Acta chir belg, 2004, 104, 401-412

Fractures of the Distal Radius : a Contemporary Approach

S. Nijs, P. L. O. Broos Dpt. of Traumatology, University Hospitals Leuven, Belgium.

Key words. Distal radius !rist fun"tional anatomy fra"ture treatment revie!. Abstract. T#e fra"ture of t#e distal radius is t#e most "ommon fra"ture !e treat. $lt#oug# sometimes stated ot#er!ise, t#e out"ome of t#ese fra"tures is not uniformly good regardless t#e treatment instituted. $ t#oroug# understanding of t#e anatomy and %iome"#ani"s of t#e !rist is a prere&uisite !#en treating t#ese lesions. T#e literature proves t#at t#ere is a stri"t relations#ip %et!een t#e &uality of anatomi"al re"onstru"tion and t#e long-term fun"tional out"ome. 'e try to "larify t#e "omple( fun"tional anatomy of t#is region. )o single treatment is t#e solution for every type of fra"ture in every *ind of patient. Based on t#e fun"tional anatomy, !e analy+e t#e a"tual treatment possi%ilities and try to develop strategies in t#e "#oi"e of treatment for different fra"ture types in different patient groups. Treatment aims s#ould %e to re"onstru"t t#e anatomy as good as possi%le, to guar- antee t#at t#ere is no loss of redu"tion and to allo! for a fun"tional after treatment as soon as possi%le.

ntroduction ,ra"tures of t#e distal radius are t#e most "ommon fra"tures !e treat. -ore t#an a si(t# of all fra"tures !e see at our emergen"y department are fra"tures of t#e distal radius. $lt#oug# t#e fre&uen"y of presentation of t#is fra"ture is e(tremely #ig#, t#ere are little or no eviden"e- %ased guidelines for its treatment .1/, 001. 2f "ourse, t#ere "an %e no general treatment advi"e "overing all fra"tures, sin"e t#e polyfragmentary arti"ular fra"ture resulting of a #ig#-energy trauma, "an %y no means %e "ompared to t#e e(tra-arti"ular, #ypere(tension fra"ture of t#e aged, osteoporoti" !omen. 2n t#e ot#er #and, t#is la"* of overall guidelines may not lead to t#erapeuti" ni#ilism %ased on t#e almost t!o #undred year old, famous statement of $%ra#am 32LL45 .11 6 72ne "onsolation only remains, t#at t#e lim% !ill at some remote period again en8oy perfe"t freedom in all of its motions and %e "ompletely e(empt from pain 6 t#e deformity, #o!ever, !ill remain undiminis#ed t#roug# life9. Treatment advi"es t#at are more t#an 200 years old, dating of an era !#ere t#ere !as no roentgen te"#nology, little or no anaest#esia, no plaster of :aris, no osteosynt#esis ; #ave little or no impa"t on today<s treatment. '#en dis"ussing t#e treatment of distal radius fra"tures, one is often "onfronted !it# t#is statement of $%ra#am 32LL45, despite 200 year of medi"al literature proving t#e "omple(ity and non-solved pro%lems in treating distal radius fra"tures. =n no ot#er fra"ture, intra-arti"ular malunion and metap#yseal malalignment is so %roadly a""epted. '#en treating t#ese fra"tures, t#e surgeon must #ave a t#oroug# *no!ledge of t#e anatomy of t#is region. T#e

!rist 8oint is "omposed of t#ree separate 8oints 6 t#e radio-"arpal, t#e ulno-"arpal and t#e distal radio-ulnar 8oint. $ malalignment or dysfun"tion of one of t#ese 8oints inevita%ly leads to a dysfun"tion of t#e !rist as a !#ole. Beside t#e %ony "artilaginous anatomy, also t#e radio-"arpal, ulno-"arpal and inter"arpal ligaments and t#e triangular fi%ro "artilaginous "omple( seem to %e of utmost importan"e. $lt#oug# t#e e(a"t role of t#e separate anatomi"al stru"tures and t#eir intera"tions is not yet fully "larified, !e *no! t#at a dysfun"tion of t#ese stru"tures "an lead to a %ad out"ome after a fra"ture of t#e distal radius. 3onsidering t#e "omple(ity and #eterogeneity of t#e fra"ture and "onsidering t#e importan"e of t#e soft tissues, it is "lear t#ere is no tailor-made ans!er to t#e &uestion #o! to treat a fra"ture of t#e distal radius. T#e surgeon !ill #ave 7to read9 t#e fra"ture and soft tissues and !ill t#an #ave to ma*e up a treatment plan. )ot only anatomi"al and %iome"#ani"al fa"ts s#ould %e ta*en into a""ount in t#is plan, %ut also t#e spe"ifi" demands and needs of t#e patient s#ould #ave a pla"e in t#e plan, sin"e !e are not treating %ones %ut patients. Today<s sur- geon needs to master different te"#ni&ues, "onservative and operative, !#en treating fra"tures of t#e distal radius. 'e !ill try to give some o%8e"tive tools to dif- ferentiate %et!een different types of fra"ture treatment. 2f "ourse, t#ese tools "annot repla"e sound surgi"al 8udgment and e(pertise. !pidemiolo"y and fracture mechanism T#e fra"ture of t#e distal radius a""ounts for 10-2>? of all fra"tures seen at our emergen"y department .21.

