Skip to content

Distal Radius ORIF

Open reduction and volar plate fixation of the distal radius — operation, recovery, rehabilitation.

Overview

Open reduction and internal fixation with a plate offers the best results for adult patients with a distal radius fracture regarding early and sustained functional recovery [5] and reduction in fracture healing complications [5]. Early mobilization for patients treated with ORIF may have a beneficial effect on function at earlier stages compared to late mobilization [1], with mean differences in DASH scores at 6 weeks surpassing the minimal clinically important difference [1]. Radial column plating of the distal radius is a safe treatment modality [6] and a valuable adjunct in the setting of complex distal radius fractures [6], though there is a 28% chance that hardware removal may be required for patients undergoing this technique [6].

Treatment of displaced intra-articular distal radius fractures with a dorsally versus a volarly placed interlocking plate system demonstrated similar clinical results [9]. However, technical precision is critical; placing the distal row of screws greater than 3mm from subchondral bone in comminuted intra-articular distal radius fractures was associated with increased odds of worsening ulnar variance [8]. While substantial variations in surgical direct costs for distal radius ORIF exist [2], implant choice is the predominant driver of this cost variation [2]. Additionally, the length of stay can be calculated for the Lift-Off Screw technique in a distal radius fracture model [3], and this technique can potentially be used with any distal radius periarticular locking plate with locking options in the shaft [3].

Anatomy & Pathophysiology

Osseous Architecture

Distal radius fractures represent the most common upper extremity fracture in the United States, affecting over 300,000 patients annually with a bimodal distribution driven by high-energy trauma in youth and low-energy falls in the elderly [27]. The distal radius articular surface is biconcave with distinct scaphoid and lunate facets, while the metaphysis features a thin cortex vulnerable to bending forces [27]. In a normal wrist with neutral ulnar variance, the distal radius bears 80% of the axial load [27]. Normal anatomical parameters include a radial height of 11 mm (accepting <5 mm shortening), radial inclination of 22 degrees (accepting <5-degree change), and volar tilt of 11 degrees (accepting <10-degree dorsal angulation) [27]. The brachioradialis insertion on the radial styloid acts as a deforming force in these fractures [27].

The carpus functions as a bridge between the forearm and hand, comprising two rows of eight bones [16]. The proximal row (scaphoid, lunate, triquetrum) serves as a key intercalated segment with no direct tendon attachments; its motion derives from bone shape, interaction, and ligamentous support [16]. The pisiform is excluded from this row as a sesamoid bone within the flexor carpi ulnaris sheath [16]. The distal row (trapezium, trapezoid, capitate, hamate) articulates proximally with the proximal row and distally with the metacarpals [16]. Specific articulations include the trapezium with the first metacarpal, trapezoid with the second, capitate with the third, and hamate with the fourth and fifth [16]. The capitate and trapezoid are tightly connected to the metacarpals, while the metacarpotrapezial joint allows 30 to 40 degrees of flexion–extension and rotation [16]. Motion of the distal row is controlled by extrinsic wrist flexors and extensors [16].

The scaphoid is an S-shaped tubular bone located on the radial aspect of the proximal row, lying at a 45-degree plane to the wrist axes [21]. It articulates with the radius, lunate, capitate, and trapezium/trapezoid [21]. The proximal articular surface is convex, while the distal surface features facets for the trapezium and trapezoid forming the scaphotrapeziotrapezoid (STT) joint [21]. The scaphoid gently pronates and flexes distally, positioning the distal pole ulnarly angulated relative to the proximal pole [21]. Over 80% of the scaphoid surface is covered with articular cartilage [21]. The scaphoid acts as a midcarpal bridge linking and synchronizing proximal and distal row motions [21].

Metacarpals form a Roman arch-like cascade where the index and small fingers are borders and the middle finger is the keystone [20]. The middle and ring fingers possess the most inherent stability due to central location, whereas border digits are prone to shortening, rotation, and angulation [20]. Metacarpal fractures are third in frequency only to phalangeal and distal radius fractures, with 70% occurring in the second and fifth decades [17]. The vast majority are inherently stable and treatable via closed means with early range of motion [17]. The metacarpal diaphysis has a tubular structure with thick cortices providing better fixation purchase than the thinner metaphyseal cortex [20]. The metacarpal head is cam-shaped in the sagittal plane and trapezoidal in the transverse plane, contributing to inherent stability during MCP flexion [20]. Collateral ligaments attach dorsally on the metacarpal head, elongating in flexion [20]. Metacarpal necks are susceptible to fracture during punching, and the fifth metacarpal has the most anterior–posterior arc at the CMC joint [20].

