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Volar versus combined dorsal and volar plate fixation of complex intraarticular distal radius fractures with small dorsoulnar fragment – a biomechanical study

Abstract

Complex intraarticular distal radius fractures (DRFs), commonly managed with volar locking plates, are challenging. Combined volar and dorsal plating is frequently applied for treatment, however, biomechanical investigations are scant. The aim of this biomechanical study was to investigate volar plating versus double plating in DRFs with different degrees of lunate facet comminution.

Thirty artificial radii with simulated AO/OTA 23-C2.1 and C3.1 DRFs, including dorsal defect and lunate facet comminution, were assigned to 3 groups: Group 1 with two equally-sized lunate facet fragments; Group 2 with small dorsal and large volar fragment; Group 3 with three equally-sized fragments. The specimens underwent volar and double locked plating and non-destructive ramped loading in 0° neutral position, 40° flexion and 40° extension.

In each tested position, stiffness: (1) did not significantly differ among groups with same fixation method (p ≥ 0.15); (2) increased significantly after supplemental dorsal plating in Group 2 and Group 3 (p ≤ 0.02).

Interfragmentary displacements between styloid process and lunate facet in neutral position were below 0.5 mm, being not significantly different among groups and plating techniques (p ≥ 0.63).

Following volar plating, angular displacement of the lunate facet to radius shaft was significantly lower in Group 1 versus both Group 2 and Group 3 (p < 0.01). It decreased significantly after supplemental dorsal plating in Group 2 and Group 3 (p < 0.01), but not in Group 1 (p ≥ 0.13), and did not differ significantly among the three groups after double plating (p ≥ 0.74).

Comminution of the lunate facet within its dorsal third significantly affected the biomechanical outcomes related to complex intraarticular DRFs treated with volar and double locked plates.

Double plating demonstrates superior stability versus volar plating only for lunate facet comminution within its dorsal third. In contrast, volar plating could achieve stability comparable with double plating when the dorsal third of the lunate facet is not separated by the fracture pattern. Both fixation methods indicated achievable absolute stability between the articular fragments.

Peer Review reports

Introduction

Volar locking plates have established a standard for reliable fixation across the wide spectrum of distal radius fractures (DRFs) [1]. Approximately 80% of the intraarticular DRFs can be treated with a single volar plate [2]. A subset of DRFs present a typical comminution pattern of the lunate facet comprising a volar ulnar corner rim fragment, a dorsoulnar fragment, and possibly a free or impacted intraarticular fragment (Fig. 1).

Fig. 1
figure 1

Coronal (top) and axial (bottom) computed tomography scans of clinical cases with intraarticular distal radius fractures with different degree of lunate facet comminution comprising two fragments of a comparable size (left), a smaller dorsal and a larger volar fragment (middle), and three fragments of a comparable size (right)

This intermediate column fragmentation, observed in both osteoporotic and healthy bone, is recognized as challenging and prone to complication [3,4,5]. Non-anatomical reduction of the ulnovolar rim fragment has been reported to render the carpal joint susceptible to volar subluxation [6]. On the other hand, the dorsoulnar fragment often comprises part of both the radiolunate and radioulnar articular surfaces and is crucial in maintaining appropriate sagittal radiocarpal alignment and preventing dorsal collapse [7, 8].

Fixed-angle volar locking plates provide reliable fracture fixation in case of osteoporotic and/or comminuted fractures [9]. This is further facilitated by the variable-angle locking plate technology allowing better targeting and purchase in the densest available subchondral bone. However, in the case of extremely comminuted and unstable fractures, a single volar plate may not provide sufficient stability to the dorsal rim, thus necessitating supplemental dorsal fixation. Combined volar and dorsal plate fixation of intraarticular fractures with comminution of both the metaphysis and the articular surface has been clinically studied [10]. However, in the extensive body of literature on the biomechanical and clinical performance of volar locking plates, there is a paucity of evidence as to the indications of dorsal plate augmentation in the setting of volar plate fixation. Moreover, no studies have subjected these two fixation methods to a direct comparison in order to provide reliable data on the biomechanical behaviour of fracture models with different degrees of comminution.

Therefore, the aim of this study was to investigate the biomechanical competency of volar-plated DRFs compared with double plate fixation in three complex fracture models with different degrees of lunate facet comminution.

We tested the hypothesis that a supplemental dorsal plate would be needed to preserve the integrity of fractures separating the dorsal third of the lunate facet.

Materials and methods

Specimens and preparation

Thirty artificial right radii (#7001, cortical bone density 0.79 g/cm3, cancellous bone density 0.17 g/cm3, SYNBONE AG, Zizers, Switzerland) were assigned to three treatment groups with ten specimens each, simulating plated complex three- or four-part intraarticular AO/OTA 23-C2.1 or C3.1 fractures with different degrees of lunate facet comminution.

