European Journal of Cardiovascular Medicine

Distal radius fractures make up a substantial proportion of upper-limb injuries seen across emergency and trauma services in India. The burden is particularly evident in urban centres, where road traffic accidents, falls on an outstretched hand, and age-related fragility contribute significantly to case volume. Among these injuries, AO Type C fractures pose unique challenges because the articular surface is fragmented, the metaphyseal block is unstable, and collapse may still occur despite an apparently satisfactory reduction. Earlier work has shown that comminuted intra-articular fractures frequently lose alignment when treated with a single fixation technique, especially in the presence of dorsal comminution or metaphyseal voids.^[1]

Volar locking plates brought a meaningful improvement by providing subchondral support and resisting recurrent displacement. Even so, their ability to maintain stability in highly comminuted fractures has limitations, prompting interest in alternative or combined strategies. Foundational clinical experience demonstrated that hybrid approaches-using an external fixator to provide ligamentotaxis and a volar plate to secure fragments-could preserve radial height and tilt more consistently through healing.^[2] Subsequent analyses have reported similar trends, noting that plate-only fixation may still be susceptible to late subsidence in fractures with extensive comminution.^[3]

Recent systematic reviews have reinforced the relevance of construct selection, showing that complication rates and long-term alignment vary significantly depending on fracture severity and fixation method.^[4] In Indian orthopaedic practice, where delayed presentation and greater fracture complexity are common, dual-modality fixation offers practical advantages by combining controlled distraction with a stable articular buttress. However, long-term Indian data remain limited. The present study addresses this gap by examining alignment preservation, union characteristics, and complications over two years in adults treated with this combined technique.

Study Design and Setting This study was conducted as a prospective observational analysis at a tertiary-care orthopaedic centre -Government Royapettah Hospital, Chennai for a period of 2 years from January 2012 to December 2014. The institute functions as a high-volume trauma referral unit, which ensured consistent case flow and uniform postoperative follow up. All operations were performed by the senior author to minimize technical variability, and the evaluation team remained the same throughout the study period. Participants Seventy-five adults with complex distal radius fractures were included. All patients met the diagnostic criteria for AO Type C fractures following radiographic assessment. Individuals were screened in the outpatient and emergency departments and enrolled only after providing informed consent. Both males and females were eligible, and the final sample consisted of 43 men and 32 women. The age distribution covered a wide clinical spectrum, ranging from early adulthood to elderly individuals with fragile bone quality. Inclusion Criteria Participants were included when they demonstrated: 1. Radiographically confirmed AO Type C fractures. 2. Closed injuries without neurovascular compromise. 3. Eligibility for surgery based on standard an aesthetic and medical fitness evaluation. 4. Willingness to participate in two-year follow up. Exclusion Criteria The study excluded patients with open fractures, associated carpal or forearm injuries requiring additional procedures, pathological fractures, previous wrist surgeries on the same side, or refusal to undergo the dual-modality fixation technique. Patients unable to commit to serial follow up visits were also excluded. Preoperative Evaluation The initial assessment involved clinical examination for deformity, swelling, wrist motion, and neurovascular status. Standard anteroposterior and lateral wrist radiographs were taken for classification and surgical planning. Computed tomography was obtained whenever articular involvement required more detailed mapping. Baseline functional status was documented, and routine blood investigations were carried out as part of the preoperative protocol. Surgical Technique All patients underwent dual-modality fixation involving an external fixator combined with a volar locking plate (Fig 1). The procedure was carried out under regional or general anaesthesia based on patient suitability. After sterile preparation, the external fixator was applied first to achieve ligamentotaxis and realign the major fragments. This step restored radial height and allowed controlled distraction across the joint. A standard volar approach was used to expose the fracture. Articular fragments were reduced under direct vision and secured to the plate. Locking screws were inserted to provide subchondral support and resist collapse. The metaphyseal voids were addressed with bone graft or substitute when necessary. Final fluoroscopy confirmed palmar tilt, inclination, and overall reduction before closure. The external fixator was retained postoperatively to maintain stability during early healing. Postoperative Management Patients received routine analgesia and antibiotic prophylaxis. Finger mobilization began immediately, while wrist exercises were initiated gradually according to pain tolerance and stability. External fixator care instructions were explained to each patient and reviewed during follow up visits. The device was removed once early consolidation was evident, typically after several weeks. Outcome Measures Radiological outcomes were assessed using serial measurements of radial length, radial inclination, and palmar tilt. These values were recorded at predetermined intervals, including immediately after surgery and during follow up visits up to 24 months. Union was evaluated using cortical bridging and trabecular continuity. Functional outcomes were measured through wrist range-of-motion testing and standardized scoring reflecting daily activities. Any complications such as malunion, delayed union, reflex sympathetic dystrophy, or implant-related issues were documented in detail. Follow-Up Protocol Patients were reviewed at regular intervals: immediate postoperative, 6 weeks, 3 months, 6 months, 12 months, and 24 months. Each visit included clinical examination, radiographs, and functional assessment. Representative photographs of operative and follow-up status have been placed in the Results section. Data Handling and Analysis All clinical and radiographic measurements were entered into a structured master chart. Descriptive statistics were applied to summarize demographic variables, alignment parameters, time to union, and complication rates. Continuous outcomes were expressed as means with appropriate dispersion, while categorical variables were summarized as proportions. No inferential statistics were applied, as the study did not involve comparison groups.

