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complex distal intra - articular radial fractures ( ao type c3 ) are a relatively rare subgroup of the ao type c fractures , corresponding to about 5% of distal radial fractures , and become more common with higher energy trauma .
it has been advocated that good functional outcome in distal radius fractures is best ( and most quickly ) achieved by anatomical reduction , stable internal fixation , and early function in analogy to the treatment principles of any other major joint injury . in recent years , a better understanding of pathophysiology and biomechanics , including the 3-column concept , better surgical approaches , and new fixation concepts ( locking implants ) has provided the prerequisites to realize these goals . today
, many authors treat extra - articular extension fractures ( ao types ax + bx ) by primary palmar plating with a locking plate .
this is a straightforward way to reliably restore radial length and allow for early motion with low morbidity and a high rate of complete functional recovery .
there is however less agreement in the treatment strategy for intra - articular fractures ( ao type c ) .
some authors prefer external fixation in combination with k - wires , whereas some advocate an extended palmar approach for complex and comminuted articular injuries ( ao type c3 ) .
following our established treatment algorithm for complex high - energy intra - articular distal radial fractures , a preoperative traction ct scan is necessary for preoperative planning . a small subset of patients are considered to need a combined palmar and dorsal approach with either double or triple plating according to the following criteria , established from ct - scan examination : a hyperextended palmar articular fragment and/or loss of palmar cortical buttress combined with a displaced dorsoulnar fragment ( that has not reduced with ligamentotaxis under external fixation ) , or with a centrally impacted articular fragment , or with an associated scapholunate carpal ligament tear , or both . in this article
, we report on a small series of initially 12 patients with comminuted intra - articular distal radius fractures that were treated with combined approaches .
after approval by an institutional review board , 12 consecutive patients who were treated between 2002 and 2004 and fulfilled the above - mentioned criteria were analyzed .
all patients gave informed consent to the temporary external fixation with an additional ct scan .
intermediate follow - up was 13.2 ( 11.932.8 months ) months , whereas median final follow - up was 10 years ( 106.8146.2 months ) and median age at trauma was 46.8 years ( 24.573.5 years ) .
three patients had a fracture of the dominant hand , 9 patients were heavy workers , and 100 patients were right - handed .
additional injuries were a fracture of the vertebral column in 1 patient , a fracture of the ipsilateral elbow in 1 patient , an additional tear of the scapholunate ligament in 1 patient , and a fracture of the radial head in 2 patients .
median operative delay from injury to definitive plate osteosynthesis was 7 days ( 214 days ) .
the additional tear of the scapholunate ligament was treated with direct ligament reattachment using suture anchors , temporary scapholunate , and scaphocapitate k - wire transfixation and a neutralizing external fixator for 8 weeks .
all patients with the exception of one ( scapholunate tear , external fixation ) received a removable velcro wrist splint and were allowed to mobilize the wrist under the supervision of a physiotherapist beginning at day 1 .
reduction was judged anatomical if there was a step or gap of < 1 mm , satisfactory if the step or gap was of 1 to 2 mm , and unsatisfactory if it was of > 2 mm . in the follow - up
setting , we analyzed the range of motion ( rom ) and the grip strength ( jamar dynamometer ) as percentage of the opposite wrist corrected according to the 10% rule , return to work ( rtw , time lapse in months from the time of trauma to time of return to part- or fulltime work ) , the disabilities of the arm , shoulder and hand ( dash , patient opinions on symptoms as well as on ability to perform activities of daily living and work ) index , and the patient - rated wrist evaluation ( prwe , patient opinions on pain and on ability to perform activities of daily living and work ) score to measure clinical outcome .
first , a standard palmar approach between the radial artery and the tendon of the flexor carpi radialis was established .
the intermediate column was approached by reducing the hyperextended palmar articular fragment , restoring radial length and preliminarily fixating the intermediate column with a locking plate that was contoured according to the individual situation . then the radial column was reduced and buttressed with a locking , precontoured s - shaped plate over the same palmar approach .
since the radial column was managed over the palmar approach , only the intermediate column was visualized through the third extensor compartment .
a limited transverse dorsal arthrotomy was performed to control the joint surface and to check the proximal carpal row for any associated ligament tear .
any centrally impacted articular fragment was reduced to the joint level . the dorso - ulnar fragment was then reduced and the intermediate column was buttressed with a contoured locking plate ( mostly l - shaped ) .
after closure of the incisions , the fixator was removed and replaced by a dorsal plaster splint .
early motion was established from day 1 under the supervision of a physiotherapist . when the swelling had subsided , the plaster splint was replaced by a removable velcro splint up to 6 weeks postoperatively .
first , a standard palmar approach between the radial artery and the tendon of the flexor carpi radialis was established .
the intermediate column was approached by reducing the hyperextended palmar articular fragment , restoring radial length and preliminarily fixating the intermediate column with a locking plate that was contoured according to the individual situation . then the radial column was reduced and buttressed with a locking , precontoured s - shaped plate over the same palmar approach .
