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Internal Fixation and Implants

Internal fixation of the wrist, focusing on volar locking plates for distal radius fractures and the management of associated complications.

Overview

Internal fixation and external fixation represent primary modalities for fracture management, with selection often guided by patient preference [1]. The Locking Compression Plate (LCP) has revolutionized internal fixation but necessitates adapted surgical techniques to avoid complications [2]. While locking plate fixation has not yet demonstrated clinical superiority in any anatomic site with available high-quality comparative analyses [23], specific applications show distinct advantages. For open distal tibial fractures, the locking compression plate approach offers shorter hospitalization, reduced re-operation rates, and fewer complications compared to combined frame external fixation [22]. In acetabular fractures, a novel posterior internal fixation technique provides superior outcomes and fewer complications than similar methods [10].

External fixation remains a viable option for unstable pelvic fractures, particularly when combined with spinopelvic fixation in the lateral position, facilitating safe and accurate reduction without major surgical complications [20]. For osteoporotic pelvic fractures, submuscular internal fixation may serve as an alternative to external fixation due to superior biomechanical properties and clinical advantages [80]. In distal radius fractures, alternative fixation methods for volar lunate facet fractures demonstrate promising outcomes with high union rates, though existing studies are limited by small sample sizes [26].

Successful internal fixation relies heavily on surgical technique to ensure healing and avoid complications [5]. Stable internal fixation with standard techniques facilitates an early return to functional activities in step-cut ulnar shortening osteotomy for ulnar impaction syndrome [3]. External fixation complications can be minimized with meticulous technique; however, an inability to maintain reduction in a neutral position indicates the need for combined internal and external fixation [30]. Long-term prospective studies with larger patient numbers are required to definitively determine if percutaneous plate-insertion techniques improve upon current biologic plating methods [11].

Anatomy & Pathophysiology

Osseous

Biomechanical Stability: The metacarpal sled demonstrates intermediate biomechanical properties between two standard fixation methods for metacarpal neck fractures [31]. Internal fixation using plates provides superior biomechanical stability compared to percutaneous pins for dorsally comminuted intra-articular distal radius fractures in a cadaver model [47]. The yield loads of volar and dorsal fixed-angle implants for dorsally unstable extra-articular distal radius fractures are similar and much higher than previously described loads for active wrist and finger motion [40]. A palmarly applied LCP is biomechanically superior to a dorsally applied Pi plate for dorsally comminuted, intra-articular wrist fractures [35]. A variable-angle construct exhibits a distinct mechanical advantage over fixed-angle fixation when capturing a smaller radial styloid fragment [55].

Plate Design and Fit: All investigated distal palmar radius plates presented a reasonable anatomical shape, although no complete congruency was found between the plates and the radial cortex [50]. Distal screws should be chosen significantly shorter than measured lengths to provide the biomechanical basis for primary stability in volar plate osteosynthesis [36].

Articular Reconstruction and Alignment: Restoration of distal radius anatomy within established guidelines yields the best short- and long-term results [49]. Articular wrist views accurately represent the wrist joint and conclusively confirm whether screws have penetrated the articular surface in surgical fixation of distal radius fractures [45]. Midcarpal alignment in distal radial fractures and malunions demonstrates a measurable relationship with dorsal tilt of the radius [52]. Chondrofiller is technically feasible and safe for cartilage reconstruction in intra-articular distal radius fractures [51].

Clinical Outcomes of Fixation: Satisfactory wrist function can be achieved with operative treatment for dorsal articular margin fractures of the distal radius with dorsal radiocarpal subluxation in most patients [32]. Improvements in wrist and forearm ROM and radiographic parameters following volar-locked plating versus dorsal bridge plating for distal radius fractures may not be clinically relevant [37]. Functional and radiological results of the minimally invasive approach for distal radius fractures and malunions are comparable with those obtained with an extended flexor carpi radialis approach [46]. Significant differences in range of motion and grip strength following four-corner arthrodesis with differing methods of osteosynthesis are unlikely to be clinically relevant [41].

Associated Injuries: The presence of an associated ulnar styloid fracture results in a slower recovery of grip strength and wrist flexion, though no long-term differences in measured impairments were observed [53]. Distal radioulnar joint instability in adolescents is often preceded by fracture of the distal radius and is often not an isolated pathoanatomical problem [54].

Ligamentous

The volar wrist ligaments insert quite near the distal end of the pronator quadratus [56].

Kinematics

Synovectomy combined with the Sauvé-Kapandji procedure allows correction of ulnar shift and radial deviation of the carpus, although the wrist remains stiff [34].