Baseline Characteristics

Seventy-five adults met the inclusion criteria, comprising 43 men and 32 women (Table 1). Their ages ranged widely, and many presented with substantial swelling and deformity at admission. AO classification revealed that C2 and C3 fractures formed the majority. Preoperative wrist mobility was uniformly restricted, and most patients demonstrated significant radial shortening with dorsal tilt.

Radiological Alignment and Healing

Immediate postoperative radiographs demonstrated successful restoration of radial geometry in almost all cases. Radial length typically returned to values between 10 and 12 mm, while radial inclination stabilized close to 20 degrees. Palmar tilt shifted favorably from the preoperative dorsal configuration to a gentle volar tilt between 5 and 8 degrees (Table 2). These values align closely with reduction outcomes reported in contemporary hybrid-fixation cohorts.

Union was achieved in the vast majority of patients within three to four months. A small number progressed more slowly, usually those with extensive comminution. No patient required secondary surgical intervention for nonunion.

Maintenance of Reduction over Time

Serial radiographs demonstrated steady preservation of alignment. At the one-year review, radial length loss was minimal, typically no more than 1–2 mm. Radial inclination dropped slightly in a few individuals but remained within functional limits. Palmar tilt showed good stability overall.

The cases with the highest comminution (particularly C3 patterns) demonstrated why dual-modality support was advantageous. The external fixator countered early collapse risk, while the volar plate provided fixed-angle buttressing. This combined effect mirrors the favourable trends described in long-term follow-up studies of similar constructs.

Functional Outcomes

Wrist function improved steadily across the two-year follow-up. Most patients demonstrated meaningful recovery of daily-use arcs, and a substantial proportion returned to occupational activity without major restrictions. Grip strength improved gradually, reaching approximately 75–85 percent of the contralateral side by the end of follow-up (Table 3). The most rapid gains occurred during the first six months, while finer range adjustments continued through the second year.

A minority experienced persistent stiffness, mostly associated with initial soft-tissue trauma or prolonged swelling rather than fixation failure.

Complications

Complications were noted in a small subset (Fig 2). Reflex sympathetic dystrophy appeared in a few patients and responded to early physiotherapy and medical treatment. Mild malunion with positive ulnar variance occurred in isolated cases but remained functionally acceptable. Delayed union was observed in patients with severe articular fragmentation, though eventual healing occurred without reoperation. These patterns closely resemble complication profiles reported in multi-centre reviews of complex distal radius fixation.

No deep infections, plate failures, or neurovascular injuries were recorded.

Representative Clinical Images

Pre-operative radiographs, immediate postoperative reduction, and 24-month follow-up images demonstrating restoration of radial length, inclination, and palmar tilt. (Fig 3 and Fig 4)

Restoration maintained at long-term follow-up.

Representative postoperative changes captured during follow-up.

Radiological and soft-tissue variations observed in a minority.

Severe Severe comminution stabilized effectively with dual-modality fixation.

The long-term follow up in this study demonstrates that dual-modality fixation provides dependable structural stability in adults with complex AO Type C distal radius fractures. Patients generally maintained restored radial geometry throughout healing, and the technique performed reliably even in markedly comminuted patterns. Such consistency aligns with clinical observations that combining ligamentotaxis with fixed-angle support can help counter early metaphyseal collapse, particularly in fractures where dorsal comminution weakens the structural integrity of the distal radius.[5]

Functional recovery progressed in a steady and predictable manner. Most patients regained useful wrist arcs by the end of two years, and only a small subgroup experienced persistent stiffness. Comparable patterns have been reported in long-term hybrid fixation series, where stable reduction enabled early motion without compromising alignment.[6] The volar plate decrease the biomechanical demand of external fixator and also helps in buttressing the subchondral volar fracture fragments.  Meanwhile the external fixator provided the temporary distraction required to maintain height as well as supports the dorsal commiutions during the inflammatory and early reparative phases.