since the radial column was managed over the palmar approach , only the intermediate column was visualized through the third extensor compartment .
a limited transverse dorsal arthrotomy was performed to control the joint surface and to check the proximal carpal row for any associated ligament tear .
any centrally impacted articular fragment was reduced to the joint level . the dorso - ulnar fragment was then reduced and the intermediate column was buttressed with a contoured locking plate ( mostly l - shaped ) .
the external fixator was opened and stability of the fixation was checked under fluoroscopy . after closure of the incisions ,
when the swelling had subsided , the plaster splint was replaced by a removable velcro splint up to 6 weeks postoperatively .
one patient was already retired at the time of injury . for more adequate interpretation of grip strength , we indicated hand dominance of the injured side in table 2 according to petersen et al .
range of motion expressed as % of the contralateral side at 10 years follow - up clinical outcome at 13.3 months and at 10 years follow - up according to the dash index , the prwe score , and the grip strength as % of the contralateral side in respect of the 10% rule in all cases , anatomical reduction was achieved .
there were no postoperative wound infections and no tendon rupture in all 10 cases during follow - up .
the patient with the additional scapholunate ligament tear developed a complex regional pain syndrome ( crps ) .
this patient and the patient with the ipsilateral elbow fracture ( case 1 and 2 in tables 1 and 2 ) were not excluded from the final evaluation , even though the outcome could be negatively skewed by reasons not concerning the distal radius fracture .
the radiologic follow - up showed no signs of secondary dislocation or further arthritic changes in all the patients .
the patient with scapholunate ligament tear did not show any progressive wrist instability . in figure 1 , the clinical and radiological outcome of case number 10 after 9 years of follow - up
case 10 : a ) accident wrist ap / lateral ; b ) traction view ct - scan before definitive osteosynthesis ; c ) postoperative x - ray ; d ) x - ray 9 years postoperative ; e ) clinical result 9 years postoperative .
during the last decade , the strategies to treat patients with comminuted intra - articular fractures ( ao type c3 ) changed with better implants , but there remains a controversy on whether the results are better with formal open reduction and internal fixation ( followed by early motion ) , or with closed reduction , external fixation , and/or k - wire fixation .
it is therefore difficult to compare these fractures in a randomized way based only on the classification of the injury into the c3 group . if an articular fracture is multifragmentary at the level of the radiocarpal joint surface , but the fragments are not substantially displaced and reduce with ligamentotaxis , the injury is still formally classified as c3 .
it is likely that the outcome of such fractures treated with external fixation and k - wires will be favorable .
however , multifragmentary articular fractures may show considerable displacement , articular components may be firmly impacted into the metaphysis ; they may be rotated 180 degree or incarcerated . formally , this is still a c3 injury , but closed and even percutaneous direct reduction will hardly ever be successfull .
the traction ct - scan allows to thoroughly study the fracture characteristics and to identify the key fragments . in traction
, some articular fragments will come into alignment and key fragments that will influence the operative strategy and the placement of the hardware will be unmasked .
ring et al have presented their series of 25 cases of comminuted distal radial fractures treated with a combined palmar and dorsal approach .
however , they did not follow a clearly defined strategy and some of their patients needed a second operation after single dorsal or palmar plating was unsuccessful .
our small case series of highly comminuted c3 fractures treated with a triple plate osteosynthesis shows good functional results after 10 years of follow - up . in all cases ,
the anatomy was restored and early function was allowed , with the exception of one case with an associated scapholunate ligament tear .
we show an intermediate and a long - term follow - up with these patients with nearly equal functional results 10 years after the initial trauma .
combined volar and dorsal approaches in  shuttered wrists  with double or triple plate osteosynthesis allow restoring articular congruency and achieving good intermediate and long - term functional results .
abstractcomplex distal intra - articular radial fractures ( ao type c3 ) are rare , but are life - changing injuries . 
 they are usually related to high - velocity trauma mechanisms in a working male population.we surveyed a cohort of these fractures treated in our institution to assess the functional long - term outcome.twelve consecutive patients with comminuted intra - articular distal radial fractures were treated at our institution . 
 osteosynthesis was performed by a single senior surgeon with volar and dorsal extended approaches . 
 the intermediate and final control included conventional x - ray , range of motion ( rom ) , grip strength , and the disabilities of the arm , shoulder , and hand index ( dash ) , as well as the patient - rated wrist evaluation ( prwe ) score for functional outcome at 1 and 10 years of follow-up.at 10 years follow - up , anatomic reconstruction with a step or gap of < 1 mm was achieved in 10 of the 12 above - mentioned patients , whereas 2 patients were lost to follow - up . 
 rom was good to excellent in 8 patients . 
 median grip strength was 107% of the contralateral side . 
 median dash - index and prwe were 2.3 and 6 respectively , at 10 years . 
 eight patients returned to premorbid heavy labor . 
 one patient was retired at the time of injury.combined volar and dorsal approaches allow achieving anatomical reconstruction in comminuted intra - articular distal radius fractures and reveal good functional outcomes at intermediate and long - time follow - up .