Ligamentous Stability

Wrist stability is predominantly maintained by extrinsic and intrinsic ligaments contained within the joint capsule [16]. Extrinsic palmar radiocarpal ligaments include the transverse carpal, radioscaphocapitate (RSC), radioscapholunate (RSL), radial collateral, long radiolunate (RLT), and short radiolunate ligaments [23]. Extrinsic ulnocarpal ligaments include the ulnotriquetral (dorsal and palmar), ulnolunate, and ulnocapitate ligaments [23]. Strong oblique extrinsic palmar radial ligaments prevent medial carpal translation on the angulated distal radius slope [23]. A V-shaped ligamentous band connects the forearm to the proximal row proximally and the distal row distally [23]. Between the radial and ulnar palmar ligaments lies the space of Poirier, a V-shaped interligamentous sulcus over the capitolunate articulation that is maximal in dorsiflexion [23]. The arcuate ligament, formed from interdigitation of the RSC, ulnocapitate, triquetrocapitate, and volar scaphotriquetral ligaments, forms a support sling for the midcarpal region and capitate head [23]. Extrinsic dorsal carpal ligaments include the dorsal radiocarpal (DRC) and dorsal intercarpal ligaments [23]. The ulnodorsal capsule is reinforced by the ulnolunate, ulnotriquetral ligaments, and floors of the fifth and sixth extensor compartments [23]. Some studies suggest an essential role for dorsal carpal ligaments in scapholunate stability [23].

Intrinsic ligaments connect individual carpal bones and include palmar midcarpal, proximal interosseous, and distal interosseous ligaments [23]. Ligaments associated with the pisiform include the pisotriquetral and pisohamate ligaments [23]. Apart from the scaphocapitate ligament, carpal ligaments are not described consistently across anatomical studies [16]. The radioscapocapitate ligament does not attach to the bone itself but crosses the scaphoid waist as a sling allowing rotation [21]. Ligamentous attachments of the scaphoid are predominantly found on the nonarticular dorsoradial surface, which also serves as the insertion for the dorsal component of the scapholunate and intercarpal ligaments [21]. There are no tendon attachments to the scaphoid [21].

Vascular Supply

The scaphoid has a reduced capacity for periosteal healing and an increased tendency for delayed union and nonunion [21]. Blood supply is provided by two vascular pedicles from the radial artery: the dorsal branch enters via foramina along the spiral groove and dorsal ridge to supply 70% to 80% of the scaphoid proximally, including the proximal pole [21]. The volar branch enters via the scaphoid tubercle to supply the remaining 20% to 30% of the distal scaphoid [21]. The scaphoid waist has minimal or no perforating vasculature, and no vessels perforate the proximal dorsal cartilaginous area or through the scapholunate ligament [21]. Proximal fractures are inexorably associated with at least temporary disruption of the interosseous blood supply to the proximal pole [21].

Kinematics and Pathophysiology

The distal radioulnar joint (DRUJ) is the articulation between the radius and ulna at the sigmoid notch [27]. Lister tubercle is a dorsal prominence serving as a landmark for the dorsal wrist approach and a cause of attritional rupture of the extensor pollicis longus (EPL) after distal radius fracture [27]. Radiocarpal dislocation or "inferior arc" injury is purely ligamentous or associated with styloid fracture, is highly unstable, and difficult to reduce closed [27]. DRUJ involvement is assessed on a true lateral radiograph for alignment [27]. Ligamentous injuries to consider include scapholunate (SL), lunotriquetral (LT), or triangular fibrocartilage complex (TFCC) injuries [27].

Surgical Approaches and Fixation

The flexor carpi radialis (FCR) approach provides excellent exposure for volar plating; incising the FCR sheath on its radial aspect may avoid injury to the palmar cutaneous branch of the median nerve [26]. After retracting the FPL tendon ulnarly, the pronator quadratus is elevated [26]. A brachioradialis tenotomy removes a deforming force [26]. Repair of the pronator quadratus did not result in better outcomes at 12 months in a randomized trial of 72 patients [26]. The extended FCR approach facilitates adequate distal exposure including the volar ulnar corner by biasing the skin incision midline to develop the interval between digital flexors and the ulnar neurovascular bundle [26]. Retracting carpal tunnel contents radially provides excellent visualization of the lunate facet fragment, an exposure that is extensile with an open carpal tunnel release [26]. A radial column approach requires protection of the superficial branch of the radial nerve and utilizes the deep interval through the first dorsal compartment or between the first and second compartments [26].

The dorsal approach is traditional for plating but enthusiasm waned due to extensor tendon complications [26]. It may be necessary to reduce and stabilize the dorsal ulnar facet fragment, with elevation of the fourth dorsal compartment on its ulnar aspect exposing the dorsal ulnar corner [26]. Unlike the volar approach, the dorsal approach affords visualization of the articular surface through a dorsal capsulotomy [26]. External fixation carries a pin tract infection rate exceeding 30%, though deep infection requiring removal occurs in less than 2% of cases [22]. Radial nerve injury occurs in 1% of external fixation cases [22]. Increased distraction leads to digit stiffness and CRPS risk, as excessive distraction decreases flexion ability [22]. Some level of distraction aids reduction via ligamentotaxis and carpal ligament tightening [22]. The large tenaculum clamp facilitates anatomical restoration of volar tilt and translation while allowing intraoperative fluoroscopy and potentially minimizing flexor tendon abrasion or rupture [36].

