CURRENT CONCEPTS

Management of Severely Comminuted Distal

Radius Fractures
David M. Brogan, MD, MSc, Marc J. Richard, MD, David Ruch, MD, Sanjeev Kakar, MD

Distal radius fractures are among the most common fractures of the upper extremity. In-
dications for operative and nonsurgical management have evolved over time, as have fixation
techniques. Volar locking plates are commonly used in the treatment of selected distal radius
fractures such as low-energy or relatively uncomplicated fractures. They have limitations,
however, in the management of highly comminuted fracture patterns and in polytrauma pa-
tients. In these patients, other methods ranging from spanning fixation to fragment-specific
fixation have emerged as useful alternatives in the surgeon’s armamentarium for treatment
of these challenging fractures. (J Hand Surg Am. 2015;-(-):-e-. Copyright Ó 2015 by
the American Society for Surgery of the Hand. All rights reserved.)
Key words Distal radius fracture, fragment specific fixation, dorsal bridge plate, external
fixation.

U
PPER EXTREMITY FRACTURES HAVE been estimated in the postmenopausal years, owing to a reduction in
to account for up to 1.5% of all United States bone mass,5 and the incidence of comminuted intra-
emergency room visits, and 44% of these are articular fractures increases in both sexes with
attributed to fractures of the radius and ulna.1 Distal advancing age.6
radius fractures tend to occur in a bimodal age distri- The increasing incidence of distal radius fractures
bution: young patients involved in high-energy trauma with advancing age has a profound impact on health
and elderly patients with low to moderate energy in- care expenditures. In 2007, Medicare spent $170
juries secondary to osteopenia or osteoporosis. Higher- million on distal radius fracture care.7 A review of
energy fractures are more likely to result in greater Medicare claims over a 10-year period ending in
articular involvement and comminution.2 Risk factors 2005 demonstrated an increase in internal fixation of
for these higher-energy fractures include younger age, distal radius fractures in the elderly from 3% to 16%.8
rural areas, and the summer season.3 Men have a 5-fold In short, patients are living longer, sustaining more
higher risk of sustaining a high-energy distal radius fractures, and undergoing more surgery than before.
fracture than women (Fig. 1). Despite this, the overall
age-adjusted incidence of distal radius fractures is 4 to DIAGNOSIS
5 times greater in women than men.3e5 In women, the Assessment of the patient begins with an examination
greatest lifetime risk for a distal radius fracture occurs of the injured limb, noting any deformity, ecchymosis,
and swelling or breaks in the skin that may indicate an
open fracture. A careful neurovascular examination
From the Division of Hand Surgery, Department of Orthopedic Surgery, Mayo Clinic, should be performed, particularly to assess for asso-
Rochester, MN; and the Division of Hand Surgery, Department of Orthopedic Surgery, Duke
University, Durham, NC. ciated median nerve injury or perhaps acute carpal
Received for publication January 4, 2015; accepted in revised form March 7, 2015.
tunnel syndrome. After a thorough history and physical
examination, the next step in treatment is an evaluation
D.R. is a consultant for Acumed. S.K. is a consultant for Skeletal Dynamics and Arthrex.
M.J.R. is a consultant for Acumed and DePuy-Synthes. of the injury with plain radiographs. X-rays (including
Corresponding author: Sanjeev Kakar, MD, Division of Hand Surgery, Department of posteroanterior, oblique, lateral, and 10 tilt lateral
Orthopaedic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905; e-mail: views) and sometimes computed tomographic scans
kakar.sanjeev@mayo.edu. are used to examine the fracture. There are a number of
0363-5023/15/---0001$36.00/0 classification systems, including Gartland and Werley,
http://dx.doi.org/10.1016/j.jhsa.2015.03.014
Mayo, Melone, the AO, Fernandez, Frykman, and

Ó 2015 ASSH r Published by Elsevier, Inc. All rights reserved. r 1

2 SEVERELY COMMINUTED DISTAL RADIUS FRACTURES

FIGURE 1: Histogram demonstrating relative distribution of distal radius fractures by age and sex (reprinted with permission from Koo
KOT, Tan DMK, Chong AKS. Distal radius fractures: an epidemiological review. Orthop Surg. 2013;5[3]:209e2132 Copyright Ó 2013
John Wiley and Sons.).