14@
Traditionally a %i-modal in"iden"e pea* is des"ri%ed. $ first pea* is seen in young men related to #ig#-energy trauma a se"ond mu"# more important pea* is re"orded in t#e post-menopausal female and is related to lo!energy trauma. $ "lear relations#ip to osteoporosis .01 and repeated falling .41 "an %e demonstrated. =t is typi"ally t#e middle-aged female patient !#o -, %eing less de%ilitated t#an t#e more elderly - tries to stop #er fall and lands on t#e outstret"#ed #and. T#e more de%ilitated elderly person la"*s t#is defensive response and lands dire"tly on #erA #is #ip. T#is "an e(plain !#y #ip fra"- tures %e"ome more fre&uent t#an !rist fra"tures in females older t#an seventy-five. 4spe"ially in t#e middle-aged group, postural insta%ility is mu"# more present in t#e female population as in t#e male, e(plaining t#e gender differen"e in prevalen"e to some a""ount. -ost "ertainly a !rist fra"ture "an %e t#e signal t#at pos- tural sta%ility and osteoporoti" "#anges s#ould %e inves- tigated and if possi%le "orre"ted. =f not, it "an %e t#e start of a series of osteoporosis-related fra"tures to t#e #ip, verte%ral "olumn and pro(imal #umerus. T#e fra"ture !it# dorsal dislo"ation .:outeau or 3olles< fra"ture1 #as traditionally %een seen as t#e e(ten- sion fra"ture, "aused %y a fall on t#e outstret"#ed #and and t#e fra"ture !it# volar displa"ement .5mit#Boyrand1 as t#e fle(ion fra"ture "aused %y a fall on t#e #yperfle(ed !rist. T#is vie! #as %een "#allenged %y %ot# 5T2,,4L4) .>1 and :43HL$)4C .@1, %ot# proving t#at every fra"ture pattern "an %e "aused %y a fall on t#e outstret"#ed #and !it# e("lusion of t#e avulsion fra"ture. =n t#e female osteoporoti" %one in /0? of all "adaver models resulted in a fra"ture lo"o typi"o, in t#e male only in >>? of t#e models a fra"ture lo"o typi"o "ould %e reali+ed. =n a prospe"tive one-year study in Bergen .)or!ay1, a fall !#ile !al*ing !as t#e most "ommon "ause of fra"- tures of t#e distal radius. =n t#is study, fra"tures of t#e distal radius o""urred t!i"e as often as fra"tures of t#e pro(imal #umerus in t#e same population, %ut persons sustaining fra"tures of t#e distal radius !ere relatively more #ealt#y and a"tive t#an t#ose sustaining a fra"ture of t#e pro(imal #umerus .D1. Classification T#ere !ill only %e fe! %ody regions in !#i"# as many eponymous "lassifi"ation systems e(ist as for t#e distal radius. -any of t#em are merely of #istori"al interest. $ good "lassifi"ation system s#ould #ave a lo! inter- and intra-o%server varian"e, s#ould %e easy to use, s#ould %e easy to "ompute, s#ould #ave a prognosti" value and s#ould #ave dire"t t#erapeuti" "onse&uen"es. -any of t#e proposed systems tend to #ave t#ese advantages, %ut mostly t#e inter- and intra-o%server reprodu"i%ility seems to %e a ma8or pro%lem. T#e $2A$5=, "lassifi"a-

S. Nijs and P. L. O. Broos

tion as proposed %y -ELL4C .F1 seems to "om%ine most of t#e re&uired "riteria, alt#oug# t#is is also "ontroversially dis"ussed. T#e "lassifi"ation differentiates %et!een non-arti"ular .$-type1, partially arti"ular .Btype1 and "omplete arti"ular .3-type1 fra"tures. T#e furt#er differentiation is %ased on "omminution and dire"tion of fra"ture lines. T#is results in 2D su%groups !#i"# are useful for s"ientifi" differentiation. =n daily pra(is, t#e / groups are more useful .,ig. 11. Functional anatomy 2f "ourse, t#e t#oroug# des"ription of t#e anatomy of t#e distal radius and "arpal region is not t#e s"ope of t#is arti"le. 2n t#e ot#er #and, a %asi" *no!ledge of t#e fun"tional anatomy is a prere&uisite for fra"ture understanding and good treatment. T#e arti"ular surfa"e of t#e distal radius is %i"on"ave and triangular !it# t#e ape( of t#e triangle dire"ted to!ards t#e styloid pro"ess, t#e %ase represents t#e sigmoid not"# for arti"ulation !it# t#e ulnar #ead. T#e surfa"e is divided into t!o fa"ets %y a !ell-defined ridge. 2ne fa"et, t#e fossa lunata arti"ulates !it# t#e lunate %one t#e se"ond, t#e fossa s"ap#oidea arti"ulates !it# t#e s"ap#oid %one. T#e volar surfa"e of t#e distal radius is relatively flat. =t is "overed pro(imally %y t#e pronator &uadratus mus"le. T#e fle(or tendons and t#e median nerve lay more superfi"ially. T#e dorsal surfa"e is "onve(. Bet!een t#e se"ond and t#e t#ird e(tensor "ompartment t#ere is a %ony ridge, Lister<s tu%er"le. T#e e(tensor tendons are only separated from t#e %ony surfa"e %y t#e floor of t#e e(tensor retina"ulum and t#e periostium. T#ese anatomi" relations %et!een t#e si( e(tensor "ompartments, t#e retina"ulum e(tensorum and t#e dorsal radial "orte( are of e(treme importan"e for t#e dorsal surgi"al approa"#es to t#e distal radius. T#e dire"t arti"ulation %et!een t#e distal ulna and t#e "arpus is less important. =t is "overed %y a "omple( "artilaginous stru"ture, t#e triangular fi%ro "artilaginous "omple( .T,331. =t is t#e development of t#is T,33 "om%ined !it# t#e la"* of a true ulno-"arpal 8oint t#at differentiates t#e #and of t#e #uman of t#at of lo!er primates and gives t#e #uman !rist its e(treme freedom of movement. 2n t#e ot#er #and, t#e T,33 is a stru"ture t#at is very sensi%le to trauma and degeneration and "an %e a sour"e of ulnar !rist pain t#at is diffi"ult to treat. T#e distal radio-ulnar 8oint .DCUG1 is of e&ual impor- tan"e as t#e radio-"arpal 8oint. =t is "omposed of t#e fi(ed ulnar #ead and t#e sigmoid not"#. T#is sigmoid not"# not only rotates around t#e ulnar #ead, %ut it ma*es at t#e same time a translational movement. =n pronation, t#e ulnar #ead moves dorsally in t#e sigmoid not"# in supination it is displa"ed anteriorly. T#e most important sta%ili+er of t#e DCUG is t#e T,33,