Imaging and Assessment

Computed tomography (CT) is used for detail of complex intraarticular patterns [27]. Magnetic resonance imaging (MRI) is used for occult fracture, bone contusion, and associated soft tissue injury [27]. Ulnar variance is assessed with the forearm in neutral rotation and compared with the contralateral side [27]. Malrotation can be difficult to assess in metacarpal fractures despite specific assessment methods [17].

Classification

Radial Column Plating: This modality is a safe treatment option and serves as a valuable adjunct for complex distal radius fractures [6]. However, there is a 28% chance that hardware removal may be required for patients undergoing this procedure [6].

Plate Positioning: In displaced intra-articular distal radius fractures, the treatment outcomes for dorsally versus volarly placed interlocking plate systems are similar [9]. Regarding screw placement in comminuted intra-articular fractures, positioning the distal row of screws greater than 3mm from subchondral bone is associated with increased odds of worsening ulnar variance [8].

Lift-Off Screw Technique: The length of stay (LOS) can be calculated for this technique in a distal radius fracture model [3]. This technique can potentially be utilized with any distal radius periarticular locking plate that includes locking options in the shaft [3].

Other Considerations: Open reduction and internal fixation with a plate provides the best results for adult patients regarding early and sustained functional recovery as well as a reduction in fracture healing complications [5]. Early mobilization for patients treated with ORIF may have a beneficial effect on function at earlier stages compared to late mobilization [1]. Mean differences in DASH scores at 6 weeks for early mobilization surpass the minimal clinically important difference [1]. Substantial variations in surgical direct costs exist, with implant choice being the predominant driver of this cost variation [2].

Clinical Presentation

Early mobilization following open reduction and internal fixation (ORIF) of distal radius fractures yields beneficial functional effects at earlier stages compared to late mobilization [1]. Patients treated with early mobilization demonstrate mean differences in DASH scores at 6 weeks that surpass the minimal clinically important difference [1]. While implant choice is the predominant driver of substantial variations in surgical direct costs for distal radius ORIF, the specific technique of radial column plating remains a safe modality for complex fractures [2, 6].

Surgical Approach and Outcomes: Open reduction and internal fixation with a plate offers the best results for adult patients regarding early and sustained functional recovery and reduction in fracture healing complications [5]. The Lift-Off Screw technique can be utilized with any distal radius periarticular locking plate possessing locking options in the shaft to calculate length of stay and correct sagittal tilt [3]. Treatment of displaced intra-articular distal radius fractures with a dorsally versus a volarly placed interlocking plate system demonstrates similar clinical results [9]. However, placing the distal row of screws greater than 3mm from subchondral bone in comminuted intra-articular fractures is associated with increased odds of worsening ulnar variance [8].

Galeazzi Fracture Patterns: Because the forearm functions as a ring, an isolated radial shaft fracture is uncommon in adults; fractures within 7.5 cm of the radiocarpal joint are more likely to represent a Galeazzi fracture [35]. Galeazzi fractures with rare exceptions require surgical fixation to restore the structural integrity of the forearm ring [35]. The goal of surgery is anatomic reduction of the radial shaft, especially the radial bow, and restoration of a stable distal radioulnar joint (DRUJ) [35]. Closed management of displaced forearm axis fractures in adults results in poor outcomes [35].

Physical Examination and Radiographic Assessment: Examination may reveal a prominent ulnar head in cases of dorsal DRUJ subluxation or dislocation [35]. Radiographic parameters associated with DRUJ injury include fracture of the base of the ulnar styloid, widening of the DRUJ on the AP wrist radiograph, dislocation of the ulna relative to the radius on a true lateral wrist radiograph, and more than 5 mm of shortening of the radius relative to the ulna (ulnar positive variance) when compared with the contralateral wrist [35]. Radial shaft fracture line obliquity greater than 30° is a statistically significant predictor of DRUJ instability [35].

Operative Management and Stability Testing: ORIF for Galeazzi fractures is typically performed through a volar Henry approach with a 3.5-mm dynamic compression plate, though a dorsal Thompson approach can be used for radial shaft fractures in the proximal third [35]. Intramedullary fixation is rarely used because it is difficult to restore the anatomic radial bow [35]. After fixation, the DRUJ is examined in full pronation and supination to assess stability [35]. If the ulna can be dislocated from the sigmoid notch with the forearm in supination, the DRUJ supporting ligaments including the triangular fibrocartilage complex (TFCC) are incompetent [35]. If the DRUJ is stable after translation or shuck stress testing, the extremity is immobilized in a long arm splint or cast in the position of greatest stability [35].

