- Email: [email protected]
A randomized comparison of locking and non-locking palmar plating for unstable Colles’ fractures in the elderly
ARTICLE IN PRESS A RANDOMIZED COMPARISON OF LOCKING AND NONLOCKING PALMAR PLATING FOR UNSTABLE COLLES’ FRACTURES IN THE ELDERLY M. KOSHIMUNE, M. KAMANO, K. TAKAMATSU and H. OHASHI From the Department of Orthopaedic Surgery, Saiseikai Nakatsu Hospital and Medical Center based on the Social Welfare Organization, Saiseikai Imperial Gift Foundation Inc, Japan
This study compared the effectiveness of locking and non-locking palmar plating for unstable Colles’ fractures in the elderly. The patients treated with locking plates included 4 men and 18 women with a mean age of 68 years (Group A) and those treated with non-locking plates included 3 men and 28 women with a mean age of 74 years (Group B). Radiographic parameters, including palmar tilt, radial inclination and radial length were measured before surgery, after surgery and at final followup. There were no significant differences in respect of any of the radiographic parameters between the two groups pre-operatively. After surgery, all of the radiographic parameters were improved in both groups and there were no significant differences between the two groups at final followup. Journal of Hand Surgery (British and European Volume, 2005) 30B: 5: 499–503 Keywords: fracture of the distal radius, locking plate, non-locking plate, palmar approach, elderly people
non-locking palmar plating for internal fixation of unstable Colles’ fractures in elderly patients through a volar approach.
INTRODUCTION Fracture of the distal radius is one of the most common injuries in elderly people. As the elderly often have osteoporosis, the distal fragment becomes unstable because the distal cortex is severely comminuted. In treating this type of fracture, internal fixation is often used and the surgical approach is selected according to the direction of displacement of the distal fragment. Thus, a dorsal approach is generally indicated for dorsally displaced fractures (Carter et al., 1998). However, this approach requires careful surgical dissection of the extensor retinaculum and tendons along with resection of Lister’s tubercle. Complications such as extensor tendonitis and tendon attrition and rupture by the plate and screws have been reported (Kambouroglou et al., 1998; Rozental et al., 2003). Therefore, a palmar approach has been used recently for Colles’ fractures. Orbay et al. (2002) showed that most dorsally displaced distal radius fractures can be anatomically reduced and fixed through a volar approach. Many new plates have been developed for internal fixation of distal radius fractures (Leung et al., 2003; Ring et al., 2004). The locking plate was conceived and designed by the AO/ASIF Hand expert group. This plate provides distal fixed-angle fixation through 2.4 mm subchondral support pegs, obtains proximal fixation through 2.7 mm cortical screws and is reinforced to withstand the expected higher loads. This concept overcomes the difficulty that the dorsal fragments are likely to fail when a volar plate is used for dorsally displaced distal radial fracture (Lee et al., 2003). Nevertheless, non-locking plates are still regularly used for fixation of this fracture through a volar approach. This study compare the effectiveness of locking and
MATERIALS AND METHODS Seven men and 46 women, with a mean age of 72 (range 65–89) years at the time of the injury, were included in the study. Indications for internal fixation were failure of closed reduction and the existence of subchondral space for distal screws or pins. The type of fracture was classified according to AO/ASIF classification. None of the patient received bone graft in this series. The group treated with locking plates included 4 men and 18 women with a mean age of 68 years (Group A). The type of fractures included A2 8, A3 1, C1 7 and C2 6. Distal radius plate (Mathys, Tokyo, Japan) was used in all patients of the group. The group treated with nonlocking plates included 3 men and 28 women with a mean age of 74 years (Group B). The type of fracture included A2 10, A3 2, C1 5 and C2 14. A 3.5 mm Tshaped plate (Mathys, Tokyo, Japan) or Symmetry plate (ACE Medical, El Segundo, CA) was used in this group. Randomization of plate selection was by sealed envelopes. The trans-Flexor Carpi Radialis (FCR) approach, with detachment of the pronator quadratus from its radial side, provided good exposure for anatomic reduction of the palmer cortex of the distal radius and for application of the plate. K-wires were inserted for temporary fixation of the fragment and were removed after plating. Distal screws or pins were inserted into the subchondral area. All patients in both groups underwent 499
ARTICLE IN PRESS 500
THE JOURNAL OF HAND SURGERY VOL. 30B No. 5 OCTOBER 2005
the same procedure, although different devices were used. Postoperatively, the wrist was immobilized in a cast for 1–2 weeks, during which time active and passive finger motion was encouraged. After removing the cast, active and active-assisted motion of the wrist was begun. Passive motion of the wrist was started 2–3 weeks after removing the cast. Postoperative follow up ranged from 6 to 24 (mean 12) months. At the final follow up, irritation or damage to the extensor tendons by the plate and screws was checked on physical examination, and median nerve injury and injury to the radial artery were also investigated. Radiographic parameters, including palmar tilt, radial inclination and radial length were measured before surgery, after surgery and at the final follow up. Student’s paired or unpaired t tests were used to compare differences among the mean values of the radiographic parameters obtained before and after surgery and between the two groups at the final examination. The modified demerit point system of Gartland and Werley was used to assess outcome (Gartland and Werley, 1951; Sarmiento et al., 1975).