Fig. 1 T#e $2 "lassifi"ation

additional sta%ili+ers are t#e interosseous mem%rane of t#e forearm, pronator &uadratus mus"le and t#e tendons and s#eets of t#e e(tensor and fle(or "arpi ulnaris mus"les. $s t#e intera"tion of all of t#ese stru"tures is of t#e utmost importan"e for sta%ility and motion, deformity after in8ury or fra"ture #as an important influen"e on t#e fun"tion of t#e entire !rist. T#e %ony ar"#ite"ture of t#e distal radius "an %e vie!ed in terms of "olumns. C=HL= and C4B$II2)= .D1 divided t#e distal forearm in t#ree "olumns 6 t#e medial "olumn "onsisting of t#e ulna, t#e T,33 and t#e DCUG t#e intermediate "olumn made up of t#e fossa lunata and t#e sigmoid not"# and t#e lateral "olumn in"luding t#e fossa s"ap#oida and t#e styloid pro"ess. ,ra"ture lines often run %et!een t#ese "olumns. T#e intermediate "olumn "an also %e split in a sagittal plane, "reating t#e dorsal and t#e volar intermediate fragment. T#e surgi"al re"onstru"tion of t#e distal radius s#ould %e %ased on t#e *no!ledge of t#ese "olumns. $lmost F0? of t#e trans- mitted for"es go over t#e distal radius %y longitudinal

loading of t#e !rist, if radius and ulna are e&ually long .ulna neutral1. Lengt#ening of t#e ulna s#ifts for"e trans- mitting in t#e dire"tion of t#e ulna, !#ereas ulnar s#ort- ening s#ifts for"es to!ards t#e radius. Radiolo"ical anatomy Besides t#e *no!ledge of t#e %ony and ligamentous ar"#ite"ture of t#e distal radius, t#e surgeon treating fra"tures of t#e distal radius needs to #ave a t#oroug# *no!ledge of t#e radiologi"al anatomy of t#e !rist. 2ne "onsiders t#e ulnar in"lination, t#e palmar in"lination, t#e radial lengt#, t#e ulnar varian"e and t#e radial !idt#. Ulnar in"lination .,ig. 21 is defined as t#e angle %et!een a line perpendi"ular to t#e long a(is of t#e radius and a line dra!n from t#e tip of t#e radial styloid pro"ess to t#e ulnar "orner of t#e arti"ular surfa"e of t#e distal radius. T#e mean ulnar in"lination is 22-20J. T#ere is #o!ever a strong interindividual varia%ility and strong

Fig. 2 Ulnar in"lination

influen"e of "#oi"e of anatomi"al landmar*s and positioning .pro-supination1. :almar in"lination .,ig. 01 is defined as t#e angle %et!een a line "onne"ting t#e most distal point of t#e dorsal and palmar "orti"al rims and a line perpendi"ular to t#e longitudinal a(is of t#e radius. T#e angle is on average 10-12J, %ut again an interindividual varia%ility of 4-22J among normal individuals is o%served. Cadial #eig#t .,ig. 41 is measured on an $:-radiograp#. =t is t#e distan"e %et!een t!o lines perpendi"ular to t#e long a(is of t#e distal radius t#e first one going t#roug# t#e tip of t#e styloid pro"ess, t#e se"ond one at t#e level of t#e arti"ular surfa"e of t#e ulnar #ead. T#e distan"e %et!een a line parallel to t#e fossa lunata and a line parallel to t#e ulnar #ead is "onsidered to %e t#e ulnar varian"e .,ig. >1. T#is s#ould %e "ompared !it# t#e unin8ured side as again interindividual varian"e is large .ulna K 2mm to L 2 mm1. =n "ase of a fra"ture,

Fig. 3 Molar tilt

t#e ulna is mostly in a relatively positive variation due to t#e s#ortening of t#e radius. Cadial !idt# .,ig. @1 is defined as t#e distan"e %et!een t!o lines parallel to t#e longitudinal a(is, one going t#roug# t#e most lateral tip of t#e styloid pro"ess and one going t#roug# t#e "entre of t#e radius on an $:- radiograp#. $n in"reased radial !idt# as "ompared !it# t#e non-in8ured side is a strong indi"ation for rotational malalignment and as su"# a predi"tor of %ad fun"tional out"ome. $dditional radiologi"al investigations "an %e of value. T#e true "omminution at t#e arti"ular surfa"e and t#e dislo"ation of intra-arti"ular fragments "an %etter %e

Fig. 4 Cadial #eig#t

Fig. 5 Ulnar varien"e

8udged on "omputed tomograp#y. 2f "ourse, t#is s#ould not %e part of t#e routine investigations for distal radius fra"tures. $rt#rograp#y or "omputed tomograp#y !it# intra-arti"ular "ontrast "an %e of value to dete"t asso"iated lesions of t#e intrinsi" "arpal ligaments andAor t#e T,33. T#eoreti"ally, -C= seems to #ave t#e same potential, %ut its feasi%ility and a""ura"y in t#e a"ute set- ting still #as to %e proven %y !ell do"umented series, as some of t#e pu%lis#ed early e(perien"es s#o! a rat#er lo! sensitivity and spe"ifi"ity .F1. $fter sta%le fi(ation, "inematograp#y "an %e used intra-operatively to demon- strate ligamenteous insta%ilities at t#e !rist ./1. #reatment "oals $s for all fra"tures, t#e goal of t#e treatment s#ould %e to restore fun"tion of t#e affe"ted !rist at t#e %est, to limit pain as mu"# as possi%le and to rea"# t#is goal as

soon as possi%le. 5o"io-e"onomi" goals s#ould %e ta*en into "onsideration too .a dis"ussion falling out of t#e s"ope of t#is arti"le1 at t#e lo!est possi%le pri"e. '#en "onsidering t#ese goals, it must %e "lear t#at no single t#erapy "an %e offered for all fra"ture types and t#at patient spe"ifi" "riteria .%iologi"al age, degree of osteoporosis, pre-e(isting limitations, et".1 are often more indi"ating !#at t#erapy s#ould %e offered t#an pure anatomi"al "onsiderations. =n "ase of intra-arti"ular fra"tures .i.e. !#en t#e radio-"arpal 8oint is involved1, t#e !or* of Gupiter demonstrates t#at anatomi"al re"onstru"tion is of utmost importan"e to o%tain good fun"tional results .101. $""ording to t#is study, an intra-arti"ular step of more t#an 2 mm inevita%ly leads to osteoart#ritis and a fun"tional defi"it. -any aut#ors agreed to t#is statement, some even stated t#at an intra-arti"ular step of 1mm is una""epta%le. Beside t#e anatomi"al re"onstru"tion,