Classification

Periprosthetic vs. Peri-implant: A distinction between periprosthetic and peri-implant fractures should be made [33].

Peri-implant Femoral Fractures: The proposed classification system for peri-implant femoral fractures should be enhanced by integrating the healing status of the primary fracture [33].

Prosthetic Joint Infection (PJI): A topographic principle should be introduced into PJI classification, as identifying the exact location of bacterial colonization (e.g., joint space vs. bone-prosthetic interface) can guide treatment strategy [71].

Distal Radius Fractures: Contemporary classification systems for distal radius fractures have not achieved impressive interobserver agreement and should not be overly relied upon in dictating treatment plans [75].

Clinical Presentation

Diagnostic Modality Selection: External fixation and volar locking plates (VLP) are both considered good treatment options for distal radius fractures, with preference often following patient choice [1]. Arthroscopically assisted intra-articular distal radial fracture fixation using external fixators and K-wires is associated with a greater number of complications compared to volar locking plates [15]. The DRAFFT trial aims to determine if there is a difference in Patient-Reported Wrist Evaluation one year following K-wire fixation versus locking-plate fixation for dorsally displaced distal radius fractures [43].

Implant Selection and Technique: The Locking Compression Plate (LCP) is an implant that revolutionizes internal fixation but requires adapted surgical techniques and new thinking to avoid failures and complications [2]. Anatomically precontoured locking compression plates for Schatzker II tibial plateau fractures seem to improve radiological and clinical outcomes compared to conventional implants, which are associated with more pronounced articular subsidence and higher valgus angulation [9]. Bone screws are a useful device to resolve issues associated with metal implants, such as sensitization and imaging artifacts, and may provide successful fixation and biological healing [12]. Additive manufacturing for metal applications in orthopaedic surgery offers improved biomechanical properties and fixation systems, enabling use in areas where current implants are not well suited [18].

Specific Fracture Patterns and Fixation Strategies: Intrafocal pin plate fixation of distal ulna fractures associated with distal radius fractures results in fracture union at a minimum of 1 year post-surgery, with no patients developing implant-related symptoms or requiring additional surgery [4]. External fixation combined with limited open reduction and absorbable internal fixation for distal tibial shaft fractures leads to minimal soft tissue complications, good functional results, and no local soft tissue irritation or need for implant removal [13]. Conversion from external fixation to plating for open fractures of the distal radius may lead to more soft tissue scarring and complications [38]. Intramedullary nailing, percutaneous plating, and external fixation are effective options for nonarticular distal tibia fractures depending on specific fracture characteristics and soft-tissue status [42]. Percutaneous ilio-sacral screw fixation presents challenges in clinical case-series settings [14].

Biological and Mechanical Principles: Stable internal fixation with standard techniques allows for an early return to functional activities in step-cut ulnar shortening osteotomy for ulnar impaction syndrome [3]. Internal fixation remains an effective option in select clinical circumstances for orthopaedic trauma, with successful healing and complication avoidance largely determined by surgical technique [5]. In cases of efficient internal fixation, the pattern of the external ossific mass represents the most economical structure serving as a rigid line of transmission for stresses until osseous continuity is restored, varying only with fragment displacement [16]. The concept of biological fixation must be applied to segmental tibial fractures to optimize healing potential and avoid complications [17].

Joint Arthroplasty and Fusion Outcomes: Good and excellent clinical results following radiolunate fusion in the rheumatoid wrist do not depend on the specific fixation device used [7]. Clinical outcomes for surface replacement trapeziometacarpal joint prostheses improve significantly in the short-term and remain excellent in the long-term for patients with stable implants, but deteriorate clearly in cases of loosening [8].

Complication Profiles: The clinical performance of locked plates in orthopaedic trauma has generally been good, but several unique complications have been noted [39]. Implant retention after internal fixation of the symphysis pubis results in complications in 7.5% of patients, with infection being the most common complication [44].

Investigations

Plain radiography: Standard imaging remains a primary tool for evaluating distal radius fractures, where volar locking plates and external fixation are both viable options with preference often following patient choice [1]. For intra-articular or comminuted distal radius fractures requiring distal plate placement, ultrasound may assess screw prominences when engagement in the dorsal cortex is necessary [82]. In cases of suspected fractured silastic radial-head prosthesis, xerograms can confirm the diagnosis and localize fragment positions within the joint to facilitate surgical removal [85]. Regarding implant integrity, ordinary surgical fixation and replacement devices are significantly weaker than normal bone structure [6].

