Injury, Int. J.

Care Injured 47S7 (2016) S25S30

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Injury
j o u r n a l h o m e p a g e : w w w. e l s e v i e r . c o m / l o c at e / I n j u r y

Fixation of intra-articular fractures of the distal radius using intramedullary

nailing: a randomized trial versus palmar locking plates
Gertraud Gradla, Steffi Falkb, Thomas Mittlmeierb, Martina Wendtb, Nadja Mielschb, Georg Gradlc,*
a
Department of Trauma and Reconstructive Surgery, Aachen University Medical Center, Pauwelstrasse 30, 52074 Aachen, Germany
b
Department of Trauma- and Reconstructive Surgery, Surgical Clinic University of Rostock, Schillingallee 35, 18055 Rostock, Germany
c
Clinic for Trauma Surgery, Orthopedic Surgery and Reconstructive Surgery, Munich Municipal Hospital Group, Sanatoriumsplatz 2, 81545 Mnchen, Germany

K E Y W O R D S A B S T R A C T

intraarticular distal radius fracture Background: Proposed benefits of intramedullary techniques include limited soft tissue dissection while affording
intramedullary technique sufficient stability to allow early wrist motion. The primary null hypothesis of this randomized trial was that there
prospective randomized trial is no significant difference with respect to functional outcome, pain and disability between patients treated with
either 2.4-mm volar locking plate fixation or intramedullary nail fixation of intra-articular fractures of the distal
radius.
Methods: We conducted a single-centre, prospective randomized matched-pairs trial. Patients with intraarticular
distal radius fractures with metaphyseal comminution and a sagittal fracture line (AO 23 C2.1) were randomized to
receive volar locking plate fixation (n = 14) or intramedullary nailing (n = 14). The outcome was measured on the
basis of the Gartland and Werley and Castaing score; the pain level; the range of wrist motion; the rate of
complications; and radiographic measurements including volar tilt and ulnar variance. Clinical and radiographic
assessment was performed at 8 weeks and 2 years after the operation.
Results: There were no significant differences between groups in terms of range of motion, grip strength or the
level of pain at eight weeks. At the final follow up, patients in the nail group had regained more extension than in
the plate group (98% of the unaffected side vs. 94%, this however, did not reach significance). Reduction was
maintained in both groups; however volar tilt and ulnar variance were significantly better in the plate group.
There was no significant difference in the complication rate between groups.
Conclusion: The present study suggests that intramedullary nail fixation is a reasonable alternative to volar plate
fixation for the treatment of intra-articular distal radius fractures and both techniques can yield reliably good
results.
2016 Elsevier Ltd. All rights reserved.

Introduction
The goal of treatment for distal radius fractures is to obtain
sufficient pain-free motion, allowing return to activities while
minimizing the risk for future degenerative changes or disability [1].
Different techniques have been established over the years to achieve
these goals. Despite numerous reports on the merits and disadvan-
tages of each technique there remains a lack of robust clinical evidence
to support any one intervention over another especially in certain
subtypes of fracture [2,3]. Intramedullary techniques for fixation of
distal radius fractures have been introduced. Purported benefits
* Corresponding author at: Georg Gradl, Department of Orthopaedic Trauma- and
Reconstructive Surgery, Stdt. Klinikum Mnchen GmbH, Krankenhaus Mnchen
Harlaching, Sanato.riumsplatz 2, 81545 Mnchen, Germany. Tel.: +49-89-6210-2304; fax:
+49-89-6210-2303.
E-mail address: Georg.Gradl@klinikum-muenchen.de (G. Gradl).
include limited soft tissue dissection, a low profile implant with less
risk of soft tissue irritation, divergent subchondral screw placement,
and locked fixed-angle fixation, affording sufficient stability to allow
early wrist motion [46]. Initial results of intramedullary nail fixation
have been previously published [46] but those studies contained
relatively few patients, short follow-up periods, and or no comparison
group. In addition, more complex fracture patterns have often been
excluded and trials have focused on extraarticular or simple intraarti-
cular fracture types [6,7].
Intraarticular distal radius fractures with metaphyseal commin-
ution and a sagittal fracture line (AO 23 C2.1) are often amenable to
closed reduction and less invasive treatment, e.g. non-bridging
external fixation [8]. In more complex fractures with displacement of
the intraarticular fragment open reduction and locking plate fixation is
recommended [9]. A retrospective study however reported loss of
reduction within the first six weeks after surgery in those fractures
with a high degree of dorsal comminution such as C2 type fractures.