vage pro"edures su"# as t#e 5auvO-Hapand8i or Darra"# pro"edure ne"essary. T#ese "an often %ring pain relief, %ut limit po!er and range of motion. -alalignment at t#e metap#yseal area leads to a "#anged load distri%ution at t#e !rist 8oint as demonstrated %y T$L4=5)=H and '$T52) .1>1. ,4C)$)D4I demonstrated t#at t#is leads to a loss of motion and t#e development of osteo-art#ritis at t#e !rist 8oint .141. Here "orre"tive measures, even in t#e older non de%ilitated patient, "an %ring a gain of fun"tion and a redu"tion of pain .1@1. Cadial s#ortening, often seen after fra"tures of t#e distal radius, leads to a radio-ulnar in"ongruen"e .1D1, su%lu(ation of t#e ulnar #ead at t#e DUCG and painful impingement of t#e T,33 .141. T#e amount of metap#yseal "omminution is related to t#e s#ortening and t#e tenden"y to loose radial lengt#, even after ade&uate redu"tion. $s su"# B$TC$ .1F1 "alls t#e radial s#ortening t#e most important fa"tor to determine t#e out"ome after fra"tures of t#e distal radius. 2ne "ould summari+e t#e a%ove-"riteria stating t#at anatomi"al redu"tion of %ot# t#e metap#yseal area and t#e radio-"arpal and distal radio-ulnar 8oint are essential to o%tain good fun"tional results. T#is is stressed %y many studies proving t#e good "orrelation %et!een radiologi"al and fun"tional out"ome in fra"tures of t#e distal radius. Conser$ati$e treatment 2f "ourse, t#e "onservative treatment of fra"tures of t#e distal radius still #as its pla"e in our treatment proto"ol. =t is t#e treatment of "#oi"e for all undispla"ed fra"tures and all 7sta%le9 fra"tures of t#e distal radius s#o!ing less t#an 10J of dorsal angulation, less t#an 1mm of lateral s#ift and less t#an 2 mm of initial s#ortening. $rti"ular fra"tures s#ould #ave an arti"ular step of less t#an 2 mm .1 mm in young patients1. '#en !e o%tain a sta%le, anatomi"al "losed redu"tion !e "an treat t#e fra"- ture non-operatively. Dis"ussion e(ists a%out #o! to immo%ilise t#e !rist in "ase of "onservative treatment of fra"tures of t#e distal radius. 7T#ere9, and = "ite t#e 3o"#rane Data%ase, 7remains insuffi"ient eviden"e from randomised trials to determine !#i"# met#ods of "onservative treatment are t#e most appropriate for t#e more "ommon types of distal radius fra"tures in adults. T#erefore pra"titioners applying "onservative management s#ould use an a""epted te"#ni&ue !it# !#i"# t#ey are familiar, and !#i"# is "ost-effe"tive from t#e perspe"tive of t#eir provider unit. :atient preferen"es and "ir"umstan"es, and t#e ris* of "ompli"ations s#ould also %e "onsidered9 .1/1. =nitially non-displa"ed fra"tures "an %e treated %y immediate mo%ilisation. 2ne "an immo%ilise for one !ee* for "omfort reasons. =mmediate mo%ilisation does

Fig. Cadial !idt#

timely diagnosis and treatment of asso"iated intra-arti"ular lesions seems to %e of importan"e too. 5ome series report asso"iated T,33-lesions in up to @0?, 5Llesions in up to F>? an LT-lesions in @1? of "ases .111. $lt#oug# "onventional radiograp#y, intra-operative "inematograp#y and intra-operative art#rograp#y "an #elp us to diagnose asso"iated lesions, art#ros"opy seems to %e t#e most sensitive and spe"ifi" and offers t#e possi%ility to treat t#e diagnosed lesion immediately. 4spe"ially fra"ture lines going into t#e dire"tion of t#e 5L-%and seem to %e "orrelated to a very #ig# per"entage of 5L-%and lesions. )ot only t#e radio-"arpal 8oint is of importan"e to t#e out"ome. $s already stated %y ,CNH-$)) in 1/@D .121 and later "onfirmed %y -4L2)4 .101 and ,4C)$)D4I .141 among ot#ers, in"ongruen"e at t#e distal radio-ulnar 8oint leads to a painful and fun"tion-limiting art#ritis. T#is painful "ondition "an %e #ard to treat, ma*ing sal-

Fig. ! ,ailed "onservative treatment ."losed redu"tion1 in a 2>-year old female

not result in se"ondary displa"ement, %ut results in an earlier fun"tional re"overy .>1. 4arlier severe palmar fle(ion and ulnar deviation #as %een advo"ated to prevent se"ondary dislo"ation after redu"tion. T#is s#ould #o!ever never %e ne"essary. T#is position not only puts more pressure on t#e "arpal tun- nel stru"tures, %ut it is a non-p#ysiologi"al immo%ilisa- tion position leading to soft tissue- and vas"ular "ompli- "ations .221. '#enever "#oosing to treat a fra"ture non-operatively, !e #ave to ensure t#at no se"ondary dislo"ation o""urs. T#is means t#at radiologi"al re-evaluations are ne"essary on a regular %ase until sound fra"ture #ealing

%e"omes o%vious. .,ig. D1. '#enever se"ondary displa"ement o""urs, surgi"al re"onstru"tion in an early stage yields %etter results t#an later re"onstru"tion .201. $ se"ond attempt of "losed redu"tion and "ast immo%ilisation only gives a good or e("ellent result in one t#ird of all "ases .211. =n t#e older de%ilitated patient, a good fun"tional out"ome s#ould %e 8udged to ot#er "riteria t#an in t#e young patient. -alalignment is often tolerated relatively !ell in t#ese patients already #aving a limited fun"tionality and t#e development of art#ritis seldom %e"omes painful %efore t#e end of t#eir lives. 3losed redu"tion is of no use in t#ese patients as redislo"ation almost al!ays