Table 2—Ranges of motion (deg) at final follow up
Extension Mean (range) Flexion Mean (range) Supination Mean (range) Pronation Mean (range)
Group A
Group B
71 (60–85)
66 (55–80)
59 (35–75)
49 (45–65)
78 (45–90)
82 (75–90)
80 (60–90)
78 (75–90)
SD, Po0.05, unpaired t-test.
Table 3—Outcome assessment using the modified demerit point system of Gartland and Werley (1951)
Excellent Good Fair Poor
Group A ðn ¼ 22Þ
Group B ðn ¼ 31Þ
8 13 1 0
10 20 1 0
RESULTS The mean palmar tilt before surgery in group A was 17.51 and that of group B was 181. The mean radial length of group A was 6.5 mm and that of group B was 6 mm and the mean radial inclination of group A was 141 and that of group B was 13.51. There were no significant differences in pre-operative radiographic parameters between the two groups. After surgery, all of the radiographic parameters were improved in both groups. At final follow up, all radiographic parameters were maintained statistically. There were no significant differences between the two groups at final follow up (Table 1). Differences in the postoperative range of motion between the groups were not significant, except for flexion (Table 2). Bony union occurred in all patients of both groups. Two patients in Table 1—Radiographic parameters pre- and post-operatively and at final follow up Preop Mean7SD
Postop
Final follow up
Palmar tilt (deg)
Group A Group B
17.579 1879
6.573.5 773
6.573.5 6.573
Radial length (mm)
Group A Group B
6.572.5 673
9.571.5 1072
9.571.5 9.571.5
Radial inclination (deg)
Group A Group B
1476 13.577.5
2173 2273.5
20.573 20.073.3
group A underwent a separate dorsal approach to reduce a die punch fracture. According to the modified Gartland and Werley rating scale (Gartland and Werley, 1951), 8 patients had an excellent results, 13 good and 1 fair in group A. In group B, 10 were rated as excellent, 20 as good and 1 as fair (Table 3). None of the patients suffered extensor tendon or nerve injury as a result of the procedures.
CASE PRESENTATION Case 1 (Group A): A 83 year-old patient sustained a dorsally displaced fracture of the distal radius (AO/ ASIF C1). A distal radius plate (Mathys, Tokyo, Japan) was placed by a palmar approach using an indirect reduction technique. Six months after surgery, there was no shortening or dorsal tilt (Fig 1). Case 2 (Group B): A 68 year-old patient with severe osteoporosis sustained a dorsally displaced fracture of the distal radius (AO/ASIF A2). A Symmetry plate (ACE Medical, El Segundo, CA) was used for internal fixation. At final follow up, there was no radiographic shortening or dorsal tilt (Fig 2).