0020-1383 / 2016 Elsevier Ltd. All rights reserved.

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Palmar plate fixation might not be able to adequately address

intraarticular fragments and maintain reduction.
Less invasive intramedullary fixation with diverging screws that
allow for fragment specific fixation might be a reasonable alternative in
this specific fracture type.
We therefore hypothesized that there is no significant difference in
functional and radiological outcome of AO type C2.1 intraarticular
fractures of the distal radius treated with either 2.4-mm volar locking
plate fixation or intramedullary nail fixation (Targon DR).

Material and methods

Study design

This was a single-centre prospective randomized matched pair trial.

Patient selection

Eligible participants were all adults aged 18 or over with AO type

C2.1 intraarticular fractures of the distal radius. All patients were
recruited at one single Level I trauma centre from September 2005 to
June 2008. Institutional Review Board approval was granted before
initiation of this study, and strict confidentiality guidelines were
followed. All patients provided written informed consent at the time of
enrolment.
We paired participants by sex and age and randomly assigned them
(computerized random numbers) to receive either plate fixation or
intramedullary nailing. Patients were assigned sequentially numbered
opaque, sealed and stapled envelopes to conceal allocation from the
enrolling researcher. The researcher was not involved in patient
treatment.
The treating physicians opened corresponding envelopes at the
preoperative visit only after the enrolled participants completed all
baseline assessments.
Treatment
According to our hospitals policies, all operations were performed
as inpatient procedures in the operating room with the patient under
regional or general anaesthesia.
Fig. 1. Fluoroscopic image confirming reduction and stable fixation with the intrame-
dullary nail.
Volar plate fixation was performed through a standard Henry
approach [10]. Once anatomic reduction was confirmed with fluoros-
copy, fractures were temporarily fixed with a Kirschner wire inserted
percutaneously through the radial styloid.
We recorded operative time, fluoroscopy time and duration of
hospital stay.
Postoperative management
Patients were not immobilized and were allowed immediate
forearm, wrist, and finger motion. Formal therapy was individualized.
Strenuous tasks, sports activity, and weight bearing were allowed
once radiographs confirmed fracture union.

Operative technique Functional assessment

Targon DR Follow-up was performed at 8 weeks, 6 months, 1 year and 2 years

Fixation was performed according to manufacturer guidelines
A 4-cm skin incision was made from the tip of the radial styloid.
Care was taken to identify and gently retract the radial sensory
branches that cross the compartment obliquely by using gentle, blunt
longitudinal dissection as soon as the deepest dermal layer of skin had
been incised.
The interval between the first and second dorsal compartments
was developed subperiosteally.
The fracture was reduced by insertion of a Kapandji wire under
fluoroscopic control. Using the Kapandji wire as a guidewire, the
intramedullary canal was opened with a cannulated reamer, followed
by broaching of the medullary cavity, using the designated profilers.
Once broaching and sizing were completed, the actual implant and
insertion jig were assembled on the back table and inserted into the
distal radius.
After correct placement was confirmed, four 1.8 mm drilling wires
were inserted through the insertion jig and replaced by fixation screws.
Length, tilt and rotation were confirmed prior to insertion of the
proximal bicortical locking screws. Final images were taken to confirm
reduction and fixation of the fracture (Figure 1). After wound closure, a
simple dressing was applied.
after the operation. All patients were evaluated by an independent
investigator not involved in the patients treatment. Blinding of the
investigator was not possible due to obvious differences in incision
placement. Functional assessment included measurement of active
range of wrist motion, using a goniometer. Grip power was measured
with a dynamometer (Jamar; JA Preston Corp., Jackson, MI) at position
3, and an average of three trials. All clinical data were compared with
the non-involved side.
Wrist pain was evaluated using the visual analogue scale (VAS)
(VAS 0 = no pain, VAS 10 = severe pain).
Subjective and objective data were summarized in the Gartland and
Werley Score (02 = excellent to >20 = poor) [11] and the Castaing Score
(0 = perfect to >25 = very poor) which comprises wrist function and
radiographic data [12].
Radiographic assessment
Standard posterior-anterior and lateral wrist radiographs were
obtained at each follow up visit. On lateral radiographs of the
symptomatic wrist in the neutral position, volar tilt (number of
degrees from the neutral position) of the articular surface of the distal