o""urs despite redu"tion and immo%ilisation as "learly demonstrated %y B4U-4C et al. .201. =n t#ese patients, t#e fra"ture s#ould %e immo%ilised until sound fra"ture #ealing is do"umented. )o furt#er treatment s#ould %e initiated. %ercutaneous pinnin" T#e 3o"#rane data%ase .001 states t#at t#ere is no eviden"e for "#oosing a parti"ular operative treatment for unsta%le fra"tures of t#e distal radius. =t is diffi"ult to dis"uss per"utaneous pinning as t#ere are almost as mu"# pinning te"#ni&ues, as t#ere are surgeons treating fra"tures of t#e distal radius. T#e advantages of per"utaneous pinning are 6 H-pins are readily availa%le in most #ospitals of t#e !orld, it is a lo! "ost te"#ni&ue, it augments t#e sta%ility of t#e redu"tion .or at least it s#ould1 and it allo!s, !#en used as 8oy-sti"*s, e(a"t re"onstru"tion of t#e 8oint surfa"e and metap#yseal area. T#e disadvantages are 6 t#e need for an additional immo%ilisation .plaster of :aris or e(ternal fi(ation1, t#e ris* of pin-tra"t infe"tion, t#e ris* of in8uring neuro-vas"ular stru"tures or tendons, t#e ris* of #ard!are migration and t#e ris* of se"ondary displa"ement after pin removal. =n young patients, per"utaneous pinning "an %e %enefi"ial. T#e good %one &uality often allo!s for a relatively sta%le redu"tion, of !#i"# t#e sta%ility "an %e augmented %y pinning. T#ere is no eviden"e t#at proves one pinning te"#ni&ue to %e superior to t#e ot#er. T#e use of Hapand8i intrafo"al pinning is #o!ever limited to relatively simple e(tra-arti"ular fra"ture patterns .>1. T#e fun"tional %enefit in t#ese rat#er simple fra"ture patterns also #as to %e &uestioned as in a randomised prospe"tive trial "ondu"ted at our institution no %enefit in fun"tional nor in radiograp#i" out"ome at one year for Hapand8i pinning as "ompared to "losed redu"tion "ould %e demonstrated .241. $lt#oug# many aut#ors report favoura%le out"ome after "losed redu"tion and per"utaneous pinning, some series s#o! disastrous results. 5ommer among ot#ers reports a /0.0? se"ondary fra"ture dislo"ation rate after per"utaneous H-!ire pining .2>1. T#e reason for t#is #ig# per"entage of se"ondary displa"ements, often related to an angulation resem%ling t#e initial displa"ement, is t#e "omminution of t#e dorsal metap#yseal "orte(. $fter redu"tion an enormous #ole is left in t#is metap#yseal area. T#is #ole "an ma*e t#e reposition, even in t#e presen"e of !ire fi(ation, so insta%le t#at redu"tion is lost. '#en t#e #ard!are is removed after @ !ee*s, t#is #ole is not yet filled !it# %one. T#is allo!s - in "om%i- nation !it# t#e still elasti" "allus - for se"ondary dis- pla"ement at t#e volar side. -any groups tried to solve t#is pro%lem %y augmenting t#eir redu"tion and pin fi(- ation !it# a %one su%stitute. =n t#e younger patient

autologous %one grafts are used, in t#e older patient one "an use #omologous grafts or one of t#e various "ommer"ially availa%le %one su%stitutes or %one "ements. T#is augments sta%ility and prevents t#eoreti"ally se"ondary displa"ement. Biome"#ani"al analysis s#o!s t#at t#e use of "al"ium p#osp#ate %one "ement alone is insuffi"ient to !it#stand p#ysiologi" fle(ion-e(tension motion of t#e !rist !it#out supplemental !ire fi(ation. '#en supplemented !it# H-!ires, fi(ation !it# %one "ement is more sta%le t#an are H-!ires alone, %ut is signifi"antly less sta%le t#an a "ement augmented e(ternal fi(ation .2@1. 2f "ourse t#is augmentation, espe"ially !#en autologous %one grafts are used, ma*es t#e treatment mu"# more invasive. T#ese augmentive te"#ni&ues are also of use in sta%ili+ing arti"ular fragments, %y sup- porting t#em t#roug# filling up t#e metap#yseal "avity. !&ternal fi&ation T#e use of 8oint %ridging e(ternal fi(ation to treat fra"tures of t#e distal radius is !idely a""epted. =t is %ased on t#e prin"iple of ligamentota(is. By distra"ting t#e 8oint area, t#e fragments are redu"ed %y tra"tion on t#e "apsuloligamentous atta"#ments. 5ometimes an additional redu"tion is a"#ieved %y "reating a va"uum in t#e 8oint. T#e latter may e(plain #o! su""essful redu"tion of fragments !it#out "apsular atta"#ment "an %e a"#ieved in some "ases. By maintaining t#e tra"tion t#roug#out t#e #ealing pro"ess, t#e fragments are *ept aligned. T#e negative effe"ts of t#e maintained tra"tion "an %e t#e "reation of e(trinsi" e(tensor tig#tness and a loss of radio"arpal and inter"arpal motion. ,urt#ermore e(ten- sive tra"tion "an %e asso"iated !it# an in"reased ris* of algoneurodystrop#y. '#en e("essive tra"tion is needed to maintain redu"tion, additional fi(ation %y H!ires s#ould %e used in order to allo! for lo!er distra"tion for"es. ,illing up t#e metap#yseal defe"t %y autologous %one grafts or %one su%stitutes "an also add e(tra sta%ili- ty .,ig. F1. ,urt#ermore t#e e(ternal fi(ator "an %e used as a devi"e to neutrali+e for"es a"ting on an unsta%le osteosynt#esis or in anatomi"ally redu"ed e(tra-arti"ular %ending fra"tures. =n "ase of #ig#-energy fra"tures !it# meta-diap#yseal "omminution andAor %one loss, t#e fi(ator "an %e used to %ridge t#e defe"t and to a"t as a %uttress. 5ome aut#ors advo"ate t#e use of non-8oint %ridging fi(ators to over"ome t#e pro%lem of radio-"arpal and inter"arpal loss of motion. T#e use of t#ese fi(ators is limited to e(tra-arti"ular fra"tures in !#i"# t#e distal fragment is large enoug# to a""ommodate t!o pins, !#i"# "an %e pla"ed transversally. =n "ase of simple arti"ular fra"tures, one "an first re"onstru"t t#e 8oint %lo"* using pins or s"re!s and fi( t#is re"onstru"ted %lo"* to t#e diap#yseal fragment using an e(ternal

Fig. " $rti"ular fra"ture treated !it# e(ternal fi(ator, additional pinning and autologeous %one grafting

fi(ator. =n t#is *ind of "onstru"tion, t#e fi(ator is often used in a "ompression mode. =n multifragmentary arti"ular fra"tures or fra"tures !it# a very small distal fragment, t#is approa"# is not appli"a%le. ,or t#ose "ases some aut#ors developed a 7dynami" e(ternal fi(ator9. T#is devi"e allo!s movement in t#e radio"arpal 8oint. T#e potential advantages 6 less stiffness, earlier return of fun"tion, %etter re"onstru"tion of t#e arti"ular "artilage and redu"tion of digital stiffness "ould #o!ever not %e "onfirmed %y 52--4CH$-: .2D1 in a prospe"tive randomi+ed study. '#enever using te"#ni&ues !it# trans"utaneous materials, su"# as H-!ires or 5"#an+ s"re!s, meti"ulous pin-"are is essential to avoid pin-tra"t infe"tions. Tra"tion of t#e pins on t#e s*in is asso"iated !it# a #ig# in"iden"e of pin tra"t-infe"tions and t#us s#ould %e avoided %y properly pla"ed and large enoug# s*in in"isions. =t "an %e useful in "omminuted fra"tures to use t#e e(ternal fi(ator as temporary redu"tion and fi(ation tool to allo! for more pre"ise evaluation of t#e fra"ture and t#e asso"iated soft tissue lesions. T#en a more a""urate definitive treatment "an %e installed. Arthroscopy $rt#ros"opy as su"# does of "ourse not redu"e t#e fra"ture or sta%ili+e it. =t "an #o!ever %e of value in arti"ular fra"tures, espe"ially in t#e younger patient.