Fragment Specific, to help guide treatment. In terms function may be achieved despite articular incongruity.
of the latter, fracture fragments that are created include Several case series have shown a high percentage of
the radial column, volar rim, dorsal rim, free intra- good to excellent patient-reported outcomes in elderly
articular fragments, and the ulnar corner. patients treated with casting,12 with operative and
Functionally, the distal radius may be thought of as nonsurgical groups displaying similar outcomes.13,14
having 3 distinct articular surfaces: the scaphoid facet, Surgical treatment results in better radiographic pa-
lunate facet, and sigmoid notch. The mechanism of rameters, but in the elderly population this has not been
injury directly affects the fracture pattern, and injuries proven to affect outcome.13,15 However, in younger,
with the wrist extended at the time of impact tend to be active patients, improving articular incongruity possibly
more common than those with the wrist in flexion. maximizes functional outcomes. Knirk and Jupiter16
Tanabe and colleagues9 studied the fracture patterns of found an association between residual articular stepoff
91 patients with intra-articular distal radius fractures. of greater than 2 mm and development of posttraumatic
When the wrist was in an extended position at the time arthritis in a young patient population (average age,
of injury, fractures of the sigmoid notch and dorsal ul- 27.6 y), with worse patient-reported outcomes in those
nar corner were most common. In neutral position, the 3 with arthritis. In contrast, Forward et al17 reviewed a
main fracture fragments were the sigmoid notch, dorsal series of 106 adults with distal radius fractures treated
radial, and volar radial corners; in wrist flexion, frac- with casting at a mean follow-up of 38 years. Among all
tures of the sigmoid notch and dorsal radial corner were patients with intra-articular and extra-articular fractures,
most common. Recognition of these various fracture they found little difference in functional outcome scores
patterns is important because failure to address these compared with population norms. The authors noted an
can result in loss of reduction or radiocarpal subluxa- increased evidence of radiographic arthritis in patients
tion.10 The ligamentous anatomy of the distal radius can with intra-articular fractures, and patients with the most
also influence the fracture pattern, with fractures more severe arthritic changes were 10 times more likely to
likely to occur between ligamentous attachments.11 demonstrate worse function compared with those with
This suggests that the ligament attachment confers no arthritic changes.
some form of protection to the bone, or that the liga- The American Academy of Orthopaedic Surgeons
ments tend to insert in areas of greater bone strength.11 practice guidelines on treatment of distal radius frac-
tures recommend operative fixation for the following
TREATMENT parameters: radial shortening greater than 3 mm, dor-
Treatment of distal radius fractures has evolved sal tilt greater than 10 from neutral, or intra-articular
substantially over the past 4 decades. In treating these displacement/stepoff of more than 2 mm. Rigid im-
fractures, it is important to recognize that adequate mobilization is advocated over removable orthoses for

