European Journal of Cardiovascular Medicine

Distal radius fractures are the most prevalent upper limb fractures presenting to emergency departments, accounting for over 16% of all fractures. Notably, these fractures exhibit a bimodal age distribution, with high-energy trauma predominantly affecting younger individuals and low-energy trauma more commonly occurring in the elderly. Women are significantly more susceptible to distal radius fractures than men, largely attributed to the higher prevalence and severity of osteoporosis among females (1). The distal radius's metaphyseal widening is prone to fractures due to its weaker cancellous bone and lower cortical bone density. Key risk factors include low bone mineral density and falls. Historically, conservative treatment yielded satisfactory results, but recent studies show surgical correction of intra-articular step-off and radial shortening improves outcomes. Anatomic reduction is recommended for younger and high-demand elderly patients, while low-demand elders require surgical intervention only for severely displaced fractures or nerve compression, prioritizing joint movement otherwise. (2,3) Treatment options for distal radius fractures are tailored to the fracture's stability and patient needs. Casting is suitable for stable, non-displaced fractures, while unstable, reducible fractures are treated with reduction and supplemental pinning (4,5). More complex cases, including irreducible or intra-articular fractures, often require surgical intervention with plating, fixation, or other stabilization techniques (6,7). Traditional treatment of distal radius fractures with close reduction and cast immobilization for distal radius fractures often yields unsatisfactory results, including malunion and joint instability. (8).

Treatment options for adult distal radius fractures include conservative management and various surgical techniques, such as percutaneous pinning, external fixation, open reduction with dorsal or volar plating, locking compression plating, MIPPO, fragment-specific fixation, and distraction plating, each offering distinct advantages for specific fracture patterns and patient needs.

VOLAR LOCKING PLATE: in the volar approach volar anatomy of the wrist presents as advantage because there is more space between volar cortex and flexor tendons, and the pronator quadratus can also act as a hedge to prevent soft tissue complications(9).The volar approach involves a longitudinal incision between the brachioradialis and flexor carpi radialis muscles, with the forearm in supination. The sensory branch of the radial nerve is protected, and the flexor carpi radialis, radial artery, and vein are retracted medially. The pronator quadratus and flexor pollicis longus are then elevated subperiosteally from the radius and stripped medially( 10, 11).

Fragment-specific fixation using dual plating :fragment specific fixation is a useful technique to restore function of wrist and to avoid postoperative complications as studies have shown that a step off of 1mm or more within the volar lunet facet is found to increase the contact pressure of radiocarpel joint (12) . it is a technique that involves stabilizing each individual fracture fragment using low-profile plates, pins, or a combination of both, to achieve anatomical reduction and biomechanical stability. This approach allows for early rehabilitation and involves minimal incisions and fixation devices that coapt with surrounding tissues. The goal is to restore distal radius geometry by applying implants symbiotically and multi-planarly, creating a rigid load-sharing construct that neutralizes deforming forces and allows for gliding motion of tendons, while minimizing soft tissue disruption and promoting early range of motion(13).

After obtaining institutional ethical committee approval(No.AIMS/IEC/2390/2021) and informed written consent from study subjects, this observational study was conducted over a period of 2years in adichunchanagiri medical college, hospital and research center,in the department of orthopedics in 40 patients in the age group of 18 to 75 years,with distal end radius fracture, with each group containing 20.

Inclusion Criteria:

1. All closed fractures of the distal end radius (bicolumnar fracture).
2. Distal end radius fractures in skeletally mature patients.

Exclusion Criteria:

1. Type I, II, III open fractures (Gustilo-Anderson classification).
2. All pathological fractures.
3. All malunited fractures of the distal end radius.
4. Concomitant segmental fractures of a single or both bones of the forearm.

