatomy of the Articular... Effect of Intra-Articular... Radiographic Studies Classification of Intra... Operative Approaches Associated Fractures of the... Associated Injuries of the... External Fixation Devices Advantages and Disadvantages of... Rehabilitation after Intra... Results of Treatment Overview References

 
Distal radial fractures can be categorized as stable, as AO type B (those with a portion of the articular surface in continuity), as AO type C (those with minimum comminution), or as unstable AO type C (those with comminution necessitating an external fixation device to maintain distraction).

Patients who have a stable fracture, which may be treated without an external fixation device, must wear a splint for four to six weeks until the edema has resolved. They can begin an active range-of-motion program, with a removable splint, during the first two to four weeks, assuming that no displacement occurs. It is essential that radiographs be made during this time-period. During the first two weeks, the patients also start an active and passive program for motion of the digits and rotation of the forearm. They then progress to a passive range-of-motion program, including exercises for the wrist (which was initially in a splint), for another two weeks, followed by resistive exercises for strengthening.

The goal for patients who do not have painful rotation is to regain a total of 120 degrees of pronation and supination. If this goal is not met within eight to ten weeks, a program of dynamic supination and pronation splinting is begun (Fig. 23). Patients who fail to regain 100 degrees of flexion and extension of the wrist are managed with a program of static progressive splinting (Fig. 24).

View larger version (100K): [in this window] [in a new window]   Fig. 23 Photograph of a splint that allows pronation-supination to improve rotation of the forearm when 120 degrees of combined motion has not been regained within eight to ten weeks after the fracture.

View larger version (91K): [in this window] [in a new window]   Fig. 24 Photograph of a static progressive splint, used for patients who do not regain 100 degrees of flexion and extension of the wrist within eight to ten weeks after the fracture.

	Results of Treatment

Top Introduction Anatomy of the Articular... Effect of Intra-Articular... Radiographic Studies Classification of Intra... Operative Approaches Associated Fractures of the... Associated Injuries of the... External Fixation Devices Advantages and Disadvantages of... Rehabilitation after Intra... Results of Treatment Overview References

 
Part of the problem in comparing the clinical outcomes of different types of treatment of fractures of the distal aspect of the radius results from the use of multiple classification and evaluation systems. Even when investigators have used the same system, it is difficult to determine if fractures with similar degrees of displacement and fragmentation have been included^{3-9,16,19,34,35}. A marked decrease in function was noted in association with fractures with more than 1.0 millimeter of displacement and more than five fragments^34,35. Patients who had additional soft-tissue injuries and carpal fractures had a worse functional result. In one study³⁵, severe AO type-C2 and C3 fractures had been treated with open reduction and internal fixation and the patients regained an average of thirty-one (69 per cent) of forty-five kilograms of grip strength, 120 degrees of combined flexion and extension of the wrist, 41 degrees of combined radial and ulnar deviation, and 140 degrees of combined pronation and supination. The 301-degree combined motion of the wrist and rotation of the forearm corresponded to 75 per cent of that on the contralateral side.

Other than a comprehensive study of volar rim fractures¹⁸, there are no reports, to our knowledge, describing the results of treatment of two-part fractures. In that study, the combined motion of the wrist averaged 90 per cent of that on the contralateral side and only nine of forty-nine patients had osteoarthrosis at an average of fifty-one months after treatment. Forty-seven of the forty-nine patients had a grip strength that was within 10 per cent of that on the contralateral side. The most important factors associated with a poor or fair result were osteoarthrosis as seen on the early postoperative radiographs and the reversal of normal volar tilt.

	Overview

Top Introduction Anatomy of the Articular... Effect of Intra-Articular... Radiographic Studies Classification of Intra... Operative Approaches Associated Fractures of the... Associated Injuries of the... External Fixation Devices Advantages and Disadvantages of... Rehabilitation after Intra... Results of Treatment Overview References

 
Intra-articular fractures of the distal aspect of the radius are a heterogeneous group of injuries with different fracture patterns. The existing classification systems are helpful for describing the fractures but not for assessing their stability or for deciding which operative approach to use. Patients who have a fracture with at least 1.0 millimeter of displacement of the articular surface may benefit from open operative treatment. Improved diagnostic imaging with computerized tomography is helpful for fracture classification and operative planning. The options for operative treatment include limited open reduction and internal fixation, arthroscopically assisted internal fixation, and open reduction and internal fixation. The operative approach is determined on the basis of the initial displacement of the fracture. Patients who have a displaced fracture of the volar rim may benefit from a volar approach; those who have a dorsally displaced fracture, from a dorsal approach; and those who have an impacted fracture such as a die-punch fracture, from a dorsal approach that provides better visualization of the articular surface.