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 SEVERELY COMMINUTED DISTAL RADIUS FRACTURES 3

nonsurgical treatment and early mobilization should polytrauma patients, or patients who may not other-
be used if stable fixation is achieved.18 wise tolerate a prolonged operative procedure (damage
Several methods of surgical stabilization exist in control orthopedics) or as an adjunct with additional
the management of distal radius fractures. One type internal fixation. In addition, external fixation can be
of fixation does not suit all fractures, and so it is used as a temporizing method of treatment when the
important for the surgeon to individualize the treat- forearm is too swollen to permit open reduction in-
ment based on the fracture, the patient, and the sur- ternal fixation. Although external fixation may not
geon’s own proficiency with the method of fixation. provide fixation as rigid as that supplied by a spanning
plate or fragment-specific fixation, it remains an
External fixation invaluable tool for highly comminuted distal radius
Surgical treatment has evolved over the past 4 de- fractures in select patient populations.
cades, from intrafocal pinning as described by
Kapandji19 to the use of external fixation or a com- Dorsal plate fixation
bination thereof. Although intrafocal pinning appears In the late 1990s, dorsal plate fixation was increas-
to have some benefit in maintaining alignment in ingly used to minimize the morbidity and stiffness of
minimally comminuted fractures in younger patients, an external fixator, but it was hampered by a high rate
it is less effective at restoring radial length, especially of hardware complications, including extensor ten-
in elderly patients with osteoporotic bone. Thus, the don irritation.25,26 A prospective randomized trial
adoption of external fixation arose to maintain radial compared open reduction and dorsal pi-plate appli-
length, volar tilt, and reduction of comminuted distal cation versus mini-open reduction, percutaneous
radius fractures not amenable to plaster immobiliza- pinning, and external fixation for treatment of intra-
tion. The technique assists with fracture reduction via articular distal radius fractures. The authors found
ligamentotaxis and tends to be used in combination that patients treated with a dorsal plate had equivalent
with Kirschner wire fixation for intra-articular frac- Disabilities of the Arm, Shoulder, and Hand (DASH)
tures to control for angulation and displacement. A scores but higher pain levels, increased rate of com-
prospective randomized trial comparing external fix- plications and lower grip strength at 1 year compared
ation with plaster cast immobilization demonstrated with the external fixation group.27 Still, further re-
improved radiographic and functional parameters at 6 finements have made the plates lower in profile and
months in younger patients with comminuted distal less irritating to tendons. Attention to surgical tech-
radius fractures treated with external fixation.20 nique is important because subperiosteal elevation of
Similarly, a prospective randomized trial of external the second and fourth extensor compartments allows
fixation versus open reduction internal fixation with for interposition of periosteum between the plate and
volar or dorsal plates for intra-articular distal radius extensor tendons at the time of closure.28 Current in-
fractures found faster return to function and less dications for dorsal plating include29 comminuted
overall pain in the external fixation group.21 dorsally displaced fractures, dorsal shear fractures,
A separate prospective randomized trial comparing comminuted intra-articular fractures requiring direct
external fixation with volar plating found no difference visualization of the joint, and fractures associated with
in grip strength, range of motion, or functional other carpal injuries requiring a dorsal approach (such
outcome between the 2 treatment groups at 1 year as proximal pole scaphoid fractures). Contraindica-
after surgery.22 The authors discovered that the volar tions to dorsal plating include a poor dorsal soft tissue
plating group had better short-term functional recov- envelope or fractures with a large, displaced volar
ery, with both achieving the same recovery at long- fracture or isolated lunate facet fracture.
term follow-up. Complication rates reported with
external fixation can range from 50% to 62%, Volar plating
including pin track infection, complex regional pain In the early part of the 21st century, volar plating paved
syndrome, digital stiffness, and nerve injury. Tech- the way for a paradigm shift in the operative treatment
niques such as the prevention of overdistraction once of distal radius fractures, with the use of locked volar
the reduction has been obtained and judicious use of plating.30,31 In an epidemiological study conducted in
incisions to avoid inadvertent nerve injury when Sweden from 2005 to 2010, the incidence of plate
placing the pins may mitigate some of these con- fixation of distal radius fractures increased 3.6-fold.32
cerns.23,24 Our main indications for the use of external Yet, in the past several years an increasing amount
fixation with or without Kirschner wire fixation are of literature has focused on complications related to
grossly contaminated intra-articular fractures, unstable volar plate fixation.33,34 A disconcerting complication