All patients underwent a comprehensive evaluation, including a thorough medical history, specialized orthopedic and physical examinations, laboratory tests, and radiological studies. A physician also assessed each patient for potential underlying medical disorders

OPERATIVEPROCEDURE(VOLARLOCKINGPLATE):

All surgical procedures were conducted under general or regional anesthesia, utilizing either a supraclavicular or interscalene block. Strict sterile and aseptic protocols were followed, including meticulous preparation and draping of the operative site. Prophylactic intravenous cefotaxime was administered preoperatively to all patients. A tourniquet was employed in 20 cases, and hemostasis was achieved in all patients prior to wound closure.

A standardized volar approach, based on the modified Henry's technique, was employed to access and stabilize the distal radius fragments. When addressing the radial column fragment, dissection was performed through the plane between the radial artery and the flexor carpi radialis tendon. For the intermediate column fragment beneath the lunate facet, the plane between the flexor carpi radialis tendon and the median nerve was utilized. The distal and lateral borders of the pronator quadratus were carefully retracted ulnarward.

Open reduction was achieved through a combination of intrafocal leverage, traction, and temporary Kirschner wire fixation, followed by definitive stabilization with the chosen implants. The accuracy of reduction was confirmed using an image intensifier during fixation and verified prior to closure of the surgical site

FIGURE 1: INTRA OPERATIVE PICS OF VOLAR LOCKING PLATE FIXATION

OPERATIVEPROCEDURE (DUAL PLATING)

The procedure was performed under supraclavicular block anesthesia, with a proximal arm tourniquet applied and prophylactic antibiotics administered prior to inflation. A modified volar Henry approach or trans-flexor carpi radialis (FCR) approach was utilized, accessing the fracture site between the radial artery and FCR tendon.

With the forearm in supination, a longitudinal skin incision was made along the FCR tendon, with the length dependent on the plate size. The fascia was released, exposing the FCR tendon, which was mobilized by incising the sheath. The tendon was retracted ulnarly, and an incision was made in the floor of the tendon sheath, exposing the flexor pollicis longus (FPL) muscle belly. Blunt dissection swept the FPL muscle to the ulnar side.

The transverse muscle fibers of the pronator quadratus were released from the radial side of the radius and elevated subperiosteally from the radius in a volar direction. The fracture line was visualized and reduced through manipulation and ligamentotaxis. Provisional K-wires maintained the reduction.

A radial styloid plate was applied to the radial column, ensuring engagement with the distal fracture fragment(s). A 2.4-mm fully threaded cortical screw was placed bicortically in the proximal fragment, nearest the fracture site, in a radial-to-ulnar direction. As the screw was tightened, the plate restored radial height and inclination. A second screw was placed proximally to prevent plate rotation.

The reduction and fixation were confirmed under C-arm guidance in both anteroposterior (AP) and lateral views. The wound was thoroughly irrigated with normal saline. The pronator quadratus was sutured to cover the distal end of the plate, preventing tendon irritation. Subcutaneous suturing was performed using Vicryl, and the skin was closed with staples or Ethilon.For patients with unstable fractures, the wrist was immobilized in a below-elbow splint for 4 weeks(14,15).

FIGURE2 : INTRA OPERATIVE PICS OF DUAL PLATEFIXATION

Postoperative data collection included time to achieve full wrist mobility, as well as complications such as median nerve compression, wound infections, and complex regional pain syndrome (CRPS(16) Patients typically commenced wrist movements four weeks postoperatively(17). Follow-up assessments were conducted at 3 weeks, 6 weeks, 3 months, and 6 months to monitor for late complications, including fixation failure, malunion, and chronic regional pain syndrome. The functional outcomes were evaluated using the Gartland and Werley Demerit point system(18), a mixed subjective and objective assessment tool that scores wrist and hand function, residual deformities, range of motion, and nerve complications. The system allocates points for residual deformity (3 points), subjective evaluation (6 points), objective evaluation of range of motion (5 points), and complications, including pain (5 points). The total score categorizes the outcome as Excellent (0-2 points), Good (3-8 points), Fair (9-20 points), or Poor (≥21 points), providing a comprehensive assessment of functional results.