The long-term functional outcome is determined in part by the severity of the fracture as defined by the amount of comminution, the initial severity of displacement, and the number of fracture fragments. The accuracy of the reconstruction of the articular surface, with the goal of establishing congruency to within 1.0 millimeter, is also important in order to minimize the risk of late osteoarthrosis. Of all of the extra-articular parameters, restoration of the length of the radius is the most important for enhancing recovery of motion and grip strength and for preventing problems involving the distal radioulnar joint—the so-called forgotten joint in distal radial fractures.

	Footnotes

 
*Printed with permission of The American Academy of Orthopaedic Surgeons. This article will appear in Instructional Course Lectures, Volume 48, The American Academy of Orthopaedic Surgeons, Rosemont, Illinois, March 1999.

No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

Department of Orthopaedics, University of Washington, Mailbox 356500, Seattle, Washington 98195.

Philadelphia Hand Center, 901 Walnut Street, Philadelphia, Pennsylvania 19107.

#Harborview Medical Center, 325 Ninth Avenue, Box 359798, Seattle, Washington 98104-2499.

**Department of Orthopaedic Surgery, University of Mississippi Medical Center, 2500 North State Street, Jackson, Mississippi 39216.

Mayo Clinic, 200 First Street S. W., Rochester, Minnesota 55905.

	References

Top Introduction Anatomy of the Articular... Effect of Intra-Articular... Radiographic Studies Classification of Intra... Operative Approaches Associated Fractures of the... Associated Injuries of the... External Fixation Devices Advantages and Disadvantages of... Rehabilitation after Intra... Results of Treatment Overview References

 

1. Andersen, D. J.; Blair, W. F.; Steyers, C. M., Jr.; Adams, B. D.; el Khouri, G. Y.; and Brandser, E. A.: Classification of distal radius fractures: an analysis of interobserver reliability and intraobserver reproducibility. J. Hand Surg., 21A: 574-582, 1996.[Medline]

2. Anglen, J. O., and Healy, W. L.: Tibial plateau fractures. Orthopedics, 11: 1527-1534, 1988.[Medline]

3. Axelrod, T. S., and McMurtry, R. Y.: Open reduction and internal fixation of comminuted, intraarticular fractures of the distal radius. J. Hand Surg., 15A: 1-11, 1990.

4. Bradway, J. K.; Amadio, P. C.; and Cooney, W. P.: Open reduction and internal fixation of displaced, comminuted intra-articular fractures of the distal end of the radius. J. Bone and Joint Surg., 71-A: 839-847, July 1989.[Abstract/Free Full Text]

5. Cooney, W. P.: Fractures of the distal radius. A modern treatment-based classification. Orthop. Clin. North America, 24: 211-216, 1993.[Medline]

6. Cooney, W. P., and Berger, R. A.: Treatment of complex fractures of the distal radius. Combined use of internal and external fixation and arthroscopic reduction. Hand Clin., 9: 603-612, 1993.[Medline]

7. Edwards, G. S., Jr.: Intra-articular fractures of the distal part of the radius treated with the small AO external fixator. J. Bone and Joint Surg., 73-A: 1241-1250, Sept. 1991.[Abstract/Free Full Text]

8. Fernandez, D. L.: Fractures of the distal radius: operative treatment. In Instructional Course Lectures, The American Academy of Orthopaedic Surgeons. Vol. 42, pp. 73-88. Rosemont, Illinois, The American Academy of Orthopaedic Surgeons, 1993.

9. Fernandez, D. L., and Geissler, W. B.: Treatment of displaced articular fractures of the radius. J. Hand Surg., 16A: 375-384, 1991.[Medline]

10. Frykman, G.: Fracture of the distal radius including sequelae—shoulder-hand-finger syndrome, disturbances in the distal radial-ulnar joint and impairment of nerve function. A clinical and experimental study. Acta Orthop. Scandinavica, Supplementum: 108, 1967.