The fracture models were created as follows. First, a 15° dorsal wedge-shaped osteotomy gap, located 10 mm proximal to the articular surface to mimic comminution of the dorsal distal radius aspect, was created in all specimens. Second, an intraarticular fracture line was set through the Lister’s tubercle in the sagittal plane. The styloid process of the radius was then separated from the shaft and the remaining articular fragments as a single piece. Third, the lunate facet was split by coronal osteotomies, so that it consisted of two equally-sized fragments in Group 1, a small dorsal and large volar fragment at a ratio of 1:2 in Group 2, and three equally sized fragments in Group 3 (Fig. 2).

Fig. 2
figure 2

Schematic illustration of the distal radius and ulna in axial view (left), together with the group assignment according to the intraarticular fracture patterns at the lunate facet (right) with two equally-sized fragments (Group 1, top right), with a small dorsal and a large volar fragment at a ratio of 1:2 (Group 2, middle right), and with three equally-sized fragments (Group 3, bottom right)

Following fracture reduction, all radii were first double-plated using a 2.4 mm Variable Angle LCP Two-Column Volar Distal Radius Plate (DePuy Synthes, Zuchwil, Switzerland) and a 2.4 mm Variable Angle LCP Dorsal Distal Radius Plate (DePuy Synthes, Zuchwil, Switzerland) – made of Ti-6Al-7Nb alloy – according to the manufacturer’s recommendations (Fig. 3).

Fig. 3
figure 3

Exemplified specimens from Group 2 after volar plating using a 2.4 mm Variable Angle LCP Two-Column Volar Distal Radius Plate (DePuy Synthes, Zuchwil, Switzerland) (left), and double plating using a supplemental Variable Angle LCP Dorsal Distal Radius Plate (DePuy Synthes, Zuchwil, Switzerland) (right)

All locking screws were inserted according to the corresponding surgical guidelines, applying widely accepted techniques to avoid dorsal compartment penetration of the volar screws [11,12,13]. The insertion of each screw was performed at 90° with respect to its hole axes, except for the middle screw in the proximal volar plate row, which was directed to the lunate facet fragment with an angulation of 15°. The diaphyseal screws of the volar plate were bicortical, whereas its articular screws were monocortical with lengths in the range 18–22 mm (depending on the specimen’s anatomy) and inserted subchondrally at a distance of 2 mm from the far cortex. All screws of the dorsal plate were monocortical with a length of 22 mm. The specimens were cut proximally to a total length of 170 mm. Two Kirschner (K-) wires were inserted into the radial shaft and one of the lunate fragments, oriented in the sagittal plane for radiological evaluation in mediolateral (ML) view. Additionally, metal balls were inserted in the volar and dorsal fragments of the lunate facet, and in the styloid process to assess their interfragmentary displacements via radiological evaluation in anteroposterior (AP) view.

Biomechanical testing

Biomechanical testing was performed on a servo-hydraulic material testing system (Mini Bionix II 858, MTS Systems Corp., Eden Prairie, MN, USA) equipped with a 4 kN loadcell. Each specimen was non-destructively loaded along the machine axis using three setups featuring neutral position along the shaft axis, flexion or extension of the radius (Fig. 4). For this purpose, the proximal end of each specimen was coupled to the machine actuator via a custom-made fixation with a set angle of 90° for neutral position and 40° for flexion and extension. The distal load transfer to the articular surfaces was achieved via two custom-molded polymethylmethacrylate (PMMA, SCS-Beracryl D28, Suter Kunststoffe AG, Fraubrunnen, Switzerland) supports, one supporting the scaphoid facet, and the other the lunate facet. Three different separate sets of supports were negatively casted for testing in neutral position, flexion and extension. Both supports rested on a metal sphere of 8 mm diameter, enabling all rotational degrees of freedom. The spheres were positioned asymmetrically on a custom-made seesaw to achieve a predefined load distribution of 60% and 40% transmitted to the scaphoid and lunate facets, respectively [14, 15]. In addition, the sphere under the scaphoid facet was supported on a miniature linear guide for free mediolateral movement. Finally, the seesaw was mounted on the machine base with an XY table to alleviate shear forces.

Fig. 4
figure 4

Test setup with a specimen mounted for biomechanical testing in extension, with vertical arrow denoting the loading direction, and indicated inclination angle of the radial shaft

The protocol for all tests consisted of a non-destructive ramped loading from 10 N to 100 N at a rate of 10 N/sec. The linear elastic behavior of the plated specimens under these loading conditions was confirmed in pilot tests. The upper limit of 100 N was defined based on previous studies [16,17,18,19]. From a clinical perspective, it was within the expected range of physiological loading for light wrist motion. The loadcell operated with a measurement uncertainty of 0.4% within a load range 0–250 N and was therefore suitable for the applied loads.