Stabilization Techniques and Complications: Stabilization of the DRUJ can be achieved by transradioulnar extra-articular Kirschner wires, which should protrude enough on the radial cortex so that if the wires break, the ends can be retrieved from both the radius and ulna without difficulty [35]. Displaced ulnar styloid fractures can be internally fixed with specialty plates, a tension band wire, or suture [35]. The DRUJ can also be stabilized by retensioning and reinsertion of the TFCC attachment with a suture anchor or transosseous suture [35]. Unreducible or complex ulnar head dislocations require arthrotomy to retrieve possible interposed extensor carpi ulnaris, extensor digitorum communis, or extensor digiti minimi tendons [35]. Other structures that can impede closed reduction include a metaphyseal fragment buttonholed through the capsule, the periosteum, or an avulsed styloid fracture fragment from the fovea [35]. After reduction and stabilization, the arm is immobilized in a long arm cast or splint for 4 to 6 weeks, and true lateral radiographs should document a reduced DRUJ [35].

Complications: Patients undergoing radial column plating should be counseled that there is a 28% chance that hardware removal may be required [6]. Complications following management of Galeazzi fractures include nonunion, malunion with limited forearm rotation, nerve or vessel injury, infection, complex regional pain syndrome, and persistent DRUJ instability [35].

Investigations

Plain radiography: Initial assessment of the wrist requires four standard views: posteroanterior with ulnar deviation, lateral, semi-pronated oblique, and semi-supinated oblique [24]. An anteroposterior view with a clenched fist is added if scapholunate injury is suspected [24]. In the lateral view, the axes of the radius, lunate, capitate, and third metacarpal must be co-linear, while the scaphoid projects at approximately 45 degrees to the radius [24]. Dorsal intercalated segmental instability (DISI) is characterized by dorsal tilting of the lunate and volar tilting of the scaphoid, whereas volar intercalated segmental instability (VISI) involves volar tilting of both bones [24]. For suspected scaphoid fractures, AP, lateral, and two oblique views are standard, though 10 to 15% of these fractures are not visible on initial X-rays [24]. In cases of ulnar translation, radiographs may show the lunate positioned just distal to the ulna with a large space between the radial styloid and scaphoid [25]. Standard scaphoid views detect most carpal injuries, but perilunate dislocations can be missed; assessment of Gilula's lines aids in diagnosing these dislocations [31]. Multiple views and repeated examinations may be necessary to detect undisplaced cracks [24].

MRI: MRI is the definitive method to confirm or exclude a scaphoid fracture diagnosis when available and reduces uncertainty in suspected cases [24][30]. It is also useful for detecting suspected fractures, avascular necrosis (AVN) of the carpus, and determining the extent of ligamentous disruption in radiocarpal instability [25][31].

CT: CT is more sensitive than X-rays for diagnosing scaphoid fractures and is required to better define associated bony injuries in radiocarpal instability [25][30]. Two-dimensional and three-dimensional CT are used to assess suspected carpal fractures, fracture displacement, malunion, nonunion, and bone loss [31]. CT is also useful for assessing union in suspected carpal fractures [31].

Bone scan: Bone scintigraphy is utilized for suspected carpal fractures and avulsion injuries [31].