11. Geissler, W. B.: Arthroscopically assisted reduction of intra-articular fractures of the distal radius. Hand Clin., 11: 19-29, 1995.[Medline]

12. Geissler, W. B., and Fernandez, D. L.: Percutaneous and limited open reduction of the articular surface of the distal radius. J. Orthop. Trauma, 5: 255-264, 1991.[Medline]

13. Geissler, W. B., and Freeland, A. E.: Arthroscopically assisted reduction of intraarticular distal radial fractures. Clin. Orthop., 327: 125-134, 1996.

14. Geissler, W. B.; Freeland, A. E.; Savoie, F. H.; McIntyre, L. W.; and Whipple, T. L.: Intracarpal soft-tissue lesions associated with an intra-articular fracture of the distal end of the radius. J. Bone and Joint Surg., 78-A: 357-365, March 1996.[Abstract/Free Full Text]

15. Graff, S., and Jupiter, J.: Fracture of the distal radius: classification of treatment and indications for external fixation. Injury, 25 (Supplement 4): 14-25, 1994.

16. Jupiter, J. B.: Current concepts review. Fractures of the distal end of the radius. J. Bone and Joint Surg., 73-A: 461-469, March 1991.[Free Full Text]

17. Jupiter, J. B., and Fernandez, D. L.: Comparative classification for fractures of the distal end of the radius. J. Hand Surg., 22A: 563-571, 1997.[Medline]

18. Jupiter, J. B.; Fernandez, D. L.; Toh, C.-L.; Fellman, T.; and Ring, D.: Operative treatment of volar intra-articular fractures of the distal end of the radius. J. Bone and Joint Surg., 78-A: 1817-1828, Dec. 1996.[Abstract/Free Full Text]

19. Knirk, J. L., and Jupiter, J. B.: Intra-articular fractures of the distal end of the radius in young adults. J. Bone and Joint Surg., 68-A: 647-659, June 1986.[Abstract/Free Full Text]

20. Kreder, H. J.; Hanel, D. P.; McKee, M.; Jupiter, J.; and Trumble, T. E.: Limited open versus standard open reduction and internal fixation of intra-articular fractures of the radius: a prospective randomized trial. Read at the Annual Meeting of the Canadian Orthopaedic Association, Auckland, New Zealand, February 5, 1998.

21. Lansinger, O.; Bergman, B.; Körner, L.; and Andersson, G. B. J.: Tibial condylar fractures. A twenty-year follow-up. J. Bone and Joint Surg., 68-A: 13-19, Jan. 1986.[Abstract/Free Full Text]

22. Levy, H. J., and Glickel, S. Z.: Arthroscopic assisted internal fixation of volar intraarticular wrist fractures. Arthroscopy, 9: 122-124, 1993.[Medline]

23. Lichtenhahn, P.; Fernandez, D. L.; and Schatzker, J.: Analyse zur "Anwenderfreundlichkeit" der AO-Klassifikation für Frakturen. Helvetica Chir. Acta, 58: 919-924, 1992.

24. Llinas, A.; McKellop, H. A.; Marshall, J.; Sharpe, F.; Lu, B.; Kirchen, M.; and Sarmiento, A.: Healing and remodeling of articular incongruities in a rabbit fracture model. J. Bone and Joint Surg., 75-A: 1508-1523, Oct. 1993.[Abstract/Free Full Text]

25. Mehara, A. K.; Rastogi, S.; Bhan, S.; and Dave, P. K.: Classification and treatment of volar Barton fractures. Injury, 24: 55-59, 1993.[Medline]

26. Melone, C. P., Jr.: Articular fractures of the distal radius. Orthop. Clin. North America, 15: 217-236, 1984.[Medline]

27. Melone, C. P., Jr.: Open treatment for displaced articular fractures of the distal radius. Clin. Orthop., 202: 103-111, 1986.

28. Melone, C. P., Jr.: Distal radius fractures: patterns of articular fragmentation. Orthop. Clin. North America, 24: 239-253, 1993.[Medline]

29. Müller, M. E.; Allgöwer, M.; Schneider, R.; and Willenegger, H.: Manual of Internal Fixation. Techniques Recommended by the AO-ASIF Group. Ed. 3. New York, Springer, 1991.