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Table 1. Table 2.
Demographic characteristics Procedure time, fluoroscopy time and hospital stay

Volar Volar plate Targon DR p

plate Targon DR
Procedure time (min) 60 (3395) 54 (3292) 0.402
Number of patients 14 14 Fluoroscopy time (sec) 1.8 (0.37) 3.15 (18) 0.062
Age 63.8 8.9 64.8 11.6 Hospital stay (d) 4 (35) 4 (36) 0.352
Gender
Male 2 2 Values are presented as median and range.
Female 12 12
Hand
dominance Table 3.
Right 14 14 Range of motion and Castaing Score at 8 weeks
Left 0 0
Injured side Volar Targon
Right 5 4 plate DR p
Left 9 10 Extension/Flexion 80 27 89 18 0.171
Dominant side injured Radial/Ulnar Deviation 47 14 56 12 0.222
Yes 5 4 Pronation/Supination 157 33 173 7 0.347
No 9 10 Castaing Score 74 33 0.091

*Values are given as mean and standard deviation. Values are presented as mean standard deviation.

radius was measured. On posteroanterior radiographs ulnar variance Clinical outcome

was measured as described by Medoff [13].
Fracture union was defined as bone bridging of the radial, ulnar, and
dorsal cortical aspect of the distal radius as seen in anteroposterior and
lateral projections within three months after surgery. Patients with
incomplete callous bridging four months after surgery were consid-
ered to have delayed healing, and patients with limited radiographic
evidence six months after surgery or initial injury were considered to
have fracture nonunion [14].
Statistical analysis
Descriptive statistics were computed for variables of interest. After
testing for normality, non-parametric Mann-Whitney Test was chosen
to assess differences between groups concerning the investigated
continuous variables. Fishers exact test was used to assess differences
for categorical variables. We used Bonferroni-correction, so the
significance level of statistical tests was set at p = 0.038 for a two-
sided confidence level of 95%.
Patients in both groups achieved 82% of wrist motion and grip
strength of the unaffected side. After eight weeks, patients in the nail
group presented with greater range of motion and lower Castaing
scores, however this difference was not significant (Table 3). At the final
follow up, active wrist extension recovery averaged 97% in the nail
group and was greater than in the plate group (Table 4).
More than 96% of patients in both groups showed perfect or good
results according to the Castaing Score and excellent or good results
according to the Gartland and Werley score. Patients in both group
reported no or very mild pain (Table 5).
Radiographic outcome
All fractures united within three months after surgery. Reduction
was maintained in all patients. Palmar tilt and ulnar variance were
significantly better in the plate group (Table 6).
Figures 2 and 3 show a typical case of intramedullary fixation.

Results
Complications and reoperations
Baseline data
Complications were noted in three patients.
Table 1 summarizes the demographic characteristics of the patients.
The mean time from injury to surgery was eight days (range, 124). Table 4.
Range of motion and grip strength at 2 years
Fractures were classified according to the AO/ASIF classification system
by a single experienced orthopaedic surgeon. Volar plate Targon DR p

Extension 94 8 97 5 0.219
Flexion 89 12 93 9 0.516
Numbers analyzed Radial Deviation 93 9 91 10 0.887
Ulnar Deviation 91 11 92 11 0.906
Pronation 100 0 100 0 0.999
The primary analysis was on-treatment and involved all patients Supination 99 3 97 7 0.738
who completed the final follow up. One patient did not attend the final Grip strength 82 17 87 10 0.599
follow up evaluation. Two patients died of unrelated conditions
Values are presented as mean standard deviation in percentage of the unaffected side.
and were excluded. A total of 25 patients were available at the final
follow up.
Table 5.
Scores at 2 years
Treatment
Volar Plate Targon DR p