Following the biomechanical testing of the double-plated specimens, their dorsal plate was removed and all tests were repeated using a single volar plate fixation.

Data acquisition and analysis

Force and crosshead displacement machine data were acquired at 128 Hz. Based on these, construct stiffness of each specimen was calculated from the linear elastic region of the force-displacement curve within a load range 40–80 N for each loading direction and type of plate fixation. Moreover, all tests were accompanied by ML and AP radiographs taken at 10 N and 100 N force levels with a C-arm (ARCADIS Varic VC10A, Siemens Healthineers, Erlangen, Germany). Based on the ML radiographs, angular displacement of the lunate facet fragments was measured with respect to the radius shaft in the sagittal plane by evaluating the angle change between the K-wires. Interfragmentary displacements between the styloid process and the lunate facet in the coronal plane were measured from the AP radiographs by the change in distance between the metal spheres in neutral specimen’s position.

Statistical analysis was performed using SPSS software package (v.27, IBM SPSS, Armonk, NY, USA). Normal distribution of the data was screened and proved with Shapiro-Wilk test. One-Way Analysis of Variance (ANOVA) with Bonferroni Post-Hoc test for multiple comparisons and Paired-Samples t-test were applied to identify significant differences between the study groups, fixation methods and radius inclinations during testing. Level of significance was set to 0.05 for all statistical tests.

Results

The results for construct stiffness, angular displacement and interfragmentary displacement are summarized in Table 1.

Table 1 Stiffness (ST), angular displacement (AD) and interfragmentary displacement (ID) in the three study groups (GR) for volar (V) and double (D) plating (PL) under neutral (N) loading condition, flexion (F) and extension (E), in terms of mean and standard deviation. P-value (P) indicates statistical differences between volar and double plating for the respective outcome. Bold values indicate significant differences

In neutral position, flexion or extension, construct stiffness remained without significant differences between the three study groups treated with same plate fixation – volar or double plating (p ≥ 0.15). However, for each separate group and fixation method, stiffness in neutral position was significantly higher versus both flexion and extension (p < 0.01), being not significantly different between flexion and extension (p ≥ 0.13). In each tested position, stiffness increased significantly after supplemental dorsal plating in both Group 2 and Group 3 (p ≤ 0.02), but not in Group 1 (p ≥ 0.12).

Following volar plating, angular displacement in neutral position, flexion or extension was significantly lower in Group 1 compared with both Group 2 and Group 3 (p < 0.01), being not significantly different between Group 2 and Group 3 (p ≥ 0.93). In each tested position, angular displacement decreased significantly after supplemental dorsal plating in both Group 2 and Group 3 (p < 0.01), but not in Group 1 (p ≥ 0.13), and did not demonstrate any significant differences between the three groups after double plate fixation (p ≥ 0.74). In addition, for each separate group and fixation method, angular displacement in neutral position was significantly lower versus both flexion and extension (p ≤ 0.03), whereas it did not differ significantly between the latter two inclinations (p ≥ 0.14).

Interfragmentary displacements between the styloid process and lunate facet in neutral position were below 0.5 mm and did not reveal any significant differences among the study groups and fixation methods (p ≥ 0.63).

Discussion

This study compares the biomechanical competency between volar locked plating and combined dorsal and volar double plate fixation of complex DRFs. We used three fracture models with different degrees of comminution to investigate the impact of lunate facet separation on the fracture stability.

Our investigation proves that when the dorsal third of the lunate facet is not separated by a fracture line, volar locked plating and double plating achieve comparable stability.

In contrast, double-plated constructs demonstrated superior fixation stability compared with a single volar locked plating in cases of lunate facet comminution within its dorsal third.

Currently, no existing studies seem to conclude and recommend if and when additional dorsal support would be necessary for reliable fixation of fracture patterns featuring the various specific types of lunate facet fragmentation.

Several biomechanical studies have focused primarily on comparisons between various volar or dorsal plate fixations [20,21,22,23,24]. However, a relationship between the stability of those constructs and the degree of lunate facet comminution has not been investigated.

We considered it justified to contrast the existing reports – advocating single volar locked plating as being able to provide reliable stability for most dorsally comminuted DRFs – via a carefully designed biomechanical experiment in the current study, in order to provide evidence answering the question which cases would require additional dorsal support [24,25,26,27,28].