30. Newey, M. L.; Ricketts, D.; and Roberts, L.: The AO classification of long bone fractures: an early study of its use in clinical practice. Injury, 24: 309-312, 1993.[Medline]

31. Palmer, A. K.: Triangular fibrocartilage complex lesions: a classification. J. Hand Surg., 14A: 594-606, 1989.[Medline]

32. Rasmussen, P. S.: Tibial condylar fractures as a cause of degenerative arthritis. Acta Orthop. Scandinavica, 43: 566-575, 1972.[Medline]

33. Tajima, T., and Saito, H.: Eine neue Einteilung der Speichenbrüche am distalen Ende und die damit Korrespondierenden Behandlungsarten. Handchir. Mikrochir. plast. Chir., 23: 227-235, 1991.[Medline]

34. Trumble, T. E.; Schmitt, S. R.; and Vedder, N. B.: Internal fixation of pilon fractures of the distal radius. Yale J. Biol. and Med., 66: 179-191, 1993.

35. Trumble, T. E.; Schmitt, S. R.; and Vedder, N. B.: Factors affecting functional outcome of displaced intra-articular distal radius fractures. J. Hand Surg., 19A: 325-340, 1994.[Medline]

36. Trumble, T. E.; Miyano, J.; Clark, J. M.; Ott, S.; Jones, C. D. E.; Fernacola, P.; Magnusson, M.; and Tencer, A.: Intra-articular fracture: a sheep fracture model with weight bearing after internal fixation. Unpublished data.

37. Waddell, J. P.; Johnston, D. W.; and Neidre, A.: Fractures of the tibial plateau: a review of ninety-five patients and comparison of treatment methods. J. Trauma, 21: 376-381, 1981.[Medline]

38. Waters, P. M.; Mintzer, C. M.; Hipp, J. A.; and Snyder, B. D.: Noninvasive measurement of distal radius instability. J. Hand Surg., 22A: 572-579, 1997.

39. Whipple, T. L.: The role of arthroscopy in the treatment of intra-articular wrist fractures. Hand Clin., 11: 13-18, 1995.[Medline]

40. Whipple, T. L., and Geissler, W. B.: Arthroscopic management of wrist triangular fibrocartilage complex injuries in the athlete. Orthopedics, 16: 1061-1067, 1993.[Medline]

41. Wolfe, S. W.; Easterling, K. J.; and Yoo, H. H.: Arthroscopic-assisted reduction of distal radius fractures. Arthroscopy, 11: 706-714, 1995.[Medline]

CiteULike

Connotea

Del.icio.us

Facebook

Technorati

Twitter

This article has been cited by other articles:

				T. Azzopardi, S. Ehrendorfer, T. Coulton, and M. Abela Unstable extra-articular fractures of the distal radius: A PROSPECTIVE, RANDOMISED STUDY OF IMMOBILISATION IN A CAST VERSUS SUPPLEMENTARY PERCUTANEOUS PINNING J Bone Joint Surg Br, June 1, 2005; 87-B(6): 837 - 840. [Abstract] [Full Text] [PDF]

				K. DOI, Y. HATTORI, K. OTSUKA, Y. ABE, and H. YAMAMOTO Intra-Articular Fractures of the Distal Aspect of the Radius: Arthroscopically Assisted Reduction Compared with Open Reduction and Internal Fixation J. Bone Joint Surg. Am., August 1, 1999; 81(8): 1093 - 110. [Abstract] [Full Text]

				W. B. GEISSLER, A. E. FREELAND, A.-P. C. WEISS, and J. C.Y. CHOW Techniques of Wrist Arthroscopy*{{dagger}} J. Bone Joint Surg. Am., August 1, 1999; 81(8): 1184 - 97. [Full Text]

This Article Extract Full Text (PDF) Free Letters to the Editor: Submit a response Alert me when this article is cited Alert me when Letters to the Editor are posted Alert me if a correction is posted Services E-mail this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Rights and Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by TRUMBLE, T. E. Articles by BERGER, R. A. Search for Related Content PubMed Articles by TRUMBLE, T. E. Articles by BERGER, R. A. Social Bookmarking                   What's this?

Stanford University Libraries' HighWire Press (TM) assists in the publication of JBJS Online.
Copyright © 1998 by The Journal of Bone and Joint Surgery, Inc. Online ISSN: 1535-1386.
The Journal of Bone and Joint Surgery®, JBJS®, JB&JS®, and eJBJS® are registered in the U.S. Patent and Trademark Office.