DISCUSSION In Colles’ fractures, the dorsal cortex of the distal fragment is often comminuted in elderly people with
ARTICLE IN PRESS UNSTABLE COLLES’ FRACTURES IN THE ELDERLY
501
Fig. 1 (A and B) The pre-operative radiographs showing an AO C1 fracture. The radial length was 4 mm, and the palmar tilt was 51. The locking plate was selected for fixation. (C and D) After surgery, the radial length was 6 mm, and the palmar tilt was 21. There was no shortening of the distal radius.
osteoporosis (Hegeman et al., 2004). The dorsal approach is often selected for dorsally displaced fractures of the distal radius (Fernandez and Jupiter, 2002). Ring et al. (2003) reported their experience, which verified the safety and efficacy of dorsal plating. However, this approach requires careful surgical dissection of the extensor retinaculum and tendons, which can be damaged or irritated after plating. Therefore, the palmar approach has been used more frequently recently for dorsally displaced fractures (Orbay and Fernandez,
2002). In this study, none of the patients experienced irritation or rupture of the tendons. All patients obtained anatomical reduction by the palmar approach, although two patients in group A with a die punch fracture required an additional, and separate, dorsal approach through a small incision to facilitate reduction. Osada et al. (2003) showed that there were no significant differences in plate fixation stability between the AO Distal Radius plate (locking system) and the
ARTICLE IN PRESS 502
THE JOURNAL OF HAND SURGERY VOL. 30B No. 5 OCTOBER 2005
Fig. 2 (A and B) The pre-operative radiographs showing an AO A2 fracture. The radial length was 3 mm, and the palmar tilt was 201. A Symmetry plate (a non-locking plate) was used for fixation: (C and D) Six months after surgery, bony fusion was obtained, radial length was 7 mm and the palmar tilt was 71.
Symmetry plate (non-locking system) in a cadaver model, although Orbay and Fernandez (2004) described the DVR plate which has a locking system, as being three times as strong as any other, commercially available, device. Osada et al. (2004) also indicated that the bending strength of the plate depends on the thickness of the plate itself when using volar plating for a Colles’ fracture in which the dorsal cortex is severely comminuted. The distal pins were securely fixed to the locking plate, which makes it impossible for them to loosen. When distal pins are inserted through a locking plate in the subchondral zone, subchondral
support is obtained. The distal screws of the non-locking plate may loosen, since they are not fixed to the plate. However, if they are inserted in the subchondral zone, they are supported by the subchondral bone and maintained normal radiographic measurements in our study. This study has shown that there was no significant difference between the two groups on any pre- and postoperative radiographic assessment and both groups obtained good reduction and results. Kamano et al. (2001) identified the fact that the location of the distal screws is important to gaining a good result and loss of
ARTICLE IN PRESS UNSTABLE COLLES’ FRACTURES IN THE ELDERLY
reduction is a problem which relates to the technique of distal screw insertion. Bone mineral density may influence the results. Evidence exists that there is an association between an increased incidence of radius fractures and decreased bone mineral density (Hegeman et al., 2004). The bone mineral density in the distal tenth of the radius is an important prognostic parameter of possible deformity of the radius after closed reduction and casting (Itoh et al., 2004). In this series, all of the patients were over 65 years and many of them may have had osteoporosis, although bone mineral density was not measured. The relationship between the locking or non-locking plating selection and bone mineral density should be investigated in a further study. References Carter PR, Frederick HA, Laseter GF (1998). Open reduction and internal fixation of unstable distal radius fractures with a lowprofile plate: a multicenter study of 73 fractures. The Journal of Hand Surgery, 23A: 300–307. Fernandez DL, Jupiter JB. Fracture of the distal radius – a practical approach to management, 2nd edn., New York, Springer, 2002. Gartland JJ, Werley CW (1951). Evaluation of healed Colles’ fractures. Journal of Bone and Joint Surgery, 33A: 895–907. Hegeman JH, Oskam J, Van Der Palen J (2004). The distal radial fracture in elderly women and the bone mineral density of the lumbar spine and hip. The Journal of Hand Surgery, 29B: 473–476. Itoh S, Tomioka H, Tanaka J (2004). Relationship between bone mineral density of the distal radius and ulna and fracture characteristics. The Journal of Hand Surgery, 29A: 123–130. Kamano M, Honda Y, Kazuki K (2001). Palmar plating for dorsally displaced fractures of the distal radius. Clinical Orthopedics, 397: 403–408. Kambouroglou GK, Axelrod TS (1998). Complications of the AO/ ASIF titanium distal radius plate system (p plate) in internal fixation of the distal radius: a brief report. The Journal of Hand Surgery, 23A: 737–741.