Gartland and Werley Scoring System (18):

Residual Deformity:

• Prominent ulnar styloid – 1
• Residual dorsal tilt – 2
• Radial deviation of hand – 3

Subjective Evaluation:

• No pain, disability, or limitation of motion – 0
• Occasional pain, slight limitation of motion, no disability – 2
• Occasional pain, some limitation of motion, activities slightly restricted, no disability – 4
• Pain, limitation of motion, disability, activities markedly restricted – 6

Objective Evaluation:

• Loss of dorsiflexion – 5
• Loss of ulnar deviation – 3
• Loss of supination – 2
• Loss of palmar flexion – 1
• Loss of radial deviation – 1
• Loss of circumduction – 1
• Pain in distal radioulnar joint – 1

Complications:

• Minimal arthritis – 1
• Minimal arthritis with pain – 3

Arthritis Scoring:

• Moderate arthritis – 2
• Moderate arthritis with pain – 4
• Severe arthritis – 3
• Severe arthritis with pain – 5
• Nerve complications – 1 to 3
• Poor finger function – 1 to 3

Score Interpretation:

• 0 to 2 – Excellent
• 3 to 8 – Good
• 9 to 20 – Fair
• 20 – Poor

The minimum ROM for normal function:

• Dorsiflexion: 45°
• Palmar flexion: 30°
• Radial deviation: 15°
• Ulnar deviation: 15°
• Pronation: 50°
• Supination: 50°

The results of the present study are discussed under the following categories:

1. Age distribution
2. Side distribution
3. Sex (gender) distribution
4. Mode of injury
5. Frequency of dominant side
6. Occupation distribution
7. Open vs closed fractures distribution
8. Distal radius columns involvement
9. Associated injuries
10. Interval between injury and surgery
11. Surgical procedure performed
12. Duration of follow-up
13. Time for fracture union
14. Radial length assessment during follow-up
15. Palmar tilt in patients studied
16. Articular step in patients studied
17. Intergroup comparison of radial length, palmar tilt, and articular step-off with normal values
18. Frequency distribution of residual deformity
19. Range of movements – frequency distribution
20. Range of movements – descriptive statistics
21. Postoperative complications
22. Gartland and Werley scoring – frequency distribution of patients studied
23. Results – frequency distribution of patients studied
24. Comparison of Gartland and Werley scores

AGEDISTRIBUTION:

Table1: In present study, majority of patients were aged more than 21 years with eldest being 74 years and youngest being 22 years old. Mean age being 50.2 years.

SIDE DISTRIBUTION:

Table2: Among the 40 patients, 22patients (55%) had right sided distal end radius fracturesand 18 patients (45%) had left sided Distal end radius fractures.

SEXDISTRIBUTION:

Table3: Gender-Frequency Distribution of Patients Studied

Among the 40 cases, Males were predominant, with a female-to-male ratio being 1.5:1

MODEOFINJURY:

Table4: Among40cases,25caseswereduetoroadtrafficaccidentsand15cases duetofall on out stretched hand

DOMINANCE:

Table5: Dominance-FrequencydistributionofpatientsstudiedInpresentstudy,20patients (50%) of the patients had fractures on their Dominant side , whereas 20patients(50%) had fractures on their Non Dominant side

OCCUPATION:

Table6:

Majority of the patients in present study were middle and old aged group who were earning members of their family. In my study majority were farmers.

OPENFRACTURESVSCLOSEDFRACTURES:

Table7: Open or closed fracture – Frequency distribution of patients studied according to

Inclusion Criteria:
We included only closed fractures. Out of 40 patients in my study, all 40 cases were closed fractures.

Distal Radius Columns Involved:

Table 8: In my study, I included only the patients who had distal end radius fractures with both the radial column (RC) and intermediate column (IC) involvement (bicolumnar). Isolated radial or intermediate column involvement was not included in this study.