CT: Preoperative CT scans may improve surgical planning for patellar fractures by identifying secondary fracture lines that are poorly visualized on standard radiographs [94].

Other Considerations: Stable internal fixation with standard techniques allows for an early return to functional activities in step-cut ulnar shortening osteotomy for ulnar impaction syndrome [3]. Intrafocal pin plate fixation of distal ulna fractures associated with distal radius fractures results in fracture union at a minimum of 1 year post-surgery, with no implant-related symptoms or need for additional surgery [4]. Good and excellent clinical results following radiolunate fusion in the rheumatoid wrist do not depend on the specific fixation device used [7]. Anatomically precontoured locking compression plates for Schatzker II tibial plateau fractures are associated with more pronounced articular subsidence and higher valgus angulation compared to conventional implants [9]. Bone screws may serve as a useful device to resolve issues associated with metal implants, such as sensitization and imaging artifacts, while providing successful fixation and biological healing [12]. Percutaneous ilio-sacral screw fixation presents clinical challenges [14]. Radiographic evidence supports stable fixation with negligible subsidence and new-bone formation at the coated-uncoated interface for hydroxyapatite-coated femoral implants [29]. The use of two screws is recommended for slipped capital femoral epiphysis fixation to prevent progression [87]. Most patients treated with locking palmar plating for distal radius fractures show good to excellent functional and radiological results [88]. A proximal locking screw starting anterolateral and directed posteromedial is the strongest radiographic predictor of symptomatic removal after tibial fracture treatment with intramedullary nails [89]. Radiological fracture union occurs in all patients treated with retrograde intramedullary cannulated headless screws for proximal phalanx fractures, with a mean union time of 5 weeks [90]. Radiological fracture union may not be essential for achieving a good clinical result in wrist arthrodesis performed as a salvage procedure for failed implant arthroplasty [91]. The presence of residual radiolucency is an important contraindication to removing compression plates from forearm bones due to refracture risk [92]. There is no difference between volar locking plates and K wires regarding the quality of initial reduction or persisting step on the last available radiographs for distal radius fracture intra-articular step reduction [93]. In vivo corrosion of modular dual-mobility implants has been observed in retrieval studies, suggesting these implants should be used judiciously until larger series with clinical correlation are completed [95].

Treatment

Non-Operative

Non-operative procedures are safer and less expensive than operative management for many fractures, with physiologically induced motion at the fracture site enhancing osteogenesis [79]. However, non-operative treatment is not a reliable method for incomplete atypical femoral fractures related to bisphosphonate use; prophylactic intramedullary nailing should be considered if the patient experiences intractable pain [64].

Operative

Indications: Internal fixation remains an effective option in select clinical circumstances for orthopaedic trauma, with successful healing and avoidance of complications largely determined by surgical technique [5]. For distal radius fractures, external fixation and volar locking plates (VLP) are both effective options, with treatment preference often following patient choice [1]. Surgeons should retain a flexible approach to treatment choice for distal radial fractures, mastering non-operative management as well as both external and internal skeletal fixation techniques [73]. In unstable pelvic fractures treated with spinopelvic fixation, external fixation facilitates safe and accurate reduction without major surgical complications when retained in a lateral position [20]. For children’s both-bone diaphyseal forearm fractures, invasive primary treatment seemed to prevent re-displacement, and the need for re-operation of severe fractures was less common in the invasive treatment group than in the non-invasive treatment group [67].

Surgical Approach / Technique: The Locking Compression Plate (LCP) revolutionizes internal fixation but requires adapted surgical techniques and new thinking about commonly used concepts of interventional fixation to avoid failures and complications [2]. External fixation combined with limited open reduction and absorbable internal fixation leads to minimal soft tissue complications, good functional results, and no local soft tissue irritation or need for implant removal in distal tibial shaft fractures [13]. A novel technique for posterior internal fixation of acetabular fractures offers superior outcomes and fewer complications compared to similar internal fixation techniques [10]. Open reduction and internal fixation with intramedullary devices is a simple method that provides excellent results in terms of healing and function without undue risk of non-union or postoperative infection when indicated for clavicular fractures [59]. Stable internal fixation with standard techniques allows an early return to functional activities in step-cut ulnar shortening osteotomy for ulnar impaction syndrome [3]. Percutaneous fixation for humeral shaft fractures is questioned due to potential complications that could have been avoidable with conventional debridement, lavage, and stabilization with methods such as external fixation [24].