Other Considerations: Assessment of metacarpal fractures requires evaluation of skin integrity, neurovascular status, ligamentous evaluation, tendon function, and malrotation [17]. The incidence of metacarpal fractures is third only to phalangeal and distal radius fractures in the upper limb, with approximately 70% occurring in the second and fifth decades [17]. The vast majority of metacarpal fractures are inherently stable and treated via closed means with early range of motion [17]. Understanding the anatomy of the eight carpal bones is essential for diagnosis; the proximal row (scaphoid, lunate, triquetrum) serves as a key intercalated segment, while the distal row includes the trapezium, trapezoid, capitate, and hamate [16]. Inherent stability is provided by extrinsic and intrinsic ligaments reinforcing the carpal capsule, though carpal ligaments (except the scaphocapitate) are not described consistently across studies [16]. Scaphoid fractures account for almost 75% of all carpal fractures but are rare in children and the elderly [30]. The usual mechanism is forced hyperextension, with fractures occurring at the distal tubercle, waist, or proximal pole [30]. The blood supply arises from the dorsal distal pole, making the proximal pole less likely to heal due to poor vascularity [30]. Some scaphoid fractures, particularly distal oblique and waist types, are unstable and predispose to non-union or malunion [30]. Diagnostic signs include precisely localized tenderness in the anatomical snuffbox, pressure over the scaphoid tubercle, palpation of the proximal pole, and telescoping of the thumb base [30]. If X-rays are normal but clinical features suggest a fracture, the patient must be immobilized and not discharged [30]. Secondary imaging modalities, including ultrasound, dynamic CT, arthrography, and wrist arthroscopy, are predominantly used for assessing intercarpal ligament injury and instability [31]. Ultrasound provides an additional tool for detecting carpal ligament injuries [31]. Dynamic CT is used by some for ligament injuries [31]. Arthrography ± videofluoroscopy is used for ligament injuries [31]. Wrist arthroscopy aids in diagnosing ligament injuries and fracture displacement [31]. Live/video fluoroscopic evaluation provides diagnostic clarity for dynamic instability with sensitivities between 86% and 95% and specificity between 80% and 97% for scapholunate ligament injury [31]. Radiographic measurements include the lateral intrascaphoid angle (cut-off >35 degrees for displacement), AP intrascaphoid angle, dorsal cortical angle (abnormal if >160 degrees), and scaphoid height-to-length ratio (abnormal if >0.65) [31]. The DISI pattern is most commonly associated with displaced scaphoid fractures and scapholunate dissociation [31]. A cortical ring sign with the wrist in flexion, pronation, and ulnar deviation helps localize the ulnar aspect of the proximal pole of the scaphoid [32]. For scaphoid fixation, a stab or mini-open incision avoids soft tissue injury; the wire is pulled distally from the palmar side until the proximal guidewire clears the radiocarpal joint, then advanced retrograde to exit dorsally [32]. Screw length must be measured carefully with several millimeters subtracted to avoid prominence, and larger screws are biomechanically stronger [32]. Cannulated screws improve central placement compared with Herbert screws [32]. In the context of proximal humerus fractures, patients with glenoid vault CT Hounsfield units less than 160 HU have a significantly increased risk of ORIF failure [38].

Treatment

Operative

Indications: Open reduction and internal fixation with a plate is the recommended option for adult patients with distal radius fractures, offering the best results for early and sustained functional recovery as well as a reduction in fracture healing complications [5]. For elderly patients aged 70 years or older with extra-articular distal humeral fractures, open reduction and internal fixation is indicated when conservative treatment has failed [19]. Radial column plating of the distal radius serves as a safe treatment modality and a valuable adjunct in the setting of complex distal radius fractures [6].

Surgical Approach / Technique: Early mobilization for patients treated with ORIF may have a beneficial effect on function at earlier stages compared to late mobilization [1]. Mean differences in DASH scores at 6 weeks for early mobilization surpass the minimal clinically important difference [1]. The Lift-Off Screw technique can potentially be used with any distal radius periarticular locking plate with locking options in the shaft, and the length of stay for this technique can be calculated within a distal radius fracture model [3]. In comminuted intra-articular distal radius fractures, placing the distal row of screws greater than 3mm from subchondral bone was associated with increased odds of worsening ulnar variance [8]. The treatment of displaced intra-articular distal radius fractures with a dorsally versus a volarly placed interlocking plate system demonstrated similar clinical results [9].

Implant Selection: Implant choice is the predominant driver of cost variation for distal radius ORIF, contributing to substantial variations in surgical direct costs [2]. Hardware removal may be required in 28% of patients undergoing radial column plating of the distal radius [6]. In the specific case of proximal plate migration after internal fixation of a pediatric distal radius fracture, the patient required washout and hardware removal, resulting in resolution of symptoms [40].

Complications

Stiffness / Arthrofibrosis: Early mobilization following ORIF may yield beneficial functional outcomes at earlier stages compared to late mobilization, with mean differences in DASH scores at 6 weeks surpassing the minimal clinically important difference [1].

Hardware Removal: Radial column plating is a safe treatment modality, though patients should be counseled regarding a 28% chance that hardware removal may be required [6].

Other Considerations: Open reduction and internal fixation with a plate offers the best results for adult patients regarding early and sustained functional recovery and a reduction in fracture healing complications [5]. Treatment of displaced intra-articular fractures with dorsally versus volarly placed interlocking plate systems demonstrates similar clinical results [9]. A low overall complication rate of 12.3% was observed in volar locking plate fixation, comprising 4.8% major and 7.5% minor complications [39]. Substantial variations in surgical direct costs exist, with implant choice serving as the predominant driver [2]. The length of stay can be calculated, and the lift-off screw technique can potentially be used with any distal radius periarticular locking plate possessing locking options in the shaft [3]. In comminuted intra-articular fractures, placing the distal row of screws greater than 3mm from subchondral bone is associated with increased odds of worsening ulnar variance [8].

Recovery

Light activity (weeks): Early mobilization is recommended for patients undergoing open reduction and internal fixation (ORIF) to optimize function at earlier stages compared to late mobilization [1]. This approach yields mean differences in DASH scores at 6 weeks that surpass the minimal clinically important difference [1].