503
Lee HC, Wong YS, Chan BK, Low CO (2003). Fixation of distal radius fractures using AO titanium volar distal radius plate. Hand Surgery, 8: 7–15. Leung F, Zhu L, Ho H, Lu WW, Chow SP (2003). Palmar plate fixation of AO type C2 fracture of distal radius using a locking compression plate-A biomechanical study in a cadaveric model. Journal of Hand Surgery (British and European Volume), 28B: 263–266. Orbay JL, Fernandez DL (2002). Volar fixation for dorsally displaced fractures of the distal radius: a preliminary report. The Journal of Hand Surgery, 27A: 205–215. Orbay JL, Fernandez DL (2004). Volar fixed-angle plate fixation for unstable distal radius fractures in the elderly patient. The Journal of Hand Surgery, 29A: 96–102. Osada D, Fujita S, Tamai K, Iwamoto A, Tomizawa K, Saotome K (2004). Biomechanics in unaxial compression of three distal radius volar plates. Journal of Hand Surgery, 29A: 446–451. Osada D, Viegas SF, Shah MA, Morris RP, Patterson RM (2003). Comparison of different distal radius dorsal and volar fracture fixation plates – A biomechanical study. Journal of Hand Surgery, 28A: 94–104. Ring D, Jupiter JB, Brennwald J (2003). Prospective multicenter trial of a plate for dorsal fixation of distal radius fractures. The Journal of Hand Surgery, 22A: 777–784. Rozental TD, Beredjiklian PK, Bozentka DJ (2003). Functional outcome and complications following two types of dorsal plating for unstable fractures of the distal part of the radius. Journal of Bone and Joint Surgery, 85A: 1956–1960. Sarmiento A, Pratt GW, Berry NC, Sinclair WF (1975). Colles’ fractures. Journal of Bone and Joint Surgery, 57A: 311–317. Received: 5 November 2004 Accepted after revision: 25 April 2005 M. Koshimune, Department of Orthopaedic Surgery, Saiseikai Nakatsu Hospital and Medical Center based on the Social Welfare Organization, Saiseikai Imperial Gift Foundation Inc, Shibata 2-10-39, Kita-ku, Osaka, 530-0012, Japan. Tel.: +81 6 6372 0333; fax: +81 6 6372 8737. E-mail: [email protected]
r 2005 The British Society for Surgery of the Hand. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhsb.2005.04.018 available online at http://www.sciencedirect.com
This study compared the effectiveness of locking and non-locking palmar plating for unstable Colles’ fractures in the elderly. The patients treated with locking plates included 4 men and 18 women with a mean age of 68 years (Group A) and those treated with non-locking plates included 3 men and 28 women with a mean age of 74 years (Group B). Radiographic parameters, including palmar tilt, radial inclination and radial length were measured before surgery, after surgery and at final followup. There were no significant differences in respect of any of the radiographic parameters between the two groups pre-operatively. After surgery, all of the radiographic parameters were improved in both groups and there were no significant differences between the two groups at final followup. Journal of Hand Surgery (British and European Volume, 2005) 30B: 5: 499–503 Keywords: fracture of the distal radius, locking plate, non-locking plate, palmar approach, elderly people
non-locking palmar plating for internal fixation of unstable Colles’ fractures in elderly patients through a volar approach.