Associated Injuries:

Table9:

Of total 40 patients ,1 patient had unilateral femur fracture, 1 patient had unilateraltibia fracture and 2 patients had unilateral clavicle fracture. Rest of them presented 10.Timeintervalbetweeninjuryandsurgery:

Table10: Majority of the surgeries were performed within the initial 3 days after admission. Delayed surgeries were due to associated injuries and comorbidities, and hence consequently delay in fitness for surgery. Mean period between admission andsurgery being 3.2 days

Surgical Procedure:

Table11:

In this Study , for 20 patients we carried out open Reduction Internal Fixation with a volar Locking Plate (VLP) and a Radial Styloid Plate(RSP) (Dual Plates)and for 20 patients fixation was done by volar locking plate 12.DurationofFollowup (months):

Table12: 3weeksfollowedby6weeks,3monthsand6 months

Time for union (in weeks):

Table13:

Out of 40 patients , 20 patients who had undergone ORIF+VLP 9 patients had union in 6 weeks,8 patients had union in 8 weeks, 3 patients had union in 10 weeks.Another set of 20 patients who had undergone ORIF+VLP+RSP 10 patients hadunion in 6 weeks, 6 patients had union in 8 weeks, 4 patients had union in 10 weeks.

Radial Length:

Table14:

In this study , out of 20 patients who had undergone ORIF+VLP , post operative x rays assessment showed aradial length of9 mm in 4 patients , radial length of10 mm in 8 patients and 11 mm in 8 patients. Another set of 20 patients who had undergone ORIF+VLP+RSP showed a radial length of 9 mm in 2 patients, radial length of10mm in 9 patients and radial length of 11mm in 9 patients

Palmar tilt (degree):

Table15:

In this study , out of 20 patients who had undergone ORIF+VLP , post operative x rays assessment showed a palmar tilt of 8 degrees in 4 patients , palmar tilt of 9 degrees in 10 patients , palmar tilt of 10 degrees in 3 patients and 11 degrees in 3 patients . Another set of 20 patients who had undergone ORIF+VLP+RSP showed a palmar tilt of 8 degrees in 2 patients, palmar tilt of 9 degrees in 12 patients , palmar tilt of 10 degrees in five patients, 11 degrees in 1 patient.

Arti cular step-off (mm):

Table16:

In this study , out of 20 patients who had undergone ORIF+VLP , post operative x rays assessment showed articular stepoffof0 mm in 18 patients ,1 mm in 2 patients. Another set of 20 patients who had undergone ORIF+VLP+RSP showed articularstep off of 0 mm in 15 patients and articular step off of 1mm in 5 patients

Comparison of Radial Length, Palmar Tilt, and Articular Step-off

Table17:

*datawasanalyzedusingindependentt-test,ap-Valueof<0.05isconsidered statistically significant.

Deformity:

Table18: Outof40patientsinpresentstudy, 39patientshadnodeformity.Onepatientwho had undergone ORIF+VLP+RSP had prominent ulnar styloid

Range of Movements:

Table19: Frequency Distribution of Patients Studied

In this study, out of 40 patients-20 patients who had undergone ORIF+VLP 15 patients had Palmar flexion and dorsiflexion of >75 degrees . (normal- 85

degrees).18patientshadRadialdeviationof>15Degrees,15patientshadUlnarDeviationof

>30degrees,14patientshadSupinationofmorethan75degreesand19patientshad

>70 degrees of pronation .20 patients who had undergone ORIF+VLP+RSP 14 patients had Palmar flexion and dorsiflexion of >75 degrees . (normal- 85 degrees).19patientshadRadialdeviationof>15Degrees,16patientshadUlnarDeviationof

>30degrees,15patientshadSupinationofmorethan75degreesand18patientshad

>70degreesofpronation.

Range of Movements: Descriptive Statistics

Table20:

*datawasanalysedusingindependentt-test,ap-Valueof<0.05isconsidered statistically significant.

Complications:

Table21:

Out of 40 patients, 20 patients who had undergone ORIF+VLP 15 patients had no complications, 2 patients had persistent pain, 5 patients had stiffness and reduced ROM,1patienthadstitchabscess.20patientswhohadundergoneORIF+VLP+RSP

11 patients had no complications, 5 patients had persistent pain, 2 patients had stiffness and reduced ROM, 2 patients had stitch abscess.