Median operative time was longer for plate fixation, whereas Castaing 1.44 1.13 1.55 2.66 0.41
fluoroscopy time was higher for intramedullary nailing. Both differ- Gartland 1.11 1.83 1.00 1.48 0.99
VAS at rest 0.00 0.00 0.00 0.00 0.99
ences were not significant ( p = 0.40 and 0.06 respectively). There was VAS with activity 0.00 0.00 0.91 2.21 0.48
no significant difference between groups with respect to hospital stay
( p = 0.35) (Table 2). Values are reported as mean standard deviation.

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Table 6. Implant removal due to screw penetration into the distal radioulnar
Radiographic measurements at 2 years
joint was performed in one case in the nail group.
Volar Plate Targon DR p One patient in each group reported persistent discomfort at the
Ulnar variance (mm) 0.4 0.8 (2 to 0) 0.8 0.9 (02) 0.036*
wrist and have had their implants removed. Implant removal was not
Volar tilt (degree) 5.5 6.2 (015) 0.0 0.0 (00) 0.003* performed routinely, but only at the patients request.
Chronic or deep soft-tissue infections or tendon irritations were not
Values are reported as mean standard deviation; range in parentheses. detected in either group.
*Indicating significance.

Discussion

Stabilization of distal radius fractures constitute an important

Fig. 2. Preoperative radiographs of a AO 23 C2.1 distal radius fracture in a 72-year-
old lady.
One patient in the volar plate group developed symptoms of carpal
tunnel syndrome and received implant removal and carpal tunnel
release. Transient paraesthesia of the superficial radial nerve occurred
in one patient in the nail group.
component of the daily work load of a trauma surgeon [1519].
The present study prospectively evaluated the differences between
2.4-mm volar locking plate fixation and intramedullary nail fixation for
a certain subtype (AO type C2.1) of intra-articular fracture of the distal
radius. Our null hypothesis was that there would be no significant
differences in any outcome between the two groups at eight weeks and
two years after the operation. However, in the early recovery period,
ulnar abduction seemed to be less compromised in the nailing group
and patients had lower Castaing scores. At the time of the final follow
up, active wrist extension recovery averaged 97% in the nail group and
was greater than in the plate group, but did not reach a level of
significance.
Patients in both groups had regained more than 82% of wrist motion
and grip strength compared to the unaffected side and reported no or
only minimal pain.
Comparison of the initial postoperative radiographs with those
taken at the last follow-up showed only minimal loss of reduction
during fracture healing in both groups. Ulnar variance and volar tilt
were significantly worse in the nail group, however, this did not seem
to affect functional outcome.
Despite the fact that we selected only dorsally displaced fractures,
there was only one case of late dorsal displacement and this occurred in
both groups.
The intramedullary device seems to provide sufficient stability to
prevent secondary displacement as has been demonstrated in clinical
and biomechanical studies [1517,2022]. In a prospective study
evaluating the efficacy of 2.4 mm column-specific plating for intra-
articular distal radius fractures in 105 patients with AO type C distal
radius fractures, the authors found that the odds of a good reduction
were 0.25 (0.0770.83) for C2 fractures and 0.17 (0.050.53) for C3

Fig. 3. Left panel: Eight weeks after intramedullary nail fixation; right panel: two years after intramedullary nail fixation.