In our study, Group 1 implemented a reference fracture model based on previous biomechanical work [15, 25, 26]. In accordance with previous investigations, three different test setups and protocols with non-destructive axial compression and volar or dorsal bending of the distal radius were developed to resemble early postoperative wrist motion and grasp [25,26,27,28,29,30,31].

In the current clinical practice, most dorsally comminuted DRFs are treated with volar instead of dorsal locking plates – an algorithm followed with insufficient evidence [8, 32, 33].

A dorsal approach has been suggested for some intraarticular fractures [1, 25], especially with lunate facet comminution involving dorsoulnar fragmentation. Dorsal plate application is performed with an additional surgical approach, which can result in additional surgical trauma and higher complication rates due to the small volume of the dorsal compartments. Most common complications are extensor tendon ruptures and tenosynovitis [12, 15, 34,35,36,37,38,39,40,41,42,43].

The need for dorsal support and several findings of our study can be explained with the mechanism of loading and injury of the lunate facet. The three-column theory of the distal radius was introduced in the context of dorsal buttress double plating and later corroborated in several in-vivo and in-vitro studies [30, 44]. The fragmentation of the lunate facet is a direct consequence of the loading conditions described by this theory. Secure fixation of the intermediate column – heavily loaded in compression – has attracted the interest of a number of investigators [15, 22, 23, 45,46,47,48].

A previous investigation reported on the bending moments acting on the bone-implant constructs and concluded that they increase as the point of the respective force application moves away from the plate [43]. Therefore, the more dorsally the point of force application is located, the greater the mechanical disadvantage will become, which can be counteracted with a volar plate.

The load transmission at the distal radius was shown to be concentrated on the volar side during flexion and more dorsally during extension [49, 50]. In contrast, a previous investigation, comparing in-vitro and in-vivo results, concluded that the load distribution to the lunate facet in flexion and extension is generally equalized [30]. In our test setups we implemented different distal load distributions for flexion and extension of the distal radius but the results were still comparable between these two positions for each separate fracture model and fixation method.

A number of clinical studies demonstrated that small volar DRF fragments are challenging to address and that an unstable fixation may result in radiocarpal and radioulnar joint subluxations [4, 5, 28, 51].

The importance of the dorsoulnar fragment and its contribution to construct stability has attracted rather little attention and the few available reports provide conflicting evidence. It is known that this fragment of the distal radius articular surface contributes considerably to the congruency of the distal radioulnar joint [7, 52]. Moreover, it plays a crucial role in the maintenance of an adequate sagittal radiocarpal alignment and the prevention of dorsal collapse [2].

In several cadaveric biomechanical studies, the change in contact pressure of the wrist was investigated for step-off intraarticular malunions [53, 54]. A step-off of 1 mm or more within the volar lunate facet was found to increase the contact pressure in the radiocarpal joint, whereas no considerable contact pressure change was reported at an articular step-off of up to 2 mm within the dorsal distal radius [55]. These findings could explain why a volar lunate facet incongruity leads to poor outcomes, whereas a displaced dorsal rim fragment does not [53].

A finite element investigation reported that in presence of a 1 mm step-off within the volar lunate facet, the contact stress distributions shifted towards the ulna [55]. A retrospective study demonstrated that the size of the dorsoulnar fragment is not associated with occurrence of postoperative fracture displacement [2]. Although fixation of this fragment – shared by the distal radioulnar and radiocarpal joints – appears valuable in preventing postoperative fracture dislocation, there is no existing consensus on its optimal fixation method. Some authors proposed fixation of the dorsoulnar fragment with a low-profile plate via additional 30 mm dorsal approach [1] or application of a single-fragment compression screw through a small incision [7]. In another work, the dorsoulnar fragment was targeted with volar plate screws after anatomical DRF reduction [53]. However, the screw length selection is under discussion because penetration of the dorsal cortex would lead to extensor tendon irritation or rupture, whereas missing screw support at the far cortex raises the question about insufficient stability of fixation.

In our study, no articular step-off of the lunate facet was observed irrespective of the fragmentation pattern.

The fracture model in Group 1 was the same as in previous work comparing the biomechanical competency of volar and double plated constructs representing AO/OTA 23-C2.1 fractures [24]. According to those findings, the two fixation methods revealed comparable biomechanical characteristics, which is in line with our study results.

In the present investigation, the magnitude of angular displacement of the lunate facet fragments with respect to the radial shaft after volar plating was related to the degree of comminution within the dorsal third of the lunate facet. In presence of such a comminution, considerably decreased angular displacement was observed following double plating. Due to the dorsal metaphyseal defect as a whole, simulated via a dorsal wedge-shaped osteotomy gap and being the principal source of instability, the tested specimens demonstrated only extraarticular displacement.