Full activity (months): Open reduction and internal fixation with a plate provides the best results for adult patients regarding early and sustained functional recovery [5]. Radial column plating is a safe treatment modality and a valuable adjunct in the setting of complex distal radius fractures [6].

Complete recovery / outcome plateau (months): While functional recovery is optimized with plating, the trajectory may be influenced by technical factors; placing the distal row of screws greater than 3mm from subchondral bone in comminuted intra-articular distal radius fractures was associated with increased odds of worsening ulnar variance [8].

Rehabilitation protocol: The evidence supports early mobilization protocols to enhance early functional outcomes [1]. Surgeons should be aware that there is a 28% chance that hardware removal may be required for patients undergoing radial column plating of the distal radius [6].

Functional milestones: Validated outcome measures indicate that early mobilization leads to DASH score improvements at 6 weeks exceeding the minimal clinically important difference [1]. Open reduction and internal fixation with a plate offers the best results for adult patients in terms of reduction in fracture healing complications [5].

Other Considerations: Substantial variations in surgical direct costs for distal radius ORIF exist, with implant choice identified as the predominant driver of this cost variation [2].

Key Evidence

  • [L1] Functionally, at earlier stages, early mobilization for patients with distal radius fractures treated with ORIF may have a beneficial effect compared to late mobilization, with mean differences in DASH scores at 6 weeks surpassing the minimal clinically important difference. (10.1186/s13018-021-02837-0)
  • [L3] Substantial variations in surgical direct costs for distal radius ORIF exist, and implant choice is the predominant driver. (10.1016/j.jhsa.2018.04.015)
  • [L5] The LOS length can be calculated, and this technique can potentially be used with any distal radius periarticular locking plate with locking options in the shaft. (10.1016/j.jhsa.2018.02.011)
  • [L1] A network meta-analysis of randomized trials revealed that open reduction and internal fixation with a plate offers the best results for adult patients with a distal radius fracture, in terms of early and sustained functional recovery and a reduction in fracture healing complications. (10.5435/jaaos-d-18-00424)
  • [L4] Radial column plating of the distal radius is a safe treatment modality and a valuable adjunct in the setting of complex distal radius fractures, but patients should be counseled that there is a 28% chance that hardware removal may be required. (10.1177/1558944718760861)
  • [L4] In this two-center retrospective cohort of comminuted intra-articular distal radius fractures, placing the distal row of screws greater than 3mm from subchondral bone was associated with increased odds of worsening ulnar variance. (10.1016/j.jhsa.2025.03.016)
  • [L3] The treatment of displaced intra-articular distal radius fractures with a dorsally versus a volarly placed interlocking plate system demonstrated similar clinical results. (10.1177/1558944716675129)
  • [L4] Osteosynthesis by open reduction and internal fixation is a recommended option for extra-articular distal humeral fractures in elderly patients aged 70 years or older in whom conservative treatment has failed. (10.1016/j.jse.2017.08.024)
  • [L4] The large tenaculum clamp facilitates anatomical restoration of volar tilt and volar translation while allowing intraoperative fluoroscopy, potentially minimizing complications such as flexor tendon abrasion or rupture. (10.1016/j.jhsa.2018.11.017)
  • [L3] Patients with computed tomography Hounsfield units (CTHU) of the glenoid vault < 160 HU who sustain a proximal humerus fracture have a significantly increased risk of ORIF failure, necessitating subsequent revision to arthroplasty. (10.1016/j.jse.2025.09.008)
  • [L4] A low overall complication rate of 12.3% was found, with 4.8% major and 7.5% minor complications. (10.1016/j.jhsa.2022.11.012)
  • [L4] The patient required washout and hardware removal, with resolution of his symptoms. (10.1177/15589447221130083)

See Also

References

[1] In adults, early mobilization may be beneficial for distal radius fractures treated with open reduction and internal fixation: a systematic review and meta-analysis. Journal of Orthopaedic Surgery and Research. 2021. DOI: 10.1186/s13018-021-02837-0

[2] Evaluation of Factors Driving Cost Variation for Distal Radius Fracture Open Reduction Internal Fixation. The Journal of Hand Surgery. 2018. DOI: 10.1016/j.jhsa.2018.04.015

[3] Lift-Off Screw Results in Accurate Sagittal Tilt Correction in a Distal Radius Fracture Model. The Journal of Hand Surgery. 2018. DOI: 10.1016/j.jhsa.2018.02.011

[5] Interventions for Distal Radius Fractures: A Network Meta-analysis of Randomized Trials. Journal of the American Academy of Orthopaedic Surgeons. 2019. DOI: 10.5435/jaaos-d-18-00424

[6] Complications of Radial Column Plating of the Distal Radius. HAND. 2018. DOI: 10.1177/1558944718760861

[8] The Association Between Distal Screw and Articular Subsidence in the Open Treatment of Intra-articular Distal Radius Fractures. The Journal of Hand Surgery. 2026. DOI: 10.1016/j.jhsa.2025.03.016

[9] Management of Intra-Articular Distal Radius Fractures: Volar or Dorsal Locking Plate—Which Has Fewer Complications?. HAND. 2016. DOI: 10.1177/1558944716675129

[16] Rockwood And Green S Fractures In Adults. 42: Fractures of the Distal Radius and Ulna > Pathoanatomy and Applied Anatomy Relating to Carpal Fractures and Dislocations.