INTRODUCTION Fracture of the distal radius is one of the most common injuries in elderly people. As the elderly often have osteoporosis, the distal fragment becomes unstable because the distal cortex is severely comminuted. In treating this type of fracture, internal fixation is often used and the surgical approach is selected according to the direction of displacement of the distal fragment. Thus, a dorsal approach is generally indicated for dorsally displaced fractures (Carter et al., 1998). However, this approach requires careful surgical dissection of the extensor retinaculum and tendons along with resection of Lister’s tubercle. Complications such as extensor tendonitis and tendon attrition and rupture by the plate and screws have been reported (Kambouroglou et al., 1998; Rozental et al., 2003). Therefore, a palmar approach has been used recently for Colles’ fractures. Orbay et al. (2002) showed that most dorsally displaced distal radius fractures can be anatomically reduced and fixed through a volar approach. Many new plates have been developed for internal fixation of distal radius fractures (Leung et al., 2003; Ring et al., 2004). The locking plate was conceived and designed by the AO/ASIF Hand expert group. This plate provides distal fixed-angle fixation through 2.4 mm subchondral support pegs, obtains proximal fixation through 2.7 mm cortical screws and is reinforced to withstand the expected higher loads. This concept overcomes the difficulty that the dorsal fragments are likely to fail when a volar plate is used for dorsally displaced distal radial fracture (Lee et al., 2003). Nevertheless, non-locking plates are still regularly used for fixation of this fracture through a volar approach. This study compare the effectiveness of locking and
MATERIALS AND METHODS Seven men and 46 women, with a mean age of 72 (range 65–89) years at the time of the injury, were included in the study. Indications for internal fixation were failure of closed reduction and the existence of subchondral space for distal screws or pins. The type of fracture was classified according to AO/ASIF classification. None of the patient received bone graft in this series. The group treated with locking plates included 4 men and 18 women with a mean age of 68 years (Group A). The type of fractures included A2 8, A3 1, C1 7 and C2 6. Distal radius plate (Mathys, Tokyo, Japan) was used in all patients of the group. The group treated with nonlocking plates included 3 men and 28 women with a mean age of 74 years (Group B). The type of fracture included A2 10, A3 2, C1 5 and C2 14. A 3.5 mm Tshaped plate (Mathys, Tokyo, Japan) or Symmetry plate (ACE Medical, El Segundo, CA) was used in this group. Randomization of plate selection was by sealed envelopes. The trans-Flexor Carpi Radialis (FCR) approach, with detachment of the pronator quadratus from its radial side, provided good exposure for anatomic reduction of the palmer cortex of the distal radius and for application of the plate. K-wires were inserted for temporary fixation of the fragment and were removed after plating. Distal screws or pins were inserted into the subchondral area. All patients in both groups underwent 499
ARTICLE IN PRESS 500
THE JOURNAL OF HAND SURGERY VOL. 30B No. 5 OCTOBER 2005
the same procedure, although different devices were used. Postoperatively, the wrist was immobilized in a cast for 1–2 weeks, during which time active and passive finger motion was encouraged. After removing the cast, active and active-assisted motion of the wrist was begun. Passive motion of the wrist was started 2–3 weeks after removing the cast. Postoperative follow up ranged from 6 to 24 (mean 12) months. At the final follow up, irritation or damage to the extensor tendons by the plate and screws was checked on physical examination, and median nerve injury and injury to the radial artery were also investigated. Radiographic parameters, including palmar tilt, radial inclination and radial length were measured before surgery, after surgery and at the final follow up. Student’s paired or unpaired t tests were used to compare differences among the mean values of the radiographic parameters obtained before and after surgery and between the two groups at the final examination. The modified demerit point system of Gartland and Werley was used to assess outcome (Gartland and Werley, 1951; Sarmiento et al., 1975).
Table 2—Ranges of motion (deg) at final follow up
Extension Mean (range) Flexion Mean (range) Supination Mean (range) Pronation Mean (range)
Group A
Group B
71 (60–85)
66 (55–80)
59 (35–75)
49 (45–65)
78 (45–90)
82 (75–90)
80 (60–90)
78 (75–90)
SD, Po0.05, unpaired t-test.
Table 3—Outcome assessment using the modified demerit point system of Gartland and Werley (1951)
Excellent Good Fair Poor
Group A ðn ¼ 22Þ
Group B ðn ¼ 31Þ
8 13 1 0
10 20 1 0
RESULTS The mean palmar tilt before surgery in group A was 17.51 and that of group B was 181. The mean radial length of group A was 6.5 mm and that of group B was 6 mm and the mean radial inclination of group A was 141 and that of group B was 13.51. There were no significant differences in pre-operative radiographic parameters between the two groups. After surgery, all of the radiographic parameters were improved in both groups. At final follow up, all radiographic parameters were maintained statistically. There were no significant differences between the two groups at final follow up (Table 1). Differences in the postoperative range of motion between the groups were not significant, except for flexion (Table 2). Bony union occurred in all patients of both groups. Two patients in Table 1—Radiographic parameters pre- and post-operatively and at final follow up Preop Mean7SD
Postop
Final follow up
Palmar tilt (deg)
Group A Group B
17.579 1879
6.573.5 773
6.573.5 6.573
Radial length (mm)
Group A Group B
6.572.5 673
9.571.5 1072
9.571.5 9.571.5
Radial inclination (deg)
Group A Group B
1476 13.577.5
2173 2273.5
20.573 20.073.3
group A underwent a separate dorsal approach to reduce a die punch fracture. According to the modified Gartland and Werley rating scale (Gartland and Werley, 1951), 8 patients had an excellent results, 13 good and 1 fair in group A. In group B, 10 were rated as excellent, 20 as good and 1 as fair (Table 3). None of the patients suffered extensor tendon or nerve injury as a result of the procedures.