This study has some limitations inherent to all biomechanical investigations. A limited sample size of synthetic bones was used, resulting in restriction of the translation to generalized clinical applications. In agreement with previous work, the radii were consistently selected to be similar in size in order to provide less variation between the study groups [48]. An osteoporotic bone model was not explicitly tested. Despite this, we were able to detect several significant differences related to the different simulated fracture patterns, plate fixations and tested specimens’ positions. The fracture creation via osteotomizing did not necessarily obey the physical laws of real fracture mechanisms, however, it was performed because of standardization purposes. Moreover, fragmentation patterns of the lunate facet in real life can rarely be assigned to standardized groups with four or five fracture fragments. In addition, the anatomic reduction of articular fragments in controlled laboratory settings were only vaguely similar to the more complicated in-vivo situations. The setup for testing of the specimens in neutral position, flexion and extension was a gross simplification of the real fractured-bone situation and physiological loading conditions, not necessarily replicating the more complex in-vivo situations that may include torsional and bending moments. Furthermore, the biomechanics of in-vivo fracture healing could not be simulated. Instead, a direct post-operative primary stability situation without bone consolidation as worse-case scenario was explored.

Conclusion

From a biomechanical perspective, fracture patterns featuring comminution of the lunate facet within its dorsal third significantly affect stability when comparing volar and double plate fixations of complex intraarticular distal radius fractures.

Double plating demonstrates superior fixation stability versus single volar plating only in case of lunate facet comminution within its dorsal third. In contrast, volar locked plating could achieve comparable stability versus double plate fixation when the dorsal third of the lunate facet is not separated by the fracture pattern. Both fixation methods indicate a potential of achieving absolute stability between the articular fragments.

From a clinical perspective, fracture fixation should be performed with a single volar plate only in cases with appropriate dorsoulnar fragment size of at least 6 mm when adequate anatomical reduction is possible.

Availability of data and materials

Access to the data will be provided upon request.

Abbreviations

AD:

Angular displacement

ANOVA:

One-Way Analysis of Variance

AO:

Arbeitsgemeinschaft für Osteosynthesefragen

AP:

Anteroposterior

D:

Double

DRF:

Distal radius fracture

E:

Extension

F:

Flexion

GR:

Group

ID:

Interfragmentary displacement

K-wire:

Kirschner wire

LCP:

Locking Compression Plate

ML:

Mediolateral

N:

Neutral

OTA:

Orthopaedic Trauma Association

P:

P-value

PL:

Plating

PMMA:

Polymethylmethacrylate

ST:

Stiffness

V:

Volar

References

  1. Ikeda K, Osamura N, Tada K. Fixation of an ulnodorsal fragment when treating an intra-articular fracture in the distal radius. Hand Surg. 2014;19(1):139–44.

    Article  PubMed  Google Scholar 

  2. Miyashima Y, Kaneshiro Y, Yano K, Teraura H, Sakanaka H, Uemura T. Size and stabilization of the dorsoulnar fragment in AO C3-type distal radius fractures. Injury. 2019;50(11):2004–8.

    Article  CAS  PubMed  Google Scholar 

  3. Lans J, Alvarez J, Kachooei AR, Ozkan S, Jupiter JB. Dorsal lunate facet fracture reduction using a bone reduction forceps. J Wrist Surg. 2019;8(2):118–23.

    Article  PubMed  Google Scholar 

  4. Moore AM, Dennison DG. Distal radius fractures and the volar lunate facet fragment: Kirschner wire fixation in addition to volar-locked plating. Hand (N Y). 2014;9(2):230–6.

    Article  Google Scholar 

  5. Obata H, Baba T, Futamura K, Obayashi O, Mogami A, Tsuji H, et al. Difficulty in fixation of the volar lunate facet fragment in distal radius fracture. Case Rep Orthop. 2017;2017:6269081.

    PubMed  PubMed Central  Google Scholar 

  6. O'Shaughnessy MA, Shin AY, Kakar S. Stabilization of volar ulnar rim fractures of the distal radius: current techniques and review of the literature. J Wrist Surg. 2016;5(02):113–9.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Lee JI, Cho JH, Lee SJ. The effects of the frag-Loc((R)) compression screw on distal radius fracture with a displaced dorsoulnar fragment. Arch Orthop Trauma Surg. 2015;135(9):1315–21.

    Article  PubMed  Google Scholar 

  8. Slutsky DJ, Osterman AL. Fractures and injuries of the distal radius and carpus: the cutting edge. Elsevier Health Sci. 2009. p. 125–33. https://www.sciencedirect.com/science/article/pii/B9781416040835000135?via%3Dihub.