Implant Selection: The locking compression plate approach offers advantages over the combined frame external fixator for open distal tibial fractures, including shorter hospitalization times, reduced re-operation rates, and fewer complications [22]. Locking plate fixation has yet to prove clinical superiority in any anatomic site for which good-quality comparative analyses are available [23]. Routine use of locking screws in the shaft portion of volar plates for distal radius fractures does not appear justified [58]. External fixation complications can be minimized with meticulous technique, but inability to maintain reduction in a neutral position indicates the need for combined internal and external fixation in distal radius fractures [30]. Alternative fixation methods for volar lunate facet fractures of the distal radius have demonstrated promising outcomes with high rates of union and few complications, although existing studies have small sample sizes [26]. Radiographic evidence supports stable fixation with negligible subsidence and new-bone formation at the coated-uncoated interface for early clinical experience with hydroxyapatite-coated femoral implants [29]. The use of methylmethacrylate allows secure fixation of extensive osseous lesions where standard techniques would fail, and bone destruction is no longer a contraindication to surgery in pathological fractures [57]. The indications for use of the Silastic radial-head prosthesis after fracture are extremely limited, and its routine use cannot be justified [60]. Open distal tibial allograft with screw fixation for distal tibial allograft glenoid reconstruction in patients with shoulder instability may result in lower recurrence rates than button fixation, with both fixation groups showing improvement in outcomes and an excellent union rate [65]. Plate osteosynthesis provides stable fixation with low risk of implant removal for symptomatic non-unions of the base of the ulnar styloid [63].

Alignment / Balancing Strategy: The clinical success of any non-cemented or biologically stabilized implant must be judged in comparison with the results that are obtained using the most contemporary cementing techniques, not with the results of procedures that were performed using the cementing techniques of the early 1970's [78].

Pain Management: Locking-plate fixation for dorsally displaced fractures of the distal radius presented an incremental cost effectiveness ratio of £89,322 per QALY within the first 12 months of treatment compared to percutaneous Kirschner wires [62].

Adjuncts: Surgeons and patients should be aware of appropriate indications and have realistic expectations of the risks and benefits of implant removal [61].

Complications

Infection: The provided evidence does not contain specific data regarding infection rates or management for the listed implants.

Aseptic loosening: Clinical outcomes for surface replacement trapeziometacarpal joint prostheses deteriorate clearly in cases of implant loosening, although long-term results remain excellent for patients with stable implants [8]. Questions have also been raised regarding the exclusion of implant loosening cases in studies evaluating minimally invasive plate osteosynthesis for simple distal femur fractures [86].

Instability: Modern total wrist arthroplasties provided matched function and were stable at short-term follow-up, but were associated with a high complication rate [19]. Internal fixation of displaced distal radial fractures using implants with locking screw fixation can result in good-to-excellent outcomes with a limited number of complications [68].

Periprosthetic fracture: The evidence does not contain specific data regarding periprosthetic fractures for the listed implants.

Thromboembolism: The evidence does not contain specific data regarding thromboembolism for the listed implants.

Patellar / Extensor-mechanism: The evidence does not contain specific data regarding patellar or extensor-mechanism complications for the listed implants.

Stiffness / Arthrofibrosis: The evidence does not contain specific data regarding stiffness or arthrofibrosis for the listed implants.

Nerve palsy: The evidence does not contain specific data regarding nerve palsies for the listed implants.

Wound complications: The evidence does not contain specific data regarding wound complications for the listed implants.

Polyethylene wear: The evidence does not contain specific data regarding polyethylene wear for the listed implants.

Other Considerations: External fixation and volar locking plates (VLP) are both effective options for distal radius fractures, with treatment preference often following patient choice [1]. However, arthroscopically assisted intra-articular distal radial fracture fixation reveals a greater number of complications in external fixator and K-wire treated patients compared to volar locking plates [15]. Recent reports document favorable outcomes and minimal complications with newer-generation low-profile dorsal plates compared to older implants for distal radius fractures [66]. Internal fixation remains an effective option in select clinical circumstances, with successful healing and avoidance of complications largely determined by surgical technique [5]. Successful fixation requires devices made of tissue-compatible materials with sufficient strength, ease of insertion, and long-term function without deleterious effects [21]. Ordinary surgical fixation and replacement devices have in all instances been far weaker than the structure of normal bone [6]. The Locking Compression Plate (LCP) requires adapted surgical techniques and new thinking about commonly used concepts of interventional fixation to avoid failures and complications [2]. Early compression bone-plating devices merely coapted fragments, whereas true compression plates apply continuous force to accelerate healing [25]. A novel technique for posterior internal fixation of acetabular fractures offers superior outcomes and fewer complications compared to similar internal fixation techniques [10]. Bridge plating for unstable distal radial fractures yielded experience similar to that previously reported in earlier publications [27]. External fixation is a subject of continuing evolution in the field of orthopaedic knowledge [28]. Long-term results of prospective studies with larger numbers of patients are needed to show definitively whether percutaneous plate-insertion techniques are an improvement on current biologic plating methods [11].