$rt#ros"opy offers t#e opportunity to "ontrol t#e &uality of t#e arti"ular redu"tion. Under dire"t vision, fragments "an %e manipulated per"utaneously or !it# H!ires as 8oy-sti"*s. '#en perfe"t arti"ular redu"tion is o%tained, t#e H-!ires introdu"ed for fragment manipulation "an %e advan"ed in ad8a"ent fragments to se"ure redu"tion. =f ne"essary, redu"tion "lamps "an %e used per"utaneously to o%tain interfragmentary "ompression. To as"ertain t#e redu"tion of t#e arti"ular %lo" to t#e s#aft, supplementary te"#ni&ues su"# as pinning, e(ternal fi(ation or plate osteosynt#esis #ave to %e used, depending on t#e fra"ture type, t#e surgeons e(perien"e and t#e patient<s preferen"es. Besides "ontrolling t#e arti"ular redu"tion, art#ros"opy allo!s us to diagnose asso"iated "arpal lesions. $rti"ular fra"tures of t#e distal radius are asso"iated !it# #ig# in"iden"es of 5L-%and lesion, LT-%and lesions and T,33 ruptures. 5L-%and lesions are reported !it# a fre&uen"y varying from 20? to F>? .11, 2F1. 5agittal fra"tures of t#e distal radius and fra"tures !it# avulsion of t#e styloid pro"ess of t#e distal radius seem to %e asso"iated !it# a very #ig# in"iden"e of 5L %and lesions. 4arly repair of t#ese lesions, often %y simple redu"tion and pinning, is related to a %etter out"ome. LT- %and lesions are mu"# less fre&uent, %ut #ere again early treatment results in a %etter out"ome. T,33 lesions are reported in >0-@0? of arti"ular distal radius fra"tures. T#ere still is mu"# "ontroversy a%out t#e radi- al avulsion lesions and t#eir treatment. Ulnar avulsions,

Fig. # Molar plate for dorsally displa"ed distal radius fra"ture

t#at are treated early #o!ever seem to #ave favoura%le results .2/1. 'crew osteosynthesis =n avulsion fra"tures or sagittal split fra"tures of t#e radial styloid pro"ess, a sta%le osteosynt#esis "an often %e a"#ieved %y using one or t!o lag s"re!s t#roug# t#e styloid. =n most "ases, t#e sta%ility of t#is osteosynt#esis is %ig enoug# to allo! for immediate mo%ilisation. =f t#e fragment is too small, per"utaneous pinning "an %e ne"essary "om%ined !it# plaster "ast immo%ilisation. %late osteosynthesis $lmost all aut#ors #ave "onsidered plate osteosynt#esis %y as t#e %est solution for volar displa"ed .5mit#1 fra"tures of t#e distal radius .011. T#e %uttressing effe"t of t#e plate, if ne"essary augmented !it# s"re!s in t#e distal fragments, yields in most "ases of $- and B-type fra"- tures in good or e("ellent results. 2f "ourse, t#e amount of intra-arti"ular "omminution and t#e "onse&uent &ual- ity of arti"ular redu"tion are predi"tive for t#e out"ome in 3-type fra"tures. Molar plating for dorsally displa"ed fra"tures #as t#e pro%lem t#at t#e plate !as laying at t#e opposite site t#an t#e dire"tion of dislo"ation. T#e plate "an t#us not a"t as a %uttress and t#e poor &uality of %one in t#is area does not give mu"# grip for t#e s"re!s to a"t as pulling s"re!s. 2ften loss of redu"tion "an %e !itnessed. Dorsal plating, "ertainly !it# 0.> mm plates !as often "ompli"ated !it# e(tensor tendon pro%lems. T#e

e(tensor tendons run dire"tly over t#e implant and ad#esion %et!een t#e plate and t#e tendons or even se"ondary tendon ruptures are often seen .021. C=HL= and C4B$I2))= .D1 tried to solve t#is pro%lem using smaller implants .2 or 2.4 mm1, pla"ed in a dorsal and lateral fas#ion %ased on t#eir t#ree pillar "on"ept. T#e smaller si+e and smoot# titan polis#ing redu"e t#e ris* of tendon irritation, %ut "annot eliminate it "ompletely. T#e smaller si+e and t!o plate te"#ni&ue ma*e it also possi%le to #ave more s"re!s in t#e distal fragment, allo!ing for re"onstru"tion of "omple( fra"tures. T#e angular sta%le plates ma*e it possi%le to treat most fra"tures from t#e volar side. T#e s"re!s, !#i"# are lo"*ed in t#e plate, are pla"ed 8ust pro(imal to t#e su%"#ondral %one. .,ig. /1 Here !e "an almost al!ays find dense %one. T#e s"re!s !ill a"t as a %uttress for t#is dense %one and t#eoreti"ally no se"ondary loss of redu"- tion is !itnessed. T#e relatively large distan"e %et!een t#e fle(or tendons and t#e plate and t#e prote"tion of t#e pronator &uadratus mus"le, ma*e fle(or tendon pro%- lems e(tremely seldom .001. 'e demonstrated t#e sta%ility of t#is "onstru"tion in an unpu%lis#ed series of 20 unsta%le fra"tures of t#e distal radius in osteoporoti" females over @> years of age, in !#i"# a volar angular sta%le 0.> mm plate osteosynt#esis .L3: -at#ys medi"al1 #as %een performed !it#out %one grafting. =n t#is series, !e !itnessed no signifi"ant loss of redu"tion or loss of radial lengt# .041. T#e use of t#is te"#ni&ue is #o!ever limited to $, B and 31type of fra"tures. T#e more "omple( arti"ular 32-and 30-fra"tures are not treata%le using t#e 0.> mm plate alone, sin"e too little s"re!s "an %e introdu"ed in t#e distal fragment. $ possi%le solution is to re"onstru"t t#e arti"ular %lo"* using pins or separate s"re!s and fi( t#is to t#e meta-diap#yseal fragment using a 0.> mm plate. Ce"ently, a 2.4 mm pre-s#aped plate #as %een introdu"ed !#i"# gives t#e opportunity to introdu"e > s"re!s in t#e distal fragment. T#e pre-s#aping of t#e plate also ma*es it possi%le to fi(ate small distal fragments. $ dorsal approa"# using 2.4 mm angular sta%le dorsally and laterally "an %e used for "omminuted fra"tures, !#i"# "annot %e re"onstru"ted using a volar plate. T#is "om%ines t#e advantages of t#e Ci*lite"#ni&ue !it# t#ese of pre-s#aped, angular sta%le plating. =n t#ese fra"- tures, t#e use of a %one su%stitute into t#e metap#yseal #ole is almost al!ays mandatory. T#is %one su%stitute not only serves to prevent se"ondary dorsal dislo"ation, %ut also #elps to redu"e t#e arti"ular fragments and to #old t#em in t#eir redu"ed position. =n some 32-30 fra"tures, !e "om%ine a dorsal and volar approa"# .,ig. 101 to o%tain a""epta%le re"onstru"tion of t#e distal radius. $ngular sta%le osteosynt#esis in !#atever form is normally sta%le enoug# to allo! for immediate mo%ilisation, preventing e("essive s"arring and 8oint stiffness.