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is volar plate prominence resulting in flexor tendon for 2 reasons. First, the proximal extension of the
irritation and possible rupture. Placement of the volar fracture would require a much longer working dis-
plate beyond the watershed line (the most prominent tance for the external fixator, thereby decreasing the
volar ridge35) results in excessive plate prominence, overall rigidity of the construct. Second, fractures at
with the potential for increased contact pressure on the metaphysealediaphyseal junction typically take
volar tendons and subsequent tendon irritation or longer to heal. This would likely require an increase
rupture.36e39 The main indications for use include in the duration of application of the external fixator.
volar shear fractures, radial shortening greater than 3 This is a challenge because of the concern for pin
mm, dorsal tilt greater than 10 from neutral, or intra- track infection with increased duration of wear. In
articular displacement/stepoff of more than 2 mm. this clinical situation, a spanning plate is able to
Despite this, they are not a panacea for all distal radius achieve more stability and can be used longer without
fracture management, and as such, surgeons should be the risk of a pin track infection.
facile with a variety of other operative techniques. Another advantage and relative indication for the
Some highly comminuted and distal fractures may not use of a spanning plate is in polytrauma patients who
be amenable to volar plate fixation, such as dorsal require the upper limb for mobility. In these patients,
shear fractures and fractures involving the distal volar a spanning plate allows immediate weightbearing
ulnar corner. Andermahr et al40 evaluated the volar with a crutch through the forearm with no exposed
lunate facet and found that the facet is on average 5 hardware. These patients do not require adjunctive
mm thick and projects 3 mm anterior (16% of the orthoses or casts for crutch use as may be required
dorsal-volar height) to the volar surface. The small size with other non-spanning modalities. The spanning
and projection of this fragment may lead to increased plate can remain in place until the fracture is healed
susceptibility to injury and subsequently to inadequate and other injuries are appropriately rehabilitated.
fixation, resulting in volar subluxation of the carpus.10 Highly comminuted, osteoporotic intra-articular
Besides wrist instability, failure to anatomically fractures in elderly patients are difficult injuries to
reduce a large lunate facet that contributes to the sig- manage owing to poor bone quality.52 These fractures
moid notch may result in distal radioulnar joint in- have also proven to be amenable to treatment with
congruity and subsequent arthritis. spanning plates.53 Ligamentotaxis is used to provide
general length and alignment. This can be preserved
Bridge plating with the application of a spanning plate. Many of
External fixation has a limited ability to prevent these fractures have severe bone loss as a result of
dorsal collapse or maintain palmar tilt in unstable comminution and benefit from the placement of
distal radius fractures.41e46 It has also been shown to subchondral bone graft for articular support. Sup-
result in poor hand function, with resultant difficulties plemental fixation can be used when necessary to
in activities of daily living.24 Complications related to achieve a more anatomic reduction. This has proven
loss of reduction, overdistraction, or pin site infection to be a successful means of fixation for these difficult
resulted in reoperation or poor outcomes. The use of fractures (Fig. 2).
external fixation remains appropriate for select clin- In addition to distal radius fractures, we currently
ical situations but there are limitations. For unstable favor the use of a spanning plate as a neutralization
fractures, the parameter of external fixation that is device for less common but challenging injuries such
most difficult to optimize is the bar-to-bone distance. as radiocarpal dislocations and articular shear fracture
The rationale for an internal spanning plate is that patterns in which often only a small fracture fragment
this construct is able to maximize the biomechanical is available for fixation.
advantage of this parameter by essentially making the
bar-to-bone distance 0. Therefore, this construct is Fragment-specific fixation
considerably more rigid than external fixation.47 The An alternative to spanning fixation is the use of
spanning plate was initially described by Burke and fragment-specific fixation. Medoff54 characterized
Singer48 for the management of comminuted, unsta- the major fracture fragments to be addressed with
ble distal radius fractures. They reported favorable fragment-specific fixation as the dorsal ulnar corner,
results for these challenging fractures, with this the dorsal wall, free intra-articular pieces, the volar
technique as an alternative to external fixation. Later rim, and the radial column. In these highly commi-
reports extended the indications for this technique to nuted fractures, the goal is to build from the strongest
distal radius fractures with metaphysealediaphyseal foundation, beginning with the critical corner (volar
extension.49e51 This pattern of injury is a logical choice ulnar corner), onto which the remainder of the radius

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 SEVERELY COMMINUTED DISTAL RADIUS FRACTURES 5

FIGURE 2: A, B Preoperative radiographs and CeF intraoperative fluoroscopy of a distal radius fracture treated with a dorsal spanning
bridge plate. The plate is applied and secured with a bone-holding clamp before final reduction and screw placement. This patient had
ipsilateral hip and ulnar fractures and required the upper extremities for assisted weight bearing; hence the choice of a bridge plate. G, H
Postoperative films with I, J subsequent plate removal after fracture union are also shown.

can be built. Our preferred order of fixation is to secure each fragment (Fig. 3). The ulnar column is
reduce and stabilize the volar ulnar corner, followed approached if there is a displaced distal ulnar fracture
by the dorsal ulnar corner, thereby restoring the sig- or evidence of distal radioulnar joint instability.
moid notch. Then, the free articular pieces and the A biomechanical study compared angulation and
radial styloid can be addressed respectively. We displacement in a 4-mm cadaveric osteotomy model
advocate routine dorsal capsulotomy to allow direct loaded in extension and fixed with a radial and ulnar pin
visualization and reduction of the articular surface. plate or a volar locking plate.55 Biomechanically,
Bone graft may be used to support these pieces before fragment-specific fixation has been shown to be su-
definitive hardware is placed. This can take the form perior to locked volar plating at resisting angulation
of various pin plates, wire forms, and hook plates to and displacement at loads encountered in postoperative