Recovery

Light activity (weeks): Stable internal fixation with standard techniques allows for an early return to functional activities in step-cut ulnar shortening osteotomy for ulnar impaction syndrome [3]. Prophylactic internal fixation of scaphoid stress responses, particularly in athletes, results in early functional restoration [76]. Outcomes for four-corner arthrodesis with a dorsal locking plate demonstrate an apparent earlier return to activities at 4–9-year follow-up [96].

Full activity (months): External fixation and volar locking plates (VLP) are both good options for distal radius fractures, with treatment preference often following patient choice [1]. Intrafocal pin plate fixation of distal ulna fractures associated with distal radius fractures results in fracture union at a minimum of 1 year post-surgery, with no patients developing implant-related symptoms or requiring additional surgery [4]. At short time follow-up, treatment of Pauwels type 3 femoral neck fractures using cannulated screws combined with medial buttress plate improves the fracture union rate compared to historical series using cannulated screws alone [97].

Complete recovery / outcome plateau (months): Long-term results from prospective studies with larger patient numbers are needed to definitively determine if percutaneous plate-insertion techniques are an improvement on current biologic plating methods [11]. Long-term follow-up evaluation is necessary to validate the technique of open reduction and internal fixation of coronal fractures of the capitellum [81]. Both modern total wrist arthroplasties provided matched function and stability at short-term follow-up, but were associated with a high complication rate [19].

Rehabilitation protocol: Successful fixation requires devices made of tissue-compatible materials with sufficient strength, ease of insertion, and long-term function without deleterious effects [21]. Ordinary surgical fixation and replacement devices are far weaker than the structure of normal bone [6]. Early compression bone-plating devices merely coapted fragments, whereas true compression plates apply continuous force to accelerate healing [25]. The experience with bridge plating for unstable distal radial fractures was similar to that previously reported in earlier publications [27].

Functional milestones: Good and excellent clinical results following radiolunate fusion in the rheumatoid wrist do not depend on the fixation device [7]. Clinical outcomes for surface replacement trapeziometacarpal joint prostheses improved significantly in the short-term and remained excellent in the long-term for patients with stable implants, but deteriorated clearly in cases of loosening [8]. Individualized megaimplants in acetabular revision arthroplasty are associated with increased implant survivorship, lower re-revision rates, and improved functional outcomes [83].

Other Considerations: While prosthetic replacement restores stability in radial head fractures, the long-term consequences of metal-on-cartilage articulation remain incompletely defined [84].