Gartland and Werley Score

Analysisof Results:

Outof20patientsoperatedbyORIF+VLP ,10patientshadExcellentresults,5 patients had good result and 5 patient had fair results

Another 20 patients operated by ORIF+VLP+RSP , 9 patients had excellent result, 8 had good results, 2 had fair results and 1 had poor outcome

Comparison of Gartland and Werley Scores

*datawasanalysedusingindependentt-test,ap-Valueof<0.05isconsidered statistically significant

INTERPRETATION:

A comparative analysis of radiological outcomes (Table 17) revealed no significant differences between the ORIF+VLP and ORIF+VLP+RSP groups, with comparable results observed for radial length (p=0.513235), palmar tilt (p=0.691233), and articular step-off, as confirmed by chi-square test, indicating that both groups achieved similar radiological outcomes.

Both groups demonstrated minimal outliers and predominantly normal range of motion (Table 20) . Comparative analysis of Palmar Flexion, Dorsiflexion, Radial Deviation, Ulnar Deviation, Supination, and Pronation revealed no statistically significant differences between the groups, indicating comparable and similar outcomes in terms of range of motion.

The Gartland & Werley scores revealed comparable outcomes (Table 24) between the two groups, with both achieving "Good" results (mean scores: 3.8 and 3). Statistical analysis confirmed no significant difference between the groups, supported by a high p-value, indicating similar outcomes.

STATISTICAL METHODS: This study employed both descriptive and inferential statistical analyses. Data were presented as mean ± SD (min-max) for continuous measurements and number (%) for categorical measurements, with significance assessed at a 5% level. Assumptions of normality, randomness, and independence were made. Statistical tests used included one-sample t-tests, chi-square/Fisher Exact tests for categorical data, and non-parametric settings for qualitative data analysis. The Fisher Exact test was employed for small sample sizes. Statistical significance was categorized as suggestive (0.05 < P < 0.10), moderately significant (0.01 < P < 0.05), and strongly significant (P < 0.01). Data analysis was performed using SPSS 22.0 and R environment ver. 3.2.2, with Microsoft Word and Excel used for generating graphs and tables.

The increasing incidence of intra-articular distal radius fractures, particularly in younger individuals, is largely attributed to high-energy trauma, such as road traffic accidents, which accounted for 60% of cases in our study. Our study's average age (50.2 years) for intra-articular distal radius fractures is comparable to that of Anakwe et al (19)(48 years), indicating a similar demographic profile for this type of fracture.

Our study demonstrated a male predominance, with 70% of cases being male, which is comparable to Jupiter et al's study(20), where males accounted for 60% of cases. Thissimilarity suggests a consistent trend of higher incidence of intra-articular distal radius fractures among males, likely due to their increased exposure to high-energy trauma and high-velocity injuries, particularly in road traffic accidents.

Our study found a slightly dominant right-side predisposition, with 55% of cases involving the right side, which is comparable to John K Bradway et al's study(21), where the right side was involved in 50% of cases, indicating a similar trend of slight right-side dominance in intra-articular distal radius fractures.

Our study's finding of a 60% incidence of RTA-related trauma as the primary mode of injury is remarkably similar to that of Jupiter et al(20), who reported a 67% incidence of RTA-related trauma. This similarity suggests that both studies identified a comparable pattern of high-energy trauma being a leading cause of intra-articular distal radius fractures.In older populations, low-energy trauma, such as falls onto an outstretched hand (FOOSH), tends to be more prevalent, especially in individuals with osteoporotic bones, which are more susceptible to fractures(20).