  9. Johnson NA, Cutler L, Dias JJ, Ullah AS, Wildin CJ, Bhowal B. Complications after volar locking plate fixation of distal radius fractures. Injury. 2014;45(3):528–33.

    Article  CAS  PubMed  Google Scholar 

  10. Ring D, Prommersberger K, Jupiter JB. Combined dorsal and volar plate fixation of complex fractures of the distal part of the radius. J Bone Joint Surg Am. 2005;87(Suppl 1(Pt 2)):195–212.

    PubMed  Google Scholar 

  11. Kilian M, Simkovic P, Zamborsky R, Skoda A, Labas P. What are the ideal screw lengths in volar locking plate fixation for distal radius fractures? Bratisl Lek Listy. 2019;120(7):505–9.

    CAS  PubMed  Google Scholar 

  12. Musgrave DS, Idler RS. Volar fixation of dorsally displaced distal radius fractures using the 2.4-mm locking compression plates. J Hand Surg Am. 2005;30(4):743–9.

    Article  PubMed  Google Scholar 

  13. Ozer K, Toker S. Dorsal tangential view of the wrist to detect screw penetration to the dorsal cortex of the distal radius after volar fixed-angle plating. Hand (N Y). 2011;6(2):190–3.

    Article  Google Scholar 

  14. Rausch S, Klos K, Stephan H, Hoffmeier K, Gras F, Windolf M, et al. Evaluation of a polyaxial angle-stable volar plate in a distal radius C-fracture model--a biomechanical study. Injury. 2011;42(11):1248–52.

    Article  PubMed  Google Scholar 

  15. Windolf M, Schwieger K, Ockert B, Jupiter JB, Gradl G. A novel non-bridging external fixator construct versus volar angular stable plating for the fixation of intra-articular fractures of the distal radius--a biomechanical study. Injury. 2010;41(2):204–9.

    Article  PubMed  Google Scholar 

  16. Tencer AF, Viegas SF, Cantrell J, Chang M, Clegg P, Hicks C, et al. Pressure distribution in the wrist joint. J Orthop Res. 1988;6(4):509–17.

    Article  CAS  PubMed  Google Scholar 

  17. Trumble T, Glisson RR, Seaber AV, Urbaniak JR. Forearm force transmission after surgical treatment of distal radioulnar joint disorders. J Hand Surg Am. 1987;12(2):196–202.

    Article  CAS  PubMed  Google Scholar 

  18. Viegas SF, Patterson R, Peterson P, Roefs J, Tencer A, Choi S. The effects of various load paths and different loads on the load transfer characteristics of the wrist. J Hand Surg Am. 1989;14(3):458–65.

    Article  CAS  PubMed  Google Scholar 

  19. Viegas SF, Pogue DJ, Patterson RM, Peterson PD. Effects of radioulnar instability on the radiocarpal joint: a biomechanical study. J Hand Surg Am. 1990;15(5):728–32.

    Article  CAS  PubMed  Google Scholar 

  20. Blythe M, Stoffel K, Jarrett P, Kuster M. Volar versus dorsal locking plates with and without radial styloid locking plates for the fixation of dorsally comminuted distal radius fractures: a biomechanical study in cadavers. J Hand Surg Am. 2006;31(10):1587–93.

    Article  PubMed  Google Scholar 

  21. Kandemir U, Matityahu A, Desai R, Puttlitz C. Does a volar locking plate provide equivalent stability as a dorsal nonlocking plate in a dorsally comminuted distal radius fracture?: a biomechanical study. J Orthop Trauma. 2008;22(9):605–10.

    Article  PubMed  Google Scholar 

  22. Osada D, Viegas SF, Shah MA, Morris RP, Patterson RM. Comparison of different distal radius dorsal and volar fracture fixation plates: a biomechanical study. J Hand Surg Am. 2003;28(1):94–104.

    Article  PubMed  Google Scholar 

  23. Peine R, Rikli DA, Hoffmann R, Duda G, Regazzoni P. Comparison of three different plating techniques for the dorsum of the distal radius: a biomechanical study. J Hand Surg Am. 2000;25(1):29–33.

    Article  CAS  PubMed  Google Scholar 

  24. Rausch S, Schlonski O, Klos K, Gras F, Gueorguiev B, Hofmann GO, et al. Volar versus dorsal latest-generation variable-angle locking plates for the fixation of AO type 23C 2.1 distal radius fractures: a biomechanical study in cadavers. Injury. 2013;44(4):523–6.

