Distal end radius fractures account for 16% of all fractures and are among the most common fractures seen in orthopedic practice ^[1]. This is the most frequent upper-limb fracture encountered. Approximately half of these fractures are intra-articular. Children aged 5–14 years, men under 50 years old, and women over 60 years old are the common age groups engaged. There is a bimodal age distribution, with different trends observed in men and women. The likelihood of these fractures increases with age in females, particularly beyond the age of 40 ^[2]; in individuals under the age of 40, males are more likely to experience them ^[3]. These fractures typically happen to young people as a result of high-velocity injuries such as car accidents or falls on outstretched hands. Elderly people are more likely to suffer fractures from low-energy trauma or moderate trauma, such as falls from a standing height. Osteoporosis causes older persons’ bones to become brittle, which is the cause of this. The treatment of DRFs has evolved significantly throughout the years. Conservative management with universal cast was replaced with bridging external fixators, which were subsequently substituted with dorsal buttress plating. The use of volar locking plates in the treatment of distal radius fractures (DRFs) is seeing an increasing trend in popularity. Locked volar plating has two benefits: Enhanced pull-out strength, especially in cases of osteoporotic bone, and a volar surgical technique that eliminates the need for extensive dorsal dissection. To avoid irritation of the flexor tendons, the plate is positioned in a well-cushioned area underneath the pronator quadratus. There is a belief that patients have a higher level of tolerance for scars on the palmar side of the wrist compared to scars on the dorsal side. Locking plates provide several advantages: The use of locking plates reduces the loss of fracture reduction mostly caused by screw toggling. In addition, it leads to an enhancement in the healing process of fractures. At the contact between the bone and the screw, a locking plate limits movement and screw-plate toggling, resulting in a design that is significantly more stable. Effective treatment of these fractures relies heavily on rigid fixation [4, 5]. The development of a variable-angle volar locking plate (VAVLP) in recent times has made it possible to change the insertion angle of each screw [6-9]. Because it enables the surgeon to modify the screw’s trajectory to capture particular pieces without disrupting the articular surface, it offers a theoretical benefit in the fixation of comminuted intra-articular fractures.

This prospective study to analyze the clinico-radiological outcome of VAVLP in the management of DRFs was conducted in the Department of Orthopaedic Surgery, Chettinad Hospital and Research Institute, Kelambakkam from July 2022 to May 2024 after obtaining the clearance from ethical committee.

Subject selection

A cohort of 25 patients who met the following specified inclusion criteria was selected for the study;

Inclusion criteria

• Patients between the ages of 18 and 65
• All DRFs
• Both intra and extra-articular DRF

Exclusion criteria

• Associated carpal bone fracture
• Open fractures
• Pathological fractures and malignancy
• Infection
• Associated neurovascular injury
• Skeletal immaturity
• Patients who are not willing for internal fixation

Clinical evaluation

In accordance with ATLS protocol, the patients were evaluated for any associated injuries. Patients who presented with concomitant head, thorax, or abdominal injuries underwent initial stabilization. A proper medical history was obtained in detail. Regarding the nature of the injury and the necessity for surgical intervention, the patient and his attendants were briefed. Patients were admitted after all uncertainties were resolved. After evaluating the local skin condition, the patient was put on below elbow POP slab and maintained in limb elevation.

Upon admission, patients had a comprehensive examination, and following investigations were sent as part of the standard procedure.

• CBC, Sr. electrolytes
• RFT
• Serology – HIV, HCV, HBsAg (Rapid)
• Bleeding time and clotting time
• ECG and chest X-ray

Radiological evaluation

Every patient taking part in the trial had bilateral wrist AP and lateral radiographs done (Fig. 1 and 2). X-rays were taken for comparison of the side that was not injured. To evaluate fracture morphology, a computed tomography scan of the affected wrist was obtained in addition to X-rays. Radiological parameters before surgery were assessed. Fractures are classified based on Frykman and AO/OTA classification.

Pre-operative assessment

Following their admission, patients had thorough systemic and local examinations. If there were any comorbidities, necessary opinions from respective departments were obtained. Surgery was postponed until the patient’s swelling subsided if they had substantial swelling. Before surgery, all patients over the age of 50 had comprehensive cardiac examinations. The procedure was thoroughly described to the patient, and their informed consent was received. Patients had routine detailed pre-anesthetic examination and underwent a supraclavicular/axillary block during the surgery. Pre-operative prophylactic intravenous cefuroxime and monopolar diathermy for hemostasis constitute our usual procedure.