Our radiological findings, with mean radial height values of 10.17-10.33mm and volar tilt values of 9.20-9.33 degrees, align closely with those reported in studies by Peter Tang et al(22) (Helmerhorst GT Kloen(23) Our study's functional outcomes, including range of motion, demonstrate comparable results to those reported in similar studies. Specifically, our findings on palmar flexion (66-70 degrees), dorsiflexion (66-67 degrees), supination (68-70

degrees), and pronation (63-65 degrees) are consistent with the results of Jupiter et al (20) and Anakwe et al (19). Furthermore, our radiographic parameters, including mean radial height (10.17-10.33 mm) and volar tilt (9.20-9.33 degrees), are also similar to those reported in studies by Peter Tang et al(22), Helmerhorst GT Kloen,(23) and Matthias Jacobi(24),Kavin khatri et al(25) Overall, our study's results align with those of similar studies, demonstrating comparable functional outcomes and radiographic parameters, and supporting the  effectiveness of our treatment approach.

Our study's outcomes, with 47.5% excellent, 32.5% good, 17.5% fair, and 2.5% poor results, are comparable to those reported in similar studies, including Jupiter et al(20) ,John K Bradway et al (21), and Anakwe et al (19). Notably, our study's excellent and good results are slightly lower than those reported in some of the comparative studies, but our fair and poor results are relatively consistent. The variation in outcomes may be attributed to differences in treatment protocols, patient demographics, and follow-up periods.

Our study demonstrates that both dual plating and volar locking plate techniques are effective in treating unstable bicolumnar fractures of the distal radius, with successful anatomic alignment and good clinical outcomes. While both techniques yield comparable results, volar locking plate is preferred due to its advantages, including shorter operative time, less hardware, and reduced risk of complications. However, long-term follow-up is necessary to confirm these findings.