[17] Rockwood And Green S Fractures In Adults. 42: Fractures of the Distal Radius and Ulna > Metacarpal Fractures.

[19] Open reduction and internal fixation for nonunion of extra-articular distal humeral fractures in patients 70 years and older. Journal of Shoulder and Elbow Surgery. 2018. DOI: 10.1016/j.jse.2017.08.024

[20] Rockwood And Green S Fractures In Adults. 42: Fractures of the Distal Radius and Ulna > Pathoanatomy and Applied Anatomy Relating to Metacarpal Fractures.

[21] Rockwood And Green S Fractures In Adults. 42: Fractures of the Distal Radius and Ulna > Pathoanatomy and Applied Anatomy Related to Scaphoid Fractures.

[22] Rockwood And Green S Fractures In Adults. 42: Fractures of the Distal Radius and Ulna > External Fixation of the Distal Radius: Preoperative Checklist > Bridging External Fixation of the Distal Radius: Key Surgical Steps.

[23] Rockwood And Green S Fractures In Adults. 42: Fractures of the Distal Radius and Ulna > Extrinsic Ligaments.

[24] Apley And Solomon S Concise System Of Orthopaedics And Trauma. FRACTURES OF THE DISTAL RADIUS IN CHILDREN > Imaging.

[25] Rockwood And Green S Fractures In Adults. 42: Fractures of the Distal Radius and Ulna > Assessment of Radiocarpal Instability.

[26] Orthopaedic Knowledge Update Trauma. Fractures of the Forearm and Distal Radius > Surgical Approaches.

[27] Miller S Review Of Orthopaedics. SECTION 16 PATELLAR TRACKING IN TOTAL KNEE ARTHROPLASTY > DISTAL RADIUS FRACTURES.

[28] Miller S Review Of Orthopaedics. DISTAL RADIUS FRACTURES.

[30] Apley And Solomon S Concise System Of Orthopaedics And Trauma. FRACTURES OF THE DISTAL RADIUS IN CHILDREN > FRACTURE OF THE SCAPHOID.

[31] Rockwood And Green S Fractures In Adults. 42: Fractures of the Distal Radius and Ulna > Secondary Imaging Methods.

[32] Rockwood And Green S Fractures In Adults. 42: Fractures of the Distal Radius and Ulna > Dorsal Approach.

[35] Orthopaedic Knowledge Update Trauma. Fractures of the Forearm and Distal Radius > Forearm Fractures > Galeazzi Fractures.

[36] Use of a Large Tenaculum Clamp as a Reduction Technique for Treatment of Distal Radius Fractures. The Journal of Hand Surgery. 2019. DOI: 10.1016/j.jhsa.2018.11.017

[38] Low glenoid vault bone density is a risk factor for failure of proximal humerus fracture fixation. Journal of Shoulder and Elbow Surgery. 2026. DOI: 10.1016/j.jse.2025.09.008

[39] Complications After Volar Locking Plate Fixation of Distal Radius Fractures: A Retrospective Study of 822 Patients. The Journal of Hand Surgery. 2024. DOI: 10.1016/j.jhsa.2022.11.012

[40] Proximal Plate Migration After Internal Fixation of a Pediatric Distal Radius Fracture. HAND. 2023. DOI: 10.1177/15589447221130083

Creative Commons BY-NC 4.0

CC Creative Commons licence
BY Attribution — you must credit the source
NC NonCommercial — not for commercial use

Attribution-NonCommercial 4.0 International

Creative Commons Corporation ("Creative Commons") is not a law firm and does not provide legal services or legal advice. Distribution of Creative Commons public licenses does not create a lawyer-client or other relationship. Creative Commons makes its licenses and related information available on an "as-is" basis. Creative Commons gives no warranties regarding its licenses, any material licensed under their terms and conditions, or any related information. Creative Commons disclaims all liability for damages resulting from their use to the fullest extent possible.

Using Creative Commons Public Licenses

Creative Commons public licenses provide a standard set of terms and conditions that creators and other rights holders may use to share original works of authorship and other material subject to copyright and certain other rights specified in the public license below. The following considerations are for informational purposes only, are not exhaustive, and do not form part of our licenses.