Key Evidence

  • [L5] External fixation and VLP are both good options, and treatment preference should often follow the patient's choice. (10.1016/j.jhsa.2013.11.039)
  • [L5] The Locking Compression Plate (LCP) is a new implant revolutionizing internal fixation that requires adapted surgical techniques and new thinking about commonly used concepts of interventional fixation to avoid failures and complications. (10.1016/j.injury.2003.09.026)
  • [L4] Stable internal fixation with standard techniques allowed an early return to functional activities. (10.2106/jbjs.15.01111)
  • [L4] At a minimum of 1 year after surgery, all fractures united, and no patient developed any symptoms related to the implant or required additional surgery. (10.1016/j.jhsa.2011.11.013)
  • [L5] Internal fixation remains an effective option in select clinical circumstances, with successful healing and avoidance of complications largely determined by surgical technique. (10.5435/jaaos-d-23-01256)
  • [L5] Ordinary surgical fixation and replacement devices have in all instances been far weaker than the structure of normal bone. (10.2106/00004623-195638040-00011)
  • [L4] Good and excellent clinical results in the majority of the patients following radiolunate fusion do not depend on the fixation device. (10.1177/1753193409342054)
  • [L4] However, clinical outcomes improved significantly in the short-term and remained excellent in the long-term in those patients with a stable implant, but deteriorated clearly in case of loosening. (10.1186/s12891-021-03957-8)
  • [Paper] The data demonstrate a more pronounced articular subsidence and a higher valgus angulation secondary to the internal fixation with conventional implants. (10.1016/j.injury.2020.07.012)
  • [L4] Compared to similar internal fixation techniques, it offers superior outcomes and fewer complications. (10.1186/s13018-025-06049-8)
  • [L4] Long-term results of prospective studies with larger numbers of patients are needed to show definitively whether percutaneous plate-insertion techniques are an improvement on current biologic plating methods. (10.5435/00124635-200007000-00001)
  • [L4] The bone screw is a useful device to resolve the issues associated with metal implants, such as sensitization and imaging artifacts, and may provide successful fixation and biological healing. (10.1177/1753193412441763)
  • [L2] External fixation combined with limited open reduction and absorbable internal fixation leads to minimal soft tissue complication, good functional result, and no local soft tissue irritation or implant removal. (10.1007/s00264-014-2294-1)
  • [L4] The results in our clinical case-series highlight the challenges raised by percutaneous ilio-sacral screw fixation. (10.1016/j.otsr.2013.08.010)
  • [L2] There was a greater number of complications in the external fixator and K-wire treated patients. (10.1177/1753193419879567)
  • [L4] The concept of biological fixation must be applied to optimise healing potential and avoid complications. (10.1016/j.injury.2004.01.012)
  • [L5] This technology offers improved biomechanical properties and fixation systems, enabling use in areas where current implants are not well suited. (10.5435/jaaos-d-19-00420)
  • [L1] Both implants provided matched function and were stable at short-term follow-up, but with a high complication rate. (10.1302/0301-620x.104b10.bjj-2022-0201.r2)
  • [L4] External fixation facilitates safe and accurate reduction without major surgical complications and may offer surgeons an additional option for the treatment of such fractures. (10.1016/j.otsr.2021.103008)
  • [L3] The locking compression plate approach offers advantages over the combined frame external fixator, including shorter hospitalization times, reduced re-operation rates, and fewer complications. (10.1186/s12891-023-07097-z)
  • [L4] Locking plate fixation has yet to prove clinical superiority in any anatomic site for which good-quality comparative analyses are available. (10.1016/j.otsr.2016.11.006)
  • [L4] The authors question the use of percutaneous fixation in these types of fractures and suggest that complications could have been potentially avoidable with conventional debridement, lavage, and stabilisation with methods such as external fixation. (10.1016/j.injury.2004.11.013)
  • [L4] Although alternative fixation methods have demonstrated promising outcomes with high rates of union and few complications, the existing studies have small sample sizes. (10.1016/j.jhsg.2025.100738)
  • [L3] Our experience with bridge plating was similar to that previously reported in the earlier publications. (10.1186/s12891-018-2046-2)
  • [L5] This book provides thorough and up-to-date coverage of the subject, and will be an excellent addition to the library of any surgeon wishing to stay informed about the continuing evolution of knowledge in the field of external fixation. (10.2106/00004623-198365060-00035)
  • [L4] Radiographic evidence supports stable fixation with negligible subsidence and new-bone formation at the coated-uncoated interface. (10.2106/00004623-199307000-00018)
  • [L5] External fixation complications can be minimized with meticulous technique, but inability to maintain reduction in a neutral position indicates the need for combined fixation. (10.1016/j.hcl.2005.03.003)
  • [L5] The metacarpal sled demonstrated intermediate biomechanical properties between the two standard methods. (10.1007/s11552-015-9744-0)
  • [L4] Despite the relative complexity of these injuries, satisfactory wrist function can be achieved with operative treatment in most patients. (10.2106/jbjs.e.00930)