Post-operative care

Following surgery, all patients were maintained with strict limb elevation. Post-operative analgesics were given in discussion with anesthesiologists. A check X-ray was taken in the immediate post-operative period (Fig. 3). IV antibiotics were continued until 2^nd post-operative day and were then changed to orals. Wound inspection and sterile dressings were done on POD 2 and POD 5. Removal of sutures was done on post-operative day 12. Following surgery, patients underwent periodic evaluation at 4 weeks, 6 weeks, 3 months, 6 months, and 1 year (Fig. 4 and 5), and radiographs were taken to evaluate fracture union during their subsequent visits (Fig. 4). After surgery, elbow and finger mobilization was started immediately. Wrist mobilization was started at the end of 1^st week as much as tolerable. Strengthening exercises were started at 6 weeks postoperatively. A digital hand dynamometer was used to measure the patient’s grip strength during each visit, and a goniometer was utilized to quantify the patient’s wrist range of motion (Fig. 6 and 7). The values were contrasted with the opposite hand. Should the patient’s results be subpar, they were instructed to adhere to proper rehabilitation exercises.

Our study involved participants with an average age of 43.04 ± 12.12 years. The highest peak in age occurred between 41 and 50 years (8 patients), followed by 31–40 years (6 patients). The gender distribution was 64% male (16 patients) and 36% female (9 patients). Fractures occurred in the right wrist in 52% (13 patients) and the left wrist in 48% (12 patients). All participants were right-handed. Road traffic accidents (RTA) were the leading cause of injury (64%, 16 patients), with 36% (9 patients) sustaining injuries from self-inflicted falls. Among RTA patients, 56.25% (9 patients) had skid and falls, while 43.75% (7 patients) were involved in collisions. Around 40% (10 patients) had associated injuries, such as lower limb fractures (60%, 6 patients), head injury with contralateral ankle fracture, chest injury with pneumothorax, and facial injuries (20%, 2 patients). Comorbidities included diabetes (36%), hypertension (24%), and hyperlipidemia (1 patient). The Frykman classification revealed type 7 fractures as the most common, followed closely by type 8. In the AO classification, type B3 was the most frequent (9 patients), followed by type A2 (6 patients). Within B3, 4 patients were B3.1, 3 were B3.2, and 2 were B3.3. For A2, 2 patients were A2.1, 3 were A2.2, and 1 was A2.3. Type C1 had 4 patients, all classified as C1.2, while B2 was represented by 3 patients (B2.1 subtype). Of the 25 patients, 24% (6 patients) had extra-articular DRFs, and 76% (19 patients) had intra-articular DRFs. A higher incidence of intra-articular fractures was seen in RTA patients. The mean waiting period for surgery was 3.04 days, and 88% (22 patients) underwent surgery within 5 days. Fracture union occurred in 68% (17 patients) within 2–3 months, while 24% (6 patients) had union in 3–4 months (Table 1). Post-surgery, significant improvements were noted in radial length and inclination (Table 2). The mean palmar flexion was 83 ± 6.12°, dorsiflexion 85.8 ± 6.06° (Table 3), and grip strength of the affected hand was 17.84 ± 6.05 kg. By 1 year, 80.07% of grip strength was regained (Table 4). The Modified Mayo Wrist Score (MMWS) improved from 55.62 ± 5.17 at 3 months to 91 ± 6.61 at 1 year (Table 5). At 1 year, 72% of patients had excellent results, 24% had good outcomes, and 4% had fair outcomes.