Fig. 1$ Molar and dorsal plates for distal radius fra"ture

Conclusion =t !ill %e "lear t#ere is no tailor-made solution for all fra"tures of t#e distal radius. =t is important to re"onstru"t t#e anatomy of t#e distal radius as good as possi%le, sin"e anatomi"al re"onstru"tion is a prerogative for good fun"tional out"ome, espe"ially in t#e a"tive patient. 2nly in t#e de%ilitated patient, malalignment and arti"ular in"ongruen"e "an %e a""epted. =n t#ese patients, redu"tion of t#e fra"ture and operative treatment seems to %e of no %enefit. ,or all ot#er patients, anatomi"al re"onstru"tion of t#e arti"ular surfa"e and t#e metap#yseal area must %e t#e goal of treatment. T#e non-displa"ed fra"ture "an %e treated fun"tionally !it# little or no immo%ili+ation. 5ta%le fra"tures or fra"tures t#at are sta%le after anatomi"al redu"tion are treated "onservatively. $ll ot#er fra"tures s#ould %e treated operatively. $s prolonged immo%ilisation leads to s"arring of t#e soft tissues, sta%le osteosynt#esis allo!ing for early movement is t#e t#erapy of first "#oi"e. =mmo%ilisation in an non-natural position s#ould %e avoided as it not only leads to stiffness %ut is also asso"iated !it# an #ig# in"iden"e of algoneurodystro- p#y. 2nly angular sta%le plates "an give long enoug# resistan"e to t#e displa"ing for"es a"ting on t#e early "allus to prevent se"ondary displa"ement in "ase of a large .dorsal1 metap#yseal defe"t after redu"tion. =f one "#ooses to use an ot#er form of sta%ilisation, t#e use of

%one su%stitutes to fill t#e defe"t most seriously s#ould %e "onsidered. =n "ase of arti"ular fra"tures, t#e arti"ular surfa"e s#ould %e re"onstru"ted anatomi"ally. To do so, art#ros"opy "an %e of use to guarantee t#e &uality of redu"tion. ,urt#ermore art#ros"opy "an #elp us to diagnose asso"iated "arpal lesions in an early p#ase and to treat t#em as needed. 4spe"ially in t#e younger patient !it# arti"ular fra"tures t#is s#ould %e advo"ated. T#e "#oi"e of treatment s#ould %e %ased on t#e fra"ture type, t#e patient<s "#ara"teristi"s, t#e patient<s demands and last %ut not least on t#e treating surgeon<s e(perien"e and preferen"e. $s long as sta%le redu"tion and anatomi" re"onstru"tion are guaranteed, many !ays "an lead to a su""essful treatment of fra"tures of t#e distal radius. References
1. 32LL45 $. 2n t#e fra"ture of t#e "arpal e(tremity of t#e radius. %dinb &ed S'rg (, 1F14, 10 6 1F2-1F@. 2. L=)D4-$))-5:4C,4LD L., :=LI ,., -$C=)T53H4M =., 2TT2 '. Der distale 5pei"#en%ru"#. -inimalinvasive Hirs"#nerdra#tosteosynt#ese. =ndi*ation und 4rge%nisse. )hir'rg, 2000, (4 6 1000-100F. 0. )BUN4) T., 5$-BC22H :., H4LLN :. et al. :redi"tion of osteoporoti" fra"tures %y insta%ility and %one density. B&(, 1//0, )0( 6 1111111>. 4. 3C=LLN C. B., D4L$BU4CC=4C4-C=3H$CD52) L. D., C2TH G. H. :ostural insta%ility and 3olles<fra"ture. Age Agening, 1/FD, 1* 6 100-10F.