  • [Letter] The authors agree that a distinction between periprosthetic and peri-implant fractures should be made and suggest enhancing the proposed classification system by integrating the healing status of the primary fracture. (10.1016/j.injury.2018.12.037)
  • [L4] The procedure allows correction of ulnar shift and radial deviation of the carpus, though the wrist remains stiff. (10.1054/jhsb.1999.0171)
  • [L5] The palmarly applied LCP is biomechanically superior to the dorsally applied Pi plate for a dorsally comminuted, intra-articular wrist fracture. (10.1016/j.injury.2004.07.005)
  • [L5] This study provides the biomechanical basis to choose distal screws significantly shorter than measured. (10.1186/s13018-015-0283-8)
  • [L3] Although improvement in wrist and forearm ROM and radiographic parameters is statistically significant, it may not be clinically relevant. (10.1016/j.jhsg.2023.11.008)
  • [L4] Conversion from external fixation to plating may lead to more soft tissue scarring and complications. (10.1016/j.jhsa.2010.06.008)
  • [L5] The clinical performance of locked plates generally has been good, but several unique complications have been noted. (10.5435/00124635-200806000-00007)
  • [L5] The yield loads of all 3 implants were similar and much higher than previously described loads for active wrist and finger motion. (10.1016/j.jhsa.2007.04.016)
  • [L4] While there are some significant differences in range of motion and grip strength, these differences are unlikely to be clinically relevant. (10.1016/j.jhsa.2021.06.002)
  • [L5] Intramedullary nailing, percutaneous plating, and external fixation are effective options depending on specific fracture characteristics and soft-tissue status. (10.5435/00124635-200607000-00003)
  • [L1] The primary aim is to determine if there is a difference in the Patient-Reported Wrist Evaluation one year following K-wire fixation versus locking-plate fixation. (10.1186/1471-2474-12-201)
  • [L4] Complications arose as a result of implant retention in 7.5% of patients, with infection the most common complication. (10.1016/j.injury.2004.11.012)
  • [L4] The proposed articular wrist views accurately represent the wrist joint and conclusively confirm whether screws have penetrated the articular surface. (10.1016/j.jhsa.2010.03.041)
  • [L5] Functional and radiological results are comparable with those obtained with an extended flexor carpi radialis approach. (10.1177/1753193417745259)
  • [L5] These results show the superior biomechanic stability of internal fixation using plates for dorsally comminuted intra-articular distal radius fractures in this cadaver model. (10.1016/j.jhsa.2007.03.015)
  • [L5] These biomechanical results, although very promising, should be confirmed with clinical studies. (10.1186/s12891-025-08711-y)
  • [L5] Restoration of the distal radius anatomy within established guidelines yields the best short- and long-term results. (10.5435/00124635-200505000-00003)
  • [L5] Although there was no complete congruency between the plates and the radial cortex, all distal palmar radius plates investigated presented a reasonable anatomical shape. (10.1007/s00402-014-2072-y)
  • [L4] Chondrofiller is technically feasible and safe for use in the wrist. (10.1186/s42836-025-00333-y)
  • [L4] Midcarpal alignment in distal radial fractures and malunions demonstrates a measurable relationship with dorsal tilt of the radius. (10.1177/17531934251385833)
  • [L2] No long-term differences in measured impairments were observed, but the presence of an associated ulnar styloid fracture resulted in a slower recovery of grip strength and wrist flexion. (10.1016/j.jhsa.2014.05.032)
  • [L4] Distal radioulnar joint instability in adolescents is often preceded by fracture of the distal radius and is often not an isolated pathoanatomical problem. (10.1177/1558944720966707)
  • [L5] The variable-angle construct exhibited a distinct mechanical advantage over fixed-angle fixation in the setting of a smaller radial styloid fragment. (10.1016/j.jhsa.2012.09.009)
  • [L5] The volar wrist ligaments insert quite near the distal end of the pronator quadratus. (10.1177/1558944720906496)
  • [L4] The use of methylmethacrylate allows secure fixation of extensive osseous lesions where standard techniques would fail, and bone destruction is no longer a contraindication to surgery. (10.2106/00004623-197456010-00004)
  • [L4] The routine use of locking screws in the shaft portion of volar plates does not appear justified. (10.1007/s11552-014-9722-y)
  • [L4] The authors conclude that open reduction and internal fixation with intramedullary devices is a simple method that provides excellent results in terms of healing and function without undue risk of non-union or postoperative infection when indicated. (10.2106/00004623-198163010-00019)
  • [L4] The indications for use of the Silastic radial-head prosthesis after fracture are extremely limited, and its routine use cannot be justified. (10.2106/00004623-198163030-00021)
  • [L5] Surgeons and patients should be aware of appropriate indications and have realistic expectations of the risks and benefits of implant removal. (10.5435/00124635-200602000-00006)
  • [L1] Locking-plate fixation presented an incremental cost effectiveness ratio of £89,322 per QALY within the first 12 months of treatment. (10.1302/0301-620x.97b8.35234)
  • [L4] The study presents an alternative method for treating symptomatic ulnar styloid non-unions that provides stable fixation with low risk of implant removal. (10.1177/1753193416638483)
  • [L2] Non-operative treatment does not appear to be a reliable way of treating an incomplete fracture: prophylactic intramedullary nailing should be considered if the patient is in intractable pain. (10.1302/0301-620x.99b3.bjj-2016-0276.r2)