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6 SEVERELY COMMINUTED DISTAL RADIUS FRACTURES

FIGURE 3: A, B Preoperative x-rays and C CT scan of a high-energy distal radius fracture in a 28-year-old male with a distal volar rim
fragment (arrow). D Intraoperative photograph of an alternative fragment-specific fixation method utilizing a hook plate attaching to a
volar locking plate. E, F Postoperative radiographs after application of a volar locking plate and hook plate for a comminuted distal,
intra-articular fracture.

rehabilitation. However, at higher loads, the volar plate of the radial nerve and 20% of patients required re-
demonstrated greater resistance to angulation. In a peat surgery. Subsequently, Benson et al58 demon-
cadaveric model of AO C2 fractures with cyclic strated good to excellent results (as graded by
loading designed to mimic postoperative rehabilita- Gartland and Werley scoring) in 100% of 85 intra-
tion, Taylor et al56 found no significant difference in articular fractures treated with fragment-specific fix-
load to failure or stiffness between fragment-specific ation. Flexion and extension averaged 85% and 91%,
fixation and volar plates. The only exception to this respectively, compared with the uninjured wrist and
was that the fragment-specific system demonstrated the average DASH score was 9. Analysis of radio-
greater stiffness in the ulnar fragment. graphic parameters at final follow-up showed no
Clinical results of fragment-specific fixation have statistical difference compared with the uninjured
demonstrated efficacy in stabilizing some of the wrist in radial inclination or height. However, volar
most difficult fracture patterns (Fig. 4). Konrath and tilt was significantly decreased in the injured wrist (9
Bahler57 reported on their experience of fragment- vs 13 ) and ulnar variance was significantly increased
specific fixation and found that after 29 months, pa- (0.8 vs e0.4 ). Saw et al59 reported good results in a
tients had average wrist flexion of 54 and extension series of 22 AO type C2 and C3 fractures with an
of 61 , with an average DASH score of 17. All average flexion-extension of 51 /62 . Grip strength
fractures healed with 1 mm or less of radial short- approached 85% of the uninjured side in patients with
ening but 32% of patients experienced sensory dis- a minimum of 6 months’ follow-up. The authors
turbances in the distribution of the superficial branch emphasized the steep learning curve required and the

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 SEVERELY COMMINUTED DISTAL RADIUS FRACTURES 7

FIGURE 4: A Preoperative radiograph and B intraoperative fluoroscopy of a distal radius fracture treated with fragment-specific fixation.
Fixation begins with C stabilization of the volar ulnar corner followed by D a dorsal arthrotomy and application of dorsal pin plates with
E subsequent radial styloid fixation. F, G Final films after fracture union are shown.

initial increase in operative time during the surgeon’s or paresthesias, which was transient in all but 2.
learning curve. Similarly, Konrath and Bahler57 reported radial
A prospective matched cohort comparing volar numbness in 8 of 27 fractures, but also noted 1 patient
plate fixation with fragment-specific fixation in 99 with a die punch fracture treated with a single pin plate
consecutive distal radius fractures demonstrated who had loss of fixation requiring additional surgery.
similar radial inclination in both groups but worse The authors used this example to underscore the
volar tilt and radial length at one year in the fragment- relative weakness of fragment-specific implants when
specific group. Similarly, at 6 months, patients treated used in isolation. In contrast, Saw et al59 had only 2
with volar plates had significantly superior grip and patients who needed hardware removal, and no loss of
lateral pinch strength at 6 months, but this was not fixation. Overall, removal of painful hardware and
statistically significant at one year. Overall, the volar transient radial numbness seem to be the most com-
plate group demonstrated better range of motion at mon complications reported with this technique.
one year with regard to flexion-extension, radial de-
viation, and supination, whereas the fragment-specific
cohort showed significantly better pronation. Patient- ADJUNCTIVE TECHNIQUES
rated outcomes (as measured by the Michigan Hand Arthroscopically assisted reduction
Outcomes Questionnaire) were superior in the locking In an attempt to visualize reduction of the articular
plate group early on, but at one year showed no surface, arthroscopy has been used to treat distal
superiority except with regard to the aesthetic and radius fractures.60 Doi et al61 compared 34 fractures
work domains. However, the fragment-specific cohort treated with arthroscopic assisted reduction, pinning,
included a higher number of intra-articular fractures and external fixation with 48 fractures treated with
and the authors reported decreased ability to initially conventional open reduction internal fixation with
correct volar tilt intraoperatively. pinning or volar plate application with or without
Complications pertaining to symptomatic hardware external fixation. The authors found that patients in
have been reported with fragment-specific fixation. the arthroscopic group had significantly better
The series by Benson et al58 reported 5 of 85 fractures reduction of volar tilt, ulnar variance, and intra-
with pain from dorsal or radial styloid hardware articular stepoff. Ruch et al62 found better wrist
requiring a second surgery for removal, whereas an flexion, extension, and supination with arthroscopic
additional 3 had loose Kirschner wires removed in the assisted reduction of distal radius fractures compared
office. Another 10 patients had radial-sided numbness with fluoroscopy alone, but no difference in DASH