CASE PRESENTATION Case 1 (Group A): A 83 year-old patient sustained a dorsally displaced fracture of the distal radius (AO/ ASIF C1). A distal radius plate (Mathys, Tokyo, Japan) was placed by a palmar approach using an indirect reduction technique. Six months after surgery, there was no shortening or dorsal tilt (Fig 1). Case 2 (Group B): A 68 year-old patient with severe osteoporosis sustained a dorsally displaced fracture of the distal radius (AO/ASIF A2). A Symmetry plate (ACE Medical, El Segundo, CA) was used for internal fixation. At final follow up, there was no radiographic shortening or dorsal tilt (Fig 2).
DISCUSSION In Colles’ fractures, the dorsal cortex of the distal fragment is often comminuted in elderly people with
ARTICLE IN PRESS UNSTABLE COLLES’ FRACTURES IN THE ELDERLY
501
Fig. 1 (A and B) The pre-operative radiographs showing an AO C1 fracture. The radial length was 4 mm, and the palmar tilt was 51. The locking plate was selected for fixation. (C and D) After surgery, the radial length was 6 mm, and the palmar tilt was 21. There was no shortening of the distal radius.
osteoporosis (Hegeman et al., 2004). The dorsal approach is often selected for dorsally displaced fractures of the distal radius (Fernandez and Jupiter, 2002). Ring et al. (2003) reported their experience, which verified the safety and efficacy of dorsal plating. However, this approach requires careful surgical dissection of the extensor retinaculum and tendons, which can be damaged or irritated after plating. Therefore, the palmar approach has been used more frequently recently for dorsally displaced fractures (Orbay and Fernandez,
2002). In this study, none of the patients experienced irritation or rupture of the tendons. All patients obtained anatomical reduction by the palmar approach, although two patients in group A with a die punch fracture required an additional, and separate, dorsal approach through a small incision to facilitate reduction. Osada et al. (2003) showed that there were no significant differences in plate fixation stability between the AO Distal Radius plate (locking system) and the
ARTICLE IN PRESS 502
THE JOURNAL OF HAND SURGERY VOL. 30B No. 5 OCTOBER 2005
Fig. 2 (A and B) The pre-operative radiographs showing an AO A2 fracture. The radial length was 3 mm, and the palmar tilt was 201. A Symmetry plate (a non-locking plate) was used for fixation: (C and D) Six months after surgery, bony fusion was obtained, radial length was 7 mm and the palmar tilt was 71.