Considerations for licensors: Our public licenses are intended for use by those authorized to give the public permission to use material in ways otherwise restricted by copyright and certain other rights. Our licenses are irrevocable. Licensors should read and understand the terms and conditions of the license they choose before applying it. Licensors should also secure all rights necessary before applying our licenses so that the public can reuse the material as expected. Licensors should clearly mark any material not subject to the license. This includes other CC- licensed material, or material used under an exception or limitation to copyright. More considerations for licensors: wiki.creativecommons.org/Considerations_for_licensors

Considerations for the public: By using one of our public licenses, a licensor grants the public permission to use the licensed material under specified terms and conditions. If the licensor's permission is not necessary for any reason--for example, because of any applicable exception or limitation to copyright--then that use is not regulated by the license. Our licenses grant only permissions under copyright and certain other rights that a licensor has authority to grant. Use of the licensed material may still be restricted for other reasons, including because others have copyright or other rights in the material. A licensor may make special requests, such as asking that all changes be marked or described. Although not required by our licenses, you are encouraged to respect those requests where reasonable. More considerations for the public: wiki.creativecommons.org/Considerations_for_licensees

Creative Commons Attribution-NonCommercial 4.0 International Public License

By exercising the Licensed Rights (defined below), You accept and agree to be bound by the terms and conditions of this Creative Commons Attribution-NonCommercial 4.0 International Public License ("Public License"). To the extent this Public License may be interpreted as a contract, You are granted the Licensed Rights in consideration of Your acceptance of these terms and conditions, and the Licensor grants You such rights in consideration of benefits the Licensor receives from making the Licensed Material available under these terms and conditions.

Section 1 -- Definitions.

a. Adapted Material means material subject to Copyright and Similar Rights that is derived from or based upon the Licensed Material and in which the Licensed Material is translated, altered, arranged, transformed, or otherwise modified in a manner requiring permission under the Copyright and Similar Rights held by the Licensor. For purposes of this Public License, where the Licensed Material is a musical work, performance, or sound recording, Adapted Material is always produced where the Licensed Material is synched in timed relation with a moving image.

b. Adapter's License means the license You apply to Your Copyright and Similar Rights in Your contributions to Adapted Material in accordance with the terms and conditions of this Public License.

c. Copyright and Similar Rights means copyright and/or similar rights closely related to copyright including, without limitation, performance, broadcast, sound recording, and Sui Generis Database Rights, without regard to how the rights are labeled or categorized. For purposes of this Public License, the rights specified in Section 2(b)(1)-(2) are not Copyright and Similar Rights.

d. Effective Technological Measures means those measures that, in the absence of proper authority, may not be circumvented under laws fulfilling obligations under Article 11 of the WIPO Copyright Treaty adopted on December 20, 1996, and/or similar international agreements.

e. Exceptions and Limitations means fair use, fair dealing, and/or any other exception or limitation to Copyright and Similar Rights that applies to Your use of the Licensed Material.

f. Licensed Material means the artistic or literary work, database, or other material to which the Licensor applied this Public License.

g. Licensed Rights means the rights granted to You subject to the terms and conditions of this Public License, which are limited to all Copyright and Similar Rights that apply to Your use of the Licensed Material and that the Licensor has authority to license.

h. Licensor means the individual(s) or entity(ies) granting rights under this Public License.

i. NonCommercial means not primarily intended for or directed towards commercial advantage or monetary compensation. For purposes of this Public License, the exchange of the Licensed Material for other material subject to Copyright and Similar Rights by digital file-sharing or similar means is NonCommercial provided there is no payment of monetary compensation in connection with the exchange.

j. Share means to provide material to the public by any means or process that requires permission under the Licensed Rights, such as reproduction, public display, public performance, distribution, dissemination, communication, or importation, and to make material available to the public including in ways that members of the public may access the material from a place and at a time individually chosen by them.

k. Sui Generis Database Rights means rights other than copyright resulting from Directive 96/9/EC of the European Parliament and of the Council of 11 March 1996 on the legal protection of databases, as amended and/or succeeded, as well as other essentially equivalent rights anywhere in the world.

l. You means the individual or entity exercising the Licensed Rights under this Public License. Your has a corresponding meaning.

Section 2 -- Scope.

a. License grant.

1. Subject to the terms and conditions of this Public License, the Licensor hereby grants You a worldwide, royalty-free, non-sublicensable, non-exclusive, irrevocable license to exercise the Licensed Rights in the Licensed Material to:

a. reproduce and Share the Licensed Material, in whole or in part, for NonCommercial purposes only; and

b. produce, reproduce, and Share Adapted Material for NonCommercial purposes only.

2. Exceptions and Limitations. For the avoidance of doubt, where Exceptions and Limitations apply to Your use, this Public License does not apply, and You do not need to comply with its terms and conditions.

3. Term. The term of this Public License is specified in Section 6(a).

4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.