>. 5T2,,4L4) D. ,ra"tures of t#e distal radius 6 an e(perimental and "lini"al approa"#. T#esis, Leuven, 1//D. @. HUH) M., :43HL$)4C 5., H4TTL4C -. et al. Distale Unterarmfra"turen in einer )euen %iome"#anis"#en 5tur+simulation. DBU- "ongress oral presentation, )ovem%er 2000. D. C=HL= D. $., C4B$II2)= :. ,ra"tures of t#e distal end of t#e radius treated %y internal fi(ation and early fun"tion. ( Bone (oint S'rg Br, 1//@, (+ 6 >FF->/2. F. 53H$D4L-H2:,)4C -., ='=)5H$-I4LD4C G., B2HC=)B4C B. et al. -C= or art#ros"opy in t#e diagnosis of s"ap#olunate ligament tears in fra"tures of t#e distal radius P *andchir &i+rochir Plast )hir, 2001, )) .41 6 204-20F. /. C$::2LD B., L4=Q)4C=)B -., :4II4= 3. 3arpal in8uries asso"iated !it# distal radius fra"tures. Diagnosis and t#erapy. *andchir &i+rochir Plast )hir, 2001, )) .41 6 221-22F. 10. H)=CH G. L., GU:=T4C G. B. =ntra-arti"ular fra"tures of t#e distal end of t#e radius in young adults. ( Bone (oint S'rg A,, 1/F@, *+ .>1 6 @4D-@>/. 11. -4TH$ G. $., B$=) B. =., H4:T=)5T$LL C. G. $natomi"al redu"tion of intra-arti"ular fra"tures of t#e distal radius. $n art#ros"opi"ally- assisted approa"#. ( Bone (oint S'rg Br, 2000, +, .11 6 D/-F@. 12. ,CNH-$)) B. ,ra"tures of t#e distal radius in"luding se&uellaes#oulder-#and-finger syndrome, distur%an"e in t#e distal radioulnar 8oint and impairment of nerve fun"tion.$ "lini"al and e(perimental study. Acta Ortho- Scand, 1/@D, 'uppl 10+ 6 1-124. 10. -4L2)4 3. :. Gr. 2pen treatment for displa"ed arti"ular fra"tures of t#e distal radius. )lin Ortho-, 1/F@, ,0, 6 100-111. 14. ,4C)$)D4I D. L. -alunion of t#e distal radius 6 "urrent approa"# to management. .nstr )o'rse Lect, 1//0, 4, 6 //-110. 1>. T$L4=5)=H G., '$T52) H. H. -id"arpal insta%ility "aused %y malu- nited fra"tures of t#e distal radius. ( *and S'rg A,, 1/F4, - .01 6 0>0-0>D. 1@. GU:=T4C G. B., C=)B D., '4=TI4L :. :. 5urgi"al treatment of redispla"ed fra"tures of t#e distal radius in patients older t#an @0 years. ( *and S'rg /A,0, 2002, ,( .41 6 D14-20. 1D. TCU-BL4 T. 4., 53H-=TT 5. C., M4DD4C ). B. ,a"tors affe"ting fun"tional out"ome of displa"ed intra-arti"ular distal radius fra"tures. ( *and S'rg A,, 1//4, 1- .21 6 02>-040. 1F. B$TC$ 5., BU:T$ $. T#e effe"t of fra"ture related fa"tors on t#e fun"tional out"ome at 1 year in distal radius fra"tures. .nj'r1, 2002, )) .@1 6 4//->02. 1/. H$)D2LL H. H., -$DH2H C. 3onservative interventions for treating distal radial fra"tures in adults. )ochrane 2atabase S1st 3e4, 2000, .21 3D000014. 20. GU:=T4C G. B., C=)B D. $ "omparison of early and late re"onstru"tion of malunited fra"tures of t#e distal end of t#e radius. ( Bone (oint S'rg A,, 1//@, (+ .>1 6 D0/-D4F. 21. L4U)B ,., 2IH$) -., 3H2' 5. :. 3onservative treatment of intraarti"ular fra"tures of t#e distal radius-fa"tors affe"ting fun"tional out"ome. *and S'rg, 2000, . .21 6 14>-1>0.

22. :4T4C52) T., DC45=)B H., 53H-=DT B. Dru"*messung im Harpal*anal %ei distaler Cadiusfra*tur. 5n6allchir'rg, 1//0, -* 6 21D-220. 20. B4U-4C $., -3 RU44) -. -. ,ra"tures of t#e distal radius in lo!demand elderly patients 6 "losed redu"tion of no value in >0 of @0 !rists. Acta Ortho- Scand, 2000, (4 .11 6 /F-100. 24. 5T2,,4L4) D. M., BC225 :. L. 3losed redu"tion versus Hapand8ipinning for e(tra-arti"ular distal radial fra"tures. ( *and S'rg Br, 1///, ,4 .11 6 F/-/1. 2>. 52--4C 3., BC4)D4B$3H L., -4=4C C., LU4T4)4BB4C $. Distal radius fra"tures-retrospe"tive &uality "ontrol after "onservative and operative treatment. S7iss S'rg 2001, ( .21 6 @F-D>. 2@. H=BB=)5 T. ,., D2DD5 5. D., '2L,4 5. '. $ %iome"#ani"al analysis of fi(ation of intra-arti"ular distal radial fra"tures !it# "al"ium-p#osp#ate %one "ement. ( Bone (oint S'rg A,, 2002, +4 ./1 6 1>D/-1>/@. 2D. 52--4CH$-: B., 544-$) -., 5=LL=-$) G. et al. Dynami" e(ternal fi(ation of unsta%le fra"tures of t#e distal part of t#e radius. ( Bone (oint S'rg A,, 1//4, (* 6 114/-11@1. 2F. 53H$D4L-H2:,)4C -., B2HC=)B4C B., GU)B4 $. et al. $rt#ros"opi" diagnosis of "on"omitant s"ap#olunate ligament in8uries in fra"tures of t#e distal radius. *andchir &i+rochir Plast )hir, 2001, )) .41 6 22/-200. 2/. CU3H D. 5., N$)B 3. 3., 5-=TH B. :. Cesults of a"ute art#ros"opi"ally repaired triangular fi%ro"artilage "omple( in8uries asso"iated !it# intra-arti"ular distal radius fra"tures. Arthrosco-1, 2000, 1- .>1 6 >11->1@. 00. H$)D2LL H. H., -$DH2H C. 5urgi"al interventions for treating dis- tal radial fra"tures in adults. )ochrane 2atabase S1st 3e4, 2000, .01 3D00020/. 01. H4$T=)B G. ,., 32UCT-BC2') 3. -., -3 RU44) -. -. =nternal fi(a- tion of volar displa"ed distal radius fra"tures. ( Bone (oint S'rg Br, 1//4, (* .01 6 401-40>. 02. H4CC2) -., ,$C$G $., 3C$=B4) -. $. Dorsal plating for displa"ed intra-arti"ular fra"tures of t#e distal radius. .nj'r1, 2000, )4 .D1 6 4/D->02. 00. 5$HH$== -., BC24)4'2LD U., HL2)I $., C4=L-$)) H. 4rge%nisse na"# palmarer :lattenosteosynt#ese mit der !in*elsta%ilen Tplatte %ei 100 distalen Cadiusfra*turen. 4ine prospe"tive 5tudie. 5n6allchir'rg, 2000, 10* .41 6 2D2-2F0. 04. )=G5 5., BC225 :. 2ral 3ommuni"ation on $2-L3: $n!ender 5ymposium, 5eptem%er 2002, Berlin. Dr. 5. )i8s Dpt. of Traumatology U.I. Bast#uis%erg Herestraat 4/ B-0000 Leuven 4-mail 6 stefaan.ni8sSu+.*uleuven.a".%e