1. Owen, R. A., Melton, L. J., Johnson, K. A., Ilstrup, D. M., and Riggs, B. L. "Incidence of Colles' Fracture in a North American Community." American Journal of Public Health, vol. 72, 1982, pp. 605–607.
2. Gehrmann, S. V., Windolf, J., and Kaufmann, R. A. "Distal Radius Fracture Management in Elderly Patients: A Literature Review." Journal of Hand Surgery [American], vol. 33, no. 3, 2008, pp. 421–429.
3. Young, B. T., and Rayan, G. M. "Outcome Following Nonoperative Treatment of Displaced Distal Radius Fractures in Low-Demand Patients Older Than 60 Years." Journal of Hand Surgery [American], vol. 25, no. 1, 2000, pp. 19–28.
4. Garcia-Elias, M., and Folgar, M. A. "The Management of Wrist Injuries: An International Perspective." Injury, vol. 37, no. 11, 2006, pp. 1049–1056.
5. Shin, E. K., and Jupiter, J. B. "Current Concepts in the Management of Distal Radius Fractures." Acta Chirurgiae Orthopaedicae et Traumatologiae Cechoslovaca, vol. 74, no. 4, 2007, pp. 233–246.
6. Keast-Butler, O., and Schemitsch, E. H. "Biology versus Mechanics in the Treatment of Distal Radial Fractures." Journal of Orthopaedic Trauma, vol. 22, no. 8 (Suppl.), 2008, pp. S91–S95.
7. Fernandez, D. L. "Should Anatomic Reduction Be Pursued in Distal Radial Fractures?" Journal of Hand Surgery [British], vol. 25, no. 6, 2000, pp. 523–527.
8. Bacorn, R. W., and Kurtzke, J. F. "Colles’ Fracture: A Study of Two Thousand Cases from the New York State’s Compensation Board." Journal of Bone and Joint Surgery, vol. 35A, 1953, pp. 643–658.
9. Patidar, A., et al. "Functional and Radiological Outcome of Locking Compression Plate for Distal End Radius Fracture." Orthopedic Journal of M P Chapter, vol. 28, no. 2, 2022, pp. 75–80.
10. Grewal, R., Perey, B., Wilmink, M., and Stothers, K. "A Randomized Prospective Study on the Treatment of Intra-Articular Distal Radius Fractures: Open Reduction and Internal Fixation with Dorsal Plating Versus Mini Open Reduction, Percutaneous Fixation, and External Fixation." Journal of Hand Surgery [American], vol. 30, no. 4, 2005, pp. 764–772.
11. B, G. W. "Management of Distal Radius and Distal Ulnar Fractures with Fragment-Specific Plate." Journal of Wrist Surgery, vol. 2, no. 2, 2013, pp. 190–194.
12. Hadzhinikolova, M., et al. "Volar Versus Combined Dorsal and Volar Plate Fixation of Complex Intra-Articular Distal Radius Fractures with Small Dorsoulnar Fragment: A Biomechanical Study." BMC Musculoskeletal Disorders, vol. 23, no. 25, 2022.
13. Medoff, R. J., and Kopylov, P. "Immediate Internal Fixation and Motion of Comminuted Distal Radius Fractures Using a New Fragment-Specific System." Orthopaedic Transactions, vol. 22, 1998, p. 165.
14. Green, R. A., editor. Fractures of the Distal Radius and Ulna. Fractures in Adults, 3rd ed., 1991, pp. 1089.
15. Köck, H., Bandl, W-D., and Chan, T. "Experiences and Results with the Locked Compression Plate for 603 Fractures of the Distal Radius." Handchirurgie, Mikrochirurgie, Plastische Chirurgie, vol. 37, no. 5, 2005, pp. 303–308.
16. Arora, R., Lutz, M., Hennerbichler, A., Krappinger, D., Espen, D., and Gabl, M. "Complications Following Internal Fixation of Unstable Distal Radius Fractures with a Palmar Locking Plate." Journal of Orthopaedic Trauma, vol. 21, no. 5, 2007, pp. 316–322.
17. Minegishi, H., Dohi, O., An, S., and Sato, H. "Treatment of Unstable Distal Radius Fractures with the Volar Locking Plate." Upsala Journal of Medical Sciences, vol. 116, no. 4, 2011, pp. 280–284.
18. Gartland, J. J., Jr., and Werley, C. W. "Evaluation of Healed Colles' Fracture." Journal of Bone and Joint Surgery [American], vol. 33, 1951, pp. 895–907.
19. Anakwe, R., Khan, L., Cook, R., and McEachan, J. "Locked Volar Plating for Complex Distal Radius Fractures: Patient Reported Outcomes and Satisfaction." Journal of Orthopaedic Surgery Research, vol. 5, no. 1, 2010, p. 51.
20. Jupiter, J. B., and Fernandez, D. L. "Comparative Classification for Fractures of the Distal End of the Radius." Journal of Hand Surgery [American], vol. 22, no. 4, 1997, pp. 563–571.
21. Bradway, J. K., Amadio, P. C., and Cooney, W. P. "Open Reduction and Internal Fixation of Displaced, Comminuted Intra-Articular Fractures of the Distal End of the Radius." Journal of Bone and Joint Surgery [American], vol. 71, no. 6, 1989, pp. 839–847.
22. Tang, P., Ding, A., and Uzumcugil, A. "Radial Column and Volar Plating (RCVP) for Distal Radius Fractures with a Radial Styloid Component or Severe Comminution." Techniques in Hand and Upper Extremity Surgery, vol. 14, no. 3, 2010, pp. 143–149.
23. Helmerhorst, G. T., and Kloen, P. "Orthogonal Plating of Intra-Articular Distal Radius Fractures with an Associated Radial Column Fracture via a Single Volar Approach." Injury, vol. 43, no. 8, 2012, pp. 1307–1312.
24. Jacobi, M., Wahl, P., and Kohut, G. "Repositioning and Stabilization of the Radial Styloid Process in Comminuted Fractures of the Distal Radius Using a Single Approach: The Radio-Volar Double Plating Technique." Journal of Orthopaedic Surgery Research, vol. 5, 2010, p. 55.
25. Khatri, K., Sharma, V., Farooque, K., and Tiwari, V. "Surgical Treatment of Unstable Distal Radius Fractures with a Volar Variable-Angle Locking Plate: Clinical and Radiological Outcomes." Archives of Trauma Research, vol. 5, no. 2, 2016, e25174.