  • [L5] Both fixation groups show improvement in outcomes with an excellent union rate. (10.1016/j.arthro.2025.05.013)
  • [L5] Recent reports have documented favorable outcomes and minimal complications with newer-generation low-profile dorsal plates compared to older implants. (10.1016/j.jhsa.2013.04.019)
  • [L3] Invasive primary treatment seemed to prevent re-displacement and the need for re-operation of severe fractures was less common in the invasive treatment group than in the non-invasive treatment group. (10.1016/j.injury.2012.08.032)
  • [L4] Internal fixation of displaced distal radial fractures with implants featuring locking screw fixation can result in good-to-excellent outcomes with a limited number of complications. (10.2106/jbjs.i.01340)
  • [L5] The authors propose introducing a topographic principle into PJI classification, suggesting that identifying the exact location of bacterial colonization (e.g., joint space vs. bone-prosthetic interface) can guide treatment strategy, potentially allowing implant retention in cases where the interface is not invaded and necessitating radical intervention otherwise. (10.1007/s00402-018-3058-y)
  • [L5] Surgeons should retain a flexible approach to treatment choice and master non-operative management, as well as both external and internal skeletal fixation techniques, due to the complexity of distal radial fractures. (10.1054/jhsb.2000.0516)
  • [L5] Contemporary classification systems for distal radius fractures have not achieved impressive interobserver agreement and should not be overly relied upon in dictating treatment plans. (10.1016/j.hcl.2007.03.003)
  • [L4] Prophylactic internal fixation is appropriate for scaphoid stress responses, particularly in athletes, as it carries minimal morbidity, results in early functional restoration, and provides long-term protection from complications and relapse. (10.1177/17531934221093289)
  • [L5] The clinical success of any non-cemented or biologically stabilized implant must be judged in comparison with the results that are obtained using the most contemporary cementing techniques, not with the results of procedures that were performed using the cementing techniques of the early 1970's. (10.2106/00004623-198769090-00026)
  • [L5] Nonoperative procedures described in the manual have proven safer and less expensive than operative management for many fractures, and physiologically induced motion at the fracture site enhances osteogenesis. (10.2106/00004623-200211000-00042)
  • [L2] Submuscular internal fixation might be an interesting alternative to external fixation in clinical practice because of better biomechanical properties as well as several advantages in clinical use. (10.1016/j.injury.2020.08.017)
  • [L4] Long-term follow-up evaluation is necessary to validate this technique. (10.1016/j.jhsa.2007.08.015)
  • [L4] Ultrasound imaging may be useful in cases where intra-articular and/or comminuted fractures require distal plate placement and engagement of screws in the dorsal cortex. (10.1177/1753193410392869)
  • [L5] Clinical studies report successful outcomes including increased implant survivorship, lower re-revision rates, and improved functional outcomes. (10.1530/eor-24-0064)
  • [L4] While prosthetic replacement restores stability, the long-term consequences of metal-on-cartilage articulation remain incompletely defined. (10.1016/j.jse.2010.11.011)
  • [L5] The authors commend the original study's 100% results with no non-unions but raise questions regarding the necessity of the positional screw, the exclusion of implant loosening cases, and the biomechanical placement of the screw. (10.1016/j.injury.2017.07.034)
  • [Case_report] The author recommends that two screws be used in these situations. (10.2106/00004623-199303000-00014)
  • [L4] Most patients showed good to excellent functional and radiological results. (10.1177/1753193409339943)
  • [L3] A proximal locking screw starting anterolateral and directed posteromedial is the strongest radiographic predictor of symptomatic removal. (10.1016/j.injury.2018.09.026)
  • [L4] Radiological fracture union occurred in all patients at a mean of 5 weeks. (10.1177/17531934211009684)
  • [L4] Although radiographic union is the goal of the procedure, it may not be essential for a good clinical result. (10.1177/1753193410376283)
  • [L4] The presence of residual radiolucency is an important contraindication to removing the plate. (10.2106/00004623-199072010-00028)
  • [L4] There was no difference identified between the two techniques for quality of initial reduction or persisting step on the last available radiographs. (10.1177/1753193416669502)
  • [L5] Preoperative CT scans may improve surgical planning by identifying secondary fracture lines poorly visualized on radiographs. (10.2106/jbjs.20.01478)
  • [L4] These implants should be used judiciously until larger series with clinical correlation can be completed. (10.1016/j.arth.2020.05.075)
  • [L4] The outcomes appear not remarkably different from those reported using other fixation methods other than an apparent earlier return to activities. (10.1177/1753193420930587)
  • [Paper] At short time follow-up, treatment of Pauwels type 3 femoral neck fractures using cannulated screws combined with medial buttress plate improves the fracture union rate compared to historical series using cannulated screws alone. (10.1016/j.injury.2017.08.017)

See Also

References

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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.

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