Symmetry plate (non-locking system) in a cadaver model, although Orbay and Fernandez (2004) described the DVR plate which has a locking system, as being three times as strong as any other, commercially available, device. Osada et al. (2004) also indicated that the bending strength of the plate depends on the thickness of the plate itself when using volar plating for a Colles’ fracture in which the dorsal cortex is severely comminuted. The distal pins were securely fixed to the locking plate, which makes it impossible for them to loosen. When distal pins are inserted through a locking plate in the subchondral zone, subchondral
support is obtained. The distal screws of the non-locking plate may loosen, since they are not fixed to the plate. However, if they are inserted in the subchondral zone, they are supported by the subchondral bone and maintained normal radiographic measurements in our study. This study has shown that there was no significant difference between the two groups on any pre- and postoperative radiographic assessment and both groups obtained good reduction and results. Kamano et al. (2001) identified the fact that the location of the distal screws is important to gaining a good result and loss of
ARTICLE IN PRESS UNSTABLE COLLES’ FRACTURES IN THE ELDERLY
reduction is a problem which relates to the technique of distal screw insertion. Bone mineral density may influence the results. Evidence exists that there is an association between an increased incidence of radius fractures and decreased bone mineral density (Hegeman et al., 2004). The bone mineral density in the distal tenth of the radius is an important prognostic parameter of possible deformity of the radius after closed reduction and casting (Itoh et al., 2004). In this series, all of the patients were over 65 years and many of them may have had osteoporosis, although bone mineral density was not measured. The relationship between the locking or non-locking plating selection and bone mineral density should be investigated in a further study. References Carter PR, Frederick HA, Laseter GF (1998). Open reduction and internal fixation of unstable distal radius fractures with a lowprofile plate: a multicenter study of 73 fractures. The Journal of Hand Surgery, 23A: 300–307. Fernandez DL, Jupiter JB. Fracture of the distal radius – a practical approach to management, 2nd edn., New York, Springer, 2002. Gartland JJ, Werley CW (1951). Evaluation of healed Colles’ fractures. Journal of Bone and Joint Surgery, 33A: 895–907. Hegeman JH, Oskam J, Van Der Palen J (2004). The distal radial fracture in elderly women and the bone mineral density of the lumbar spine and hip. The Journal of Hand Surgery, 29B: 473–476. Itoh S, Tomioka H, Tanaka J (2004). Relationship between bone mineral density of the distal radius and ulna and fracture characteristics. The Journal of Hand Surgery, 29A: 123–130. Kamano M, Honda Y, Kazuki K (2001). Palmar plating for dorsally displaced fractures of the distal radius. Clinical Orthopedics, 397: 403–408. Kambouroglou GK, Axelrod TS (1998). Complications of the AO/ ASIF titanium distal radius plate system (p plate) in internal fixation of the distal radius: a brief report. The Journal of Hand Surgery, 23A: 737–741.
503
Lee HC, Wong YS, Chan BK, Low CO (2003). Fixation of distal radius fractures using AO titanium volar distal radius plate. Hand Surgery, 8: 7–15. Leung F, Zhu L, Ho H, Lu WW, Chow SP (2003). Palmar plate fixation of AO type C2 fracture of distal radius using a locking compression plate-A biomechanical study in a cadaveric model. Journal of Hand Surgery (British and European Volume), 28B: 263–266. Orbay JL, Fernandez DL (2002). Volar fixation for dorsally displaced fractures of the distal radius: a preliminary report. The Journal of Hand Surgery, 27A: 205–215. Orbay JL, Fernandez DL (2004). Volar fixed-angle plate fixation for unstable distal radius fractures in the elderly patient. The Journal of Hand Surgery, 29A: 96–102. Osada D, Fujita S, Tamai K, Iwamoto A, Tomizawa K, Saotome K (2004). Biomechanics in unaxial compression of three distal radius volar plates. Journal of Hand Surgery, 29A: 446–451. Osada D, Viegas SF, Shah MA, Morris RP, Patterson RM (2003). Comparison of different distal radius dorsal and volar fracture fixation plates – A biomechanical study. Journal of Hand Surgery, 28A: 94–104. Ring D, Jupiter JB, Brennwald J (2003). Prospective multicenter trial of a plate for dorsal fixation of distal radius fractures. The Journal of Hand Surgery, 22A: 777–784. Rozental TD, Beredjiklian PK, Bozentka DJ (2003). Functional outcome and complications following two types of dorsal plating for unstable fractures of the distal part of the radius. Journal of Bone and Joint Surgery, 85A: 1956–1960. Sarmiento A, Pratt GW, Berry NC, Sinclair WF (1975). Colles’ fractures. Journal of Bone and Joint Surgery, 57A: 311–317. Received: 5 November 2004 Accepted after revision: 25 April 2005 M. Koshimune, Department of Orthopaedic Surgery, Saiseikai Nakatsu Hospital and Medical Center based on the Social Welfare Organization, Saiseikai Imperial Gift Foundation Inc, Shibata 2-10-39, Kita-ku, Osaka, 530-0012, Japan. Tel.: +81 6 6372 0333; fax: +81 6 6372 8737. E-mail: [email protected]
r 2005 The British Society for Surgery of the Hand. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhsb.2005.04.018 available online at http://www.sciencedirect.com