Managing a DRF presents significant challenges due to the variety of fracture patterns, making no single treatment approach universally effective. A thorough understanding of the fracture’s anatomy is crucial, as both intra and extra-articular fractures can lead to complications such as reduced grip strength, post-traumatic arthritis, carpal instability, and limited range of motion, all of which can be avoided with proper treatment. For fractures with minor comminution or those that are undisplaced or minimally displaced, closed reduction and immobilization with a plaster cast may be considered. However, questions regarding the ideal position for immobilization, the duration of immobilization, and the extent of the cast are still unanswered. In addition, fractures treated this way require constant monitoring, as there is a significant risk of displacement. K-wires, known for their minimal invasiveness and ease of application, have limitations. These include poor fixation in osteoporotic bones, loss of fracture reduction, prolonged immobilization leading to stiffness, delayed mobilization, increased risk of pin tract infections, and delayed fracture collapse. For open fractures with soft tissue or neurological compromise, external fixators are increasingly used. These work through ligamentotaxis and are useful for highly comminuted fractures, but they also require extended immobilization and may cause joint stiffness and reduced range of motion. Surgical intervention with plate osteosynthesis is recommended for unstable fractures or those with articular incongruity that cannot be corrected with external manipulation. Initially, conventional plates were used for minimally comminuted fractures, but their toggle mechanism often caused deranged fracture reductions. FA-LCP (functional anatomical locking compression plate) has since become more popular, providing better stability, facilitating early mobilization, and promoting faster recovery, particularly in geriatric patients with delayed healing. Recent advancements in volar plates with variable angle and locking functions offer improved versatility, accommodating different fracture variations and providing better fixation. This has made them a valuable tool in treating DRFs. In a prospective cohort study of 25 patients with DRFs, treated with a VA-LCP (Fig. 1), we followed patients for 1 year, assessing pre-operative and post-operative radiological data and functional outcomes using the MMWS, which considers pain, satisfaction, range of motion, and hand grip strength.[10-12] Our study found that the average age of patients was similar to other studies: 52.9 years (Chen et al.) ^[13], 57 years (Fowler et al.) ^[7], 59 years (Nishiwaki et al.) ^[14], and 55.9 years (Elerian et al.) ^[15]. Regarding gender distribution, 64% of the patients were male, mirroring studies by Mohamed et al., (64% male) and Karthik and Ethiraj (75% male) [16-20]. We observed that the dominant hand was more commonly affected, with 52% of cases involving the right wrist. This is consistent with findings from other studies, such as Abdel-Wahed et al., (64.1% dominant hand injuries) ^[17] and Karthik and Ethiraj (60% right hand) ^[20]. Most injuries were caused by RTA, with 64% of cases linked to RTA and 36% to self-falls. Other studies, such as Karthik and Ethiraj’s, also showed a high prevalence of RTA-related injuries ^[20]. Fractures were categorized using Frykman and AO/OTA classifications. Our study found that 76% of fractures were intra-articular, with the remaining 24% being extra-articular, a trend consistent with findings from Fang et al., ^[18] and Mehrzad et al. ^[12]. Based on AO/OTA classification, most fractures in our study were type B (partially articular), which differs from studies where type C fractures predominated. Regarding associated injuries, 40% of patients in our study had additional injuries, with 60% of those having ipsilateral lower-limb fractures. Other studies, such as Elerian et al.’s, noted a similar occurrence of distal ulna fractures in conjunction with DRFs ^[16]. Comorbidities in our patients included hypertension (24%), diabetes (36%), and no comorbidities in 48%. The mean waiting time for surgery in our study was 3.04 days, similar to Chen et al.’s findings of 2.8 days ^[13]. Post-operative outcomes showed that 68% of patients achieved union within 2–3 months, with 24% achieving union in 3–4 months. Our results align with Park et al.’s and Elerian et al.’s studies on fracture healing timelines [10, 16]. Radiological outcomes showed significant improvements in radial height and radial inclination. Pre-operative mean radial height was 7.36 ± 2.67 mm, corrected to 11.62 ± 2.79 mm postoperatively. This increase is comparable to results from Park et al. (9.9 mm) ^[10] and Fowler et al. (21 ± 3 mm) ^[7]. Similarly, the mean radial inclination improved from 16.38 ± 6.38° to 22.95 ± 4.54°, consistent with findings from Khatri et al., ^[18] and Fang et al. ^[17]. Regarding functional outcomes, the average range of motion at the end of the study showed comparable results to other studies, such as palmar flexion (83 ± 6.12°), dorsiflexion (85.8 ± 6.06°), and supination/pronation (83.4 ± 6.40°/86.2 ± 4.84°), which were in line with the findings of Mishra et al., ^[21] and Fowler et al. ^[7]. In conclusion, the use of VA-LCP for the treatment of DRFs shows favorable radiological and functional outcomes, with the potential for early mobilization and faster recovery, particularly in comparison to other treatment options.

Managing DRFs is technically difficult because they have such a wide range of fracture patterns and no single approach has been shown to be universally effective. A good understanding of the intricate anatomy is a must before taking up these patients for treatment. Closed reduction and immobilization with a Plaster of Paris application may be indicated for fractures with minor comminution and those that are either undisplaced or minimally displaced. However, this treatment requires constant monitoring because there is a somewhat high probability that the fracture will get displaced. K-wires are characterized by their minimal invasiveness and ease of application, but they possess several drawbacks that warrant consideration. External fixators are indicated for the treatment of open fractures and fractures that are severely comminuted, acting on the principle of ligamentotaxis. These patients require a longer period of immobilization, and there is a possibility that it will cause joint stiffness and a reduction in the range of motion. Surgical intervention with plate osteosynthesis is recommended for fixing fractures which are unstable and those with articular incongruity that cannot be corrected with external manipulation and ligamentotaxis. Conventional plates when utilized to treat fractures that had minimal comminution have the disadvantage that the cancellous bone pieces were held loosely, and the toggle mechanism of screws in the distal holes resulted in a loss of fracture reduction. The utilization of FA-LCP has gained popularity as an effective means of providing subchondral support. It provides better stability, facilitates early post-operative mobilization, and promotes a faster recovery of function. The variable angle locking plate is highly effective in achieving anatomic reduction and rigid fixation. In addition, it targets specific fracture fragments and allows for precise adjustment of reduction. Extra care should be taken with individual screw placement to avoid breaching the joint. We recommend the use of VAVLP in treating unstable intra-articular DRFs because of the advantages it possesses;

• Provides excellent reduction of articular surface
• Helps in initiating rehabilitation and mobilization at the earliest
• Issues related to hardware are very minimal
• Lower rate of morbidity.

Surgical management of DRFs through open reduction and internal fixation using VAVLP has proven to be highly effective. This technique ensures precise fracture reduction, maintains stable fixation, and allows for early mobilization, contributing to better functional recovery. The variable angle feature enhances adaptability for different fracture patterns, improving alignment and stability. As a result, patients experience favorable clinical and radiological outcomes, with reduced complications and better long-term wrist function.