    Article  PubMed  Google Scholar 

  25. Chou YC, Chen AC, Chen CY, Hsu YH, Wu CC. Dorsal and volar 2.4-mm titanium locking plate fixation for AO type C3 dorsally comminuted distal radius fractures. J Hand Surg Am. 2011;36(6):974–81.

    Article  PubMed  Google Scholar 

  26. Drobetz H, Weninger P, Grant C, Heal C, Muller R, Schuetz M, et al. More is not necessarily better. A biomechanical study on distal screw numbers in volar locking distal radius plates. Injury. 2013;44(4):535–9.

    Article  PubMed  Google Scholar 

  27. Orbay JL, Touhami A, Orbay C. Fixed angle fixation of distal radius fractures through a minimally invasive approach. Tech Hand Up Extrem Surg. 2005;9(3):142–8.

    Article  PubMed  Google Scholar 

  28. Tordjman D, Hinds RM, Ayalon O, Yang SS, Capo JT. Volar-ulnar approach for fixation of the volar lunate facet fragment in distal radius fractures: a technical tip. J Hand Surg Am. 2016;41(12):e491–500.

    Article  PubMed  Google Scholar 

  29. Majima M, Horii E, Matsuki H, Hirata H, Genda E. Load transmission through the wrist in the extended position. J Hand Surg Am. 2008;33(2):182–8.

    Article  PubMed  Google Scholar 

  30. Rikli DA, Honigmann P, Babst R, Cristalli A, Morlock MM, Mittlmeier T. Intra-articular pressure measurement in the radioulnocarpal joint using a novel sensor: in vitro and in vivo results. J Hand Surg Am. 2007;32(1):67–75.

    Article  PubMed  Google Scholar 

  31. Varga P, Zysset PK, Schefzig P, Unger E, Mayr W, Erhart J. A finite element analysis of two novel screw designs for scaphoid waist fractures. Med Eng Phys. 2016;38(2):131–9.

    Article  PubMed  Google Scholar 

  32. Ring D, Prommersberger K, Jupiter JB. Combined dorsal and volar plate fixation of complex fractures of the distal part of the radius. J Bone Joint Surg Am. 2004;86-a(8):1646–52.

    Article  Google Scholar 

  33. Sagerfors M, Bjorling P, Niklasson J, Pettersson K. Combined volar T-plate and dorsal pi-plate for distal radius fractures: a consecutive series of 80 AO type C2 and C3 cases. J Wrist Surg. 2019;8(3):180–5.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Jakob M, Rikli DA, Regazzoni P. Fractures of the distal radius treated by internal fixation and early function. A prospective study of 73 consecutive patients. J Bone Joint Surg Br. 2000;82(3):340–4.

    Article  CAS  PubMed  Google Scholar 

  35. Kamath AF, Zurakowski D, Day CS. Low-profile dorsal plating for dorsally angulated distal radius fractures: an outcomes study. J Hand Surg Am. 2006;31(7):1061–7.

    Article  PubMed  Google Scholar 

  36. Kambouroglou GK, Axelrod TS. Complications of the AO/ASIF titanium distal radius plate system (pi plate) in internal fixation of the distal radius: a brief report. J Hand Surg Am. 1998;23(4):737–41.

    Article  CAS  PubMed  Google Scholar 

  37. Mellstrand-Navarro C, Pettersson HJ, Tornqvist H, Ponzer S. The operative treatment of fractures of the distal radius is increasing: results from a nationwide Swedish study. Bone Joint J. 2014;96-B(7):963–9.

    Article  CAS  PubMed  Google Scholar 

  38. Orbay J. Volar plate fixation of distal radius fractures. Hand Clin. 2005;21(3):347–54.

    Article  PubMed  Google Scholar 

  39. Orbay JL. The treatment of unstable distal radius fractures with volar fixation. Hand Surg. 2000;5(2):103–12.

    Article  CAS  PubMed  Google Scholar 

  40. Orbay JL, Fernandez DL. Volar fixation for dorsally displaced fractures of the distal radius: a preliminary report. J Hand Surg Am. 2002;27(2):205–15.

    Article  PubMed  Google Scholar 

  41. Ruch DS, Papadonikolakis A. Volar versus dorsal plating in the management of intra-articular distal radius fractures. J Hand Surg Am. 2006;31(1):9–16.

    Article  PubMed  Google Scholar 

  42. Simic PM, Robison J, Gardner MJ, Gelberman RH, Weiland AJ, Boyer MI. Treatment of distal radius fractures with a low-profile dorsal plating system: an outcomes assessment. J Hand Surg Am. 2006;31(3):382–6.

    Article  PubMed  Google Scholar 

  43. Trease C, McIff T, Toby EB. Locking versus nonlocking T-plates for dorsal and volar fixation of dorsally comminuted distal radius fractures: a biomechanical study. J Hand Surg Am. 2005;30(4):756–63.