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 G. Gradl et al. / Injury, Int. J. Care Injured 47S7 (2016) S25S30
fractures compared with the C1 subtype [23]. In a previous parallel-
group trial with patients with dorsally displaced extra-articular distal
radius fractures, intramedullary fixation yielded similarly good results
as volar plate fixation. At the time of the final follow up, patients in
both groups had regained more than 82% of wrist motion and grip
strength compared to the unaffected side and reported no or only
minimal pain.
Comparison of the initial postoperative radiographs with those
taken at the last follow-up showed no loss of reduction during fracture
healing [7].
Ilyas and Thoder presented their preliminary experience with an
intramedullary Nail (Micronail) for displaced extraarticular and simple
intraarticular distal radius fractures (AO type A and C1) [6]. The average
age of the ten patients was 55 years, and average follow-up was 21
months. Similar to our findings, they found transient radial nerve
disturbance in 20% of cases and implant related complications in 30%.
Grip strength was 91% of the uninjured side and the mean DASH
score was 2.7 points. They experienced three cases of screw penetration
into the DRUJ on final follow-up radiographs, one of which was
symptomatic and presented with DRUJ arthritis. Loss of reduction at
final follow up as determined by a difference of greater than 5
between immediate postoperative and final radiographs occurred in
two patients. Interestingly enough, both cases represented AO type A3
fractures.
The authors specifically avoided use of the Micronail for all AO type
B and C2 or C3 fractures in their study and concluded good outcomes
could be obtained with intramedullary fixation of extra-articular and
simple intraarticular fracture patterns.
In a prospective study, Tan et al. [4] reported on 23 consecutive
patients with unstable distal radius fractures treated with an intra-
medullary nail. At the 6-month follow-up, flexion averaged 58 (range,
2575), extension 73 (range, 5590), radial deviation 22 (range,
1530), ulnar deviation 28 (range, 2035), supination 78 (range, 50
90) and pronation 87 (range, 8090). The mean grip strength was
80% (range, 68100%) of the uninjured side. Comparison of the initial
postoperative radiographs with those taken at the latest follow-up
showed complete reduction was maintained in all but three patients.
Two of these had AO type C2 fractures. The investigators attribute this to
diminished dorsal-volar divergence of the distal screws in the first-
generation design of the device.
Nishiwaki et al. [20] performed a prospective study on 29 patients
with 25 AO type A and 5 AO type C fractures. After 12 months, patients
had regained 90% of motion of the uninjured side and the results were
rated as excellent in 20 cases, and good in 9 cases according to the
modified Mayo Wrist Score.
They reported loss of reduction in two cases, and transient radial
sensory nerve neuritis in one case.
The intramedullary implant appeared to avoid some of the soft
tissue injuries, such as tendon irritation or rupture that can result with
traditional plating. However, there is considerable risk of articular
surface screw penetration, as evidenced in one of our cases, specifically
of the DRUJ.
One patient had temporary minor radial sensory nerve disturbance
that resolved within 2 months of surgery. Insertion of the nail through
the radial styloid places the superficial radial sensory nerve at risk and
diligent identification and protection of the radial sensory nerve is
required.
Arora et al. reported a 27% complication rate in their study on 141
patients with distal radius fractures treated with volar plating. The
most frequent problems were flexor and extensor tendon irritation
(57%) followed by complex regional pain syndrome and carpal tunnel
syndrome [9].
Due to the less direct exposure and indirect reduction technique,
requiring frequent fluoroscopic controls, higher fluoroscopy times
were needed to position the Targon DR nail. Median operative time
however was shorter than in the plate group.
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S29
A prospective randomized pilot study reported experience and
early results with an intramedullary wrist pin in the treatment of extra-
articular and simple intra-articular distal radius fractures. At the time
of the final follow up the authors found no significant differences
between groups with regard to wrist motion and radiographic
parameters. Mean operative time was significantly shorter in the nail
group. The authors concluded that intramedullary fixation is reliable
and effective and prevents complications that are related to extensive
soft tissue dissection [24].
There are several limitations to our study. First, functional and
radiographic assessment could not be blinded due to obvious
placement of surgical incisions and implants visible on radiographs.
Second, a relatively small number of patients were enrolled in this
study due to the limited inclusion criteria (specific fracture type). Third,
we did not use any patient reported outcome measures and did not
address the patients perspective.
Despite these shortcomings, the present study suggests that
intramedullary nail fixation is a reasonable alternative to volar plate
fixation for the treatment of displaced intraarticular distal radius
fractures. Extraarticular and simple intraarticular fractures however
might yield more reliable results in terms of maintenance of reduction.
Conflict of interest
None
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