The complication profile observed here was modest. Reflex sympathetic dystrophy, delayed union, and minor malunion were the main issues encountered, and all were manageable with conservative treatment. Importantly, no deep infections or hardware failures occurred. Several contemporary analyses have reported that hybrid constructs, when applied correctly, do not significantly increase complication risk compared with isolated volar plating or external fixation alone.[7] Instead, the technique may reduce the likelihood of redisplacement in severely fragmented fractures, as suggested in comparative studies evaluating radiographic maintenance over time.[8]

For fractures with pronounced metaphyseal voids or unstable articular blocks, the dual strategy appears particularly helpful. The external fixator maintains overall length, while the volar plate provides angular stability for the articular fragments. Biomechanical assessments support this concept by demonstrating increased resistance to axial collapse and improved load-sharing when a plate is combined with external distraction.[9] These advantages may be especially relevant in Indian trauma practice, where many patients present late or with extensive comminution that challenges single-modality constructs.

Nevertheless, the study’s limitations must be addressed. The absence of a comparison group restricts direct evaluation against volar plating alone, and the single- centre nature limits generalizability. Larger multicentric evaluations have shown that outcomes may vary depending on fracture complexity, surgeon experience, and implant selection.[10] A future trial comparing hybrid fixation with plate-only constructs across different Indian populations could help clarify the true magnitude of benefit. Despite these constraints, the present findings support what several recent clinical series have suggested: dual-modality fixation can be a strong and sensible choice for complex distal radius fractures, particularly when long-term alignment preservation is the priority.[11]

Dual-modality fixation, combining an external fixator with a volar locking plate, provided reliable alignment, sustained metaphyseal support, and meaningful long-term functional recovery in adults with complex AO Type C distal radius fractures. Complications were infrequent and manageable, and most patients regained satisfactory wrist motion by the end of two years. Although the absence of a comparison group limits direct benchmarking, the findings reinforce the value of this hybrid method for challenging intra-articular fractures frequently seen in Indian trauma practice. Broader multi- centre analyses may help clarify comparative advantages, yet the present study supports dual-modality fixation as a stable and practical option in complex fracture reconstruction.

[1]        Jupiter JB, Fernandez DL. Comparative classification for fractures of the distal end of the radius. J Hand Surg Am 1997;22(4):563-71.

[2]        Orbay JL. Volar plate fixation of distal radius fractures. Hand Clin 2005;21(3):347-54.

[3]        Thorninger R, Madsen ML, Wæver D, Borris LC, Rölfing JHD, Hansen TB. Complications of volar locking plate osteosynthesis for distal radius fractures in 576 patients. Dan Med J 2014;61(7):A4876.

[4]        Bentohami A, de Burlet K, de Korte N, van Dijkman BA, de Vries MR, van der Oest MJW, et al. Complications following volar locking plate fixation for distal radial fractures: a systematic review. J Hand Surg Eur Vol 2014;39(7):745-54.

[5]        Kwon BC, Kim JH, Baek GH, Lee YH, Chung MS, Gong HS. Factors affecting radiographic and functional outcomes after volar plate fixation of distal radius fractures. J Hand Surg Am 2010;35(3):404-10.

[6]        Osada D, Kamei S, Masuzaki K, Takai S. Prospective study of distal radius fractures treated with volar locking plates and early mobilisation. J Orthop Surg Res 2012;7:4.

[7]        Abboud JA, Hakim Z, Byrd J, Bozentka DJ, Beredjiklian PK. The use of external fixation and supplementary Kirschner wires for unstable distal radius fractures. J Hand Surg Am 2010;35(11):1871-8.

[8]        Ruch DS, Ginn TA, Yang CC, Smith BP, Rushing JT, Hanel DP. Use of a distraction plate for distal radius fractures with metaphyseal and diaphyseal comminution. J Bone Joint Surg Am 2005;87(5):948-54.

[9]        Drobetz H, Kutscha-Lissberg F. Osteosynthesis of distal radial fractures with a volar locking plate: biomechanical and clinical considerations. Injury 2014;45 Suppl 1:S2-8.

[10]      Song J, Yu AX, Li ZH, Li YL. Volar locking plate versus external fixation for distal radius fractures: a meta-analysis of randomized controlled trials. J Orthop Surg Res 2015;10:108.

[11]         Ma Y, Messina J, Leong NL, Kwon JY. Outcomes of volar plating versus combined fixation for intra-articular distal radius fractures: a systematic review. J Wrist Surg 2021;10(5):396-403.