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8 SEVERELY COMMINUTED DISTAL RADIUS FRACTURES

score, radial shortening, or joint congruity. One protocols after volar plate fixation may vary by sur-
technical challenge associated with its use is the geon but some have advocated a weight restriction of
risk of fluid extravasation with subsequent compart- 2.3 kg on the operative extremity during rehabilita-
ment syndrome.63 This has led others to support the tion.35 A prospective randomized trial compared
use of dry arthroscopy to reduce the risk of fluid initiation of wrist range of motion exercises 2 weeks
extravasation.64 after surgery with initiation 6 weeks after surgery.69
The investigators found no difference in the total arc
Bone grafting and bone graft substitutes of motion at 3 and 6 months postoperatively. For
Bone grafts may be used as an adjunct to fixation and patients undergoing fragment-specific fixation, a
may be divided into 2 major categories: osteoinduc- postoperative orthosis is applied for 1 to 2 weeks to
tive, which stimulates bone formation, and osteo- ensure wound healing. At the surgeon’s discretion,
conductive, which provides structural support. The additional immobilization in a cast or application of a
metaphysis of the distal radius is well vascularized; removable orthosis can be used at that time, with
therefore, the use of bone graft to achieve union is subsequent commencement of gentle active range of
rarely necessary.65 However, it may function as a motion. Regardless of the fixation method, patients
structural support to fill metaphyseal voids and pre- should be instructed on the day of surgery in anti-
vent loss of reduction. An example of this is Norian edema measures and continuous active and passive
SRS calcium phosphate cement, which has been motion of the fingers. Formal supervised post-
approved by the Food and Drug Administration for operative rehabilitation is not routinely necessary in
treatment of unstable distal radius fractures.65 A pro- the treatment of distal radius fractures because home
spective randomized trial compared treatment of distal exercise programs have been found to result in
radius fractures with casting alone versus reduction equivalent outcomes.70
with injection of Norian SRS and application of a cast In conclusion, with the advent of different fixation
for 2 weeks. Patients had faster return to function with technologies over the past 4 decades, options avail-
better radiographic parameters at final follow-up in the able for the treatment of distal radius fractures are
bone cement group compared with casting alone.66 more numerous than ever. If the decision is made to
Goto et al67 examined the use of hydroxyapatite proceed with surgery, careful selection of the appro-
bone graft substitute as an adjunct to volar plate fix- priate fixation method can have a strong impact on
ation of distal radius fractures. They found no sig- functional and radiographic outcomes. Although
nificant difference in palmar tilt or radial inclination in many fracture patterns may be amenable to several
patients with the bone substitute compared with those different types of fixation, the treating physician
without, but the authors noted a statistically significant should be aware of the limitations of each. Despite
increase in ulnar variance in those without the bone the treatment method selected, the goals of fixation
graft substitute. are enduring: restoration of articular congruity and
A recent Cochrane Review of bone grafting of stable initial fixation to allow earlier return of motion
distal radius fractures found a paucity of high-quality and maximize functional outcomes.
evidence examining this topic.68 Most available
literature compared bone grafting with plaster casts or
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