    Article  PubMed  Google Scholar 

  44. Rikli DA, Regazzoni P. Fractures of the distal end of the radius treated by internal fixation and early function. A preliminary report of 20 cases. J Bone Joint Surg Br. 1996;78(4):588–92.

    Article  CAS  PubMed  Google Scholar 

  45. Hart AJ, Seepaul T, Hewitt RJ, Ang S, Hansen U, Amis AA. The palmar locking compression plate is biomechanically comparable to the dorsal pi plate for dorsally comminuted, intraarticular wrist fractures. J Hand Surg Eur. 2007;32(4):388–93.

    Article  CAS  Google Scholar 

  46. Knox J, Ambrose H, McCallister W, Trumble T. Percutaneous pins versus volar plates for unstable distal radius fractures: a biomechanic study using a cadaver model. J Hand Surg Am. 2007;32(6):813–7.

    Article  PubMed  Google Scholar 

  47. Liporace FA, Gupta S, Jeong GK, Stracher M, Kummer F, Egol KA, et al. A biomechanical comparison of a dorsal 3.5-mm T-plate and a volar fixed-angle plate in a model of dorsally unstable distal radius fractures. J Orthop Trauma. 2005;19(3):187–91.

    Article  PubMed  Google Scholar 

  48. Willis AA, Kutsumi K, Zobitz ME, Cooney WP. 3rd: internal fixation of dorsally displaced fractures of the distal part of the radius. A biomechanical analysis of volar plate fracture stability. J Bone Joint Surg Am. 2006;88(11):2411–7.

    Article  PubMed  Google Scholar 

  49. Short WH, Werner FW, Fortino MD, Mann KA. Analysis of the kinematics of the scaphoid and lunate in the intact wrist joint. Hand Clin. 1997;13(1):93–108.

    Article  CAS  PubMed  Google Scholar 

  50. Short WH, Werner FW, Fortino MD, Palmer AK, Mann KA. A dynamic biomechanical study of scapholunate ligament sectioning. J Hand Surg Am. 1995;20(6):986–99.

    Article  CAS  PubMed  Google Scholar 

  51. Harness NG. Fixation options for the volar lunate facet fracture: thinking outside the box. J Wrist Surg. 2016;5(1):9–16.

    Article  PubMed  PubMed Central  Google Scholar 

  52. Dy CJ, Wolfe SW, Jupiter JB, Blazar PE, Ruch DS, Hanel DP. Distal radius fractures: strategic alternatives to volar plate fixation. Instr Course Lect. 2014;63:27–37.

    PubMed  Google Scholar 

  53. Kim JK, Yun YH, Kim DJ. The effect of displaced dorsal rim fragment in a distal radius fracture. J Wrist Surg. 2016;5(1):31–5.

    Article  PubMed  PubMed Central  Google Scholar 

  54. Wagner WF Jr, Tencer AF, Kiser P, Trumble TE. Effects of intra-articular distal radius depression on wrist joint contact characteristics. J Hand Surg Am. 1996;21(4):554–60.

    Article  PubMed  Google Scholar 

  55. Anderson DD, Bell AL, Gaffney MB, Imbriglia JE. Contact stress distributions in malreduced intraarticular distal radius fractures. J Orthop Trauma. 1996;10(5):331–7.

    Article  CAS  PubMed  Google Scholar 

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Acknowledgements

The authors are not compensated and there are no other institutional subsidies, corporate affiliations, or funding sources supporting this work unless clearly documented and disclosed. This investigation was performed with the assistance of the AO Foundation.

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This investigation was performed with the assistance of the AO Foundation.

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M.H. – literature review, specimens preparation, experiments conduction, manuscript draft; I.Z. – test setup development, data evaluation, statistical analysis, manuscript draft; D.C. – experiments conduction, data evaluation, manuscript draft revision; J.P.B. – concept development, specimens preparation, data evaluation; D.E., K.S. and M.R. – clinical input, study concept, data analysis and interpretation; L.R. – specimens preparation, experiments conduction, data interpretation; G.R. – study supervision, financial support, study concept; B.G. and P.V. – data evaluation, results analysis, critical manuscript draft review; A.B. – study supervision, results analysis and interpretation. All authors read and approved the final manuscript version.

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Hadzhinikolova, M., Zderic, I., Ciric, D. et al. Volar versus combined dorsal and volar plate fixation of complex intraarticular distal radius fractures with small dorsoulnar fragment – a biomechanical study. BMC Musculoskelet Disord 23, 35 (2022). https://doi.org/10.1186/s12891-021-04989-w

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