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 Table of Contents  
ORIGINAL ARTICLE
Year : 2023  |  Volume : 6  |  Issue : 1  |  Page : 84-89

Functional outcome of volar variable angle locking compression plate in distal end radius fractures: A retrospective case record analysis


1 Department of Orthopaedics, BGS Global Institute of Medical Sciences, Kengeri, Bengaluru, Karnataka, India
2 Department of Orthopedics, MIMS, Mandya, Karnataka, India

Date of Submission24-Aug-2022
Date of Decision11-Nov-2022
Date of Acceptance13-Nov-2022
Date of Web Publication27-Dec-2022

Correspondence Address:
K M Pawan Kumar
Department of Orthopaedics, BGS GIMS Under RGUHS, Kengeri, Bengaluru - 560 090, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jodp.jodp_72_22

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  Abstract 


Background: Distal end-of-radius fractures are one of the most common fractures seen worldwide, accounting for approximately one-sixth of all fractures. Closed reduction and cast immobilization have been the mainstay of treatment, but recently open reduction and plating with conventional plates have gained importance as they can be of great value in treating distal end radius fractures. This study is based on the latest innovation in this regard, the effectiveness of the volar variable angle locking compression plate in treating distal end radius fractures. Aim and Objectives: To evaluate the functional outcome associated with volar variable angle locking compression plate for distal end radius fractures and also to study the efficacy of the plate in capturing the fracture fragments. Materials and Methods: A retrospective study involving 30 patients with distal end radius fractures who were treated with open reduction and internal fixation using a volar variable angle locking compression plate. Patients admitted between November 2018 and November 2019 were included in this study. Clinical, functional, and radiological outcomes were used to assess the efficacy of the plate. Results were calculated using the Disabilities of the Arm, Shoulder and Hand (DASH) score questionnaire at the end of 1-year postsurgery. Follow-up data for all patients for 1 year were available in our medical records. The extent of the range of motion (ROM) at the wrist joint was noted. Results: 53.3% of patients had excellent results, 36.7% of patients had good results, while 10% of patients had fair results. Almost all the patients had good ROM postoperatively except two patients. One of them developed wrist stiffness and another patient had reduced ROM due to noncompliance to the treating doctor's advice. Conclusion: Our study signifies the importance fragment specific fixation of distal end radius fractures. Patients were mobilized sooner than other accepted modalities of treatment. We conclude that volar variable angle locking compression plates are superior to the other accepted modalities of treatment for distal end radius fractures.

Keywords: DASH score, distal end radius fractures, volar variable angle LCP


How to cite this article:
Pawan Kumar K M, Hawaldar SV, Patil M. Functional outcome of volar variable angle locking compression plate in distal end radius fractures: A retrospective case record analysis. J Orthop Dis Traumatol 2023;6:84-9

How to cite this URL:
Pawan Kumar K M, Hawaldar SV, Patil M. Functional outcome of volar variable angle locking compression plate in distal end radius fractures: A retrospective case record analysis. J Orthop Dis Traumatol [serial online] 2023 [cited 2023 Jan 30];6:84-9. Available from: https://jodt.org/text.asp?2023/6/1/84/365289




  Introduction Top


Distal radius fractures are the most common orthopedic injury and generally result from a fall on an outstretched hand. They account for 17.5% of all fractures in adults, and have been reported to be more common in females (2–3:1).[1] Demographics tend to follow a bimodal distribution. Events in younger patients are generally due to high-energy mechanisms like road traffic accidents (RTAs) or direct trauma. However, in older patients, they are generally due to low-energy mechanisms like fall on the outstretched hand. Osteoporosis can make a relatively minor fall resulting in a broken wrist. Many distal radius fractures in people over the age of 60 years are caused by a fall from a standing position.[2],[3],[4]

Conventionally, these fractures have been treated with closed reduction and casting. However, due to recent technological advances and emerging preferences for anatomic reduction and absolute stability, open reduction and plating are being preferred as a treatment choice.

Various types of plates are available in the market, i.e., Volar or dorsal, Compression plates, fixed angle locking compression plates, and variable angle locking compression plates.

The application of a volar buttress plate in open reduction and internal fixation (ORIF) for distal radius fractures provides both construct stability and recovery of wrist function. Various methods and techniques have been deployed to stabilize these fractures, including tension band wires, distal buttress plates, and external fixators. The variable angle volar rim locking compression plate system (VALPC) has been designed to be placed distal to the watershed line with a low profile contour to prevent flexor tendon irritation. The VALCP system also has 15° off-axis variable angle screws that assist in avoiding penetrating the wrist joint. In addition, VALCP has distal radial and ulnar “teardrop” holes which are used to augment fixation of the radial styloid, lunate facet, and distal radial-ulnar joint. Due to these advantages, VALCP is emerging as the treatment of choice in distal radial fractures.[5],[6],[7]

However, there is a dearth of published literature in assessing functional outcomes using VALCP fixation for distal radius fractures involving the volar rim. The aim of our study is to assess the functional outcome of the volar variable angle locking compression plates in treating distal end radius fractures using clinical, functional, and radiological outcomes.

Aims and objectives

  1. To evaluate clinical and functional outcomes associated with volar variable angle locking plate in distal radius fractures
  2. To study the efficacy of variable angle locking compression plate in capturing fracture fragments.



  Materials and Methods Top


Inclusion and exclusion criteria

Thirty consecutive patients with intra-and extra-articular fractures of distal end radius admitted to our institution were included in this study. VALCP was done on all of them. Availability of medical records and postoperative 1 year follow-up data was mandatory for patients to be included in this study. The study was approved by the institutional ethics committee at our hospital. Patients with incomplete data and lost to follow-up were excluded from this study.

Study design and duration

This is a retrospective review of a consecutive series of patients. The study duration was 1 year – patients admitted between November 2018 and November 2019 were included in this study.

Assessment tools

The data collected from source documents for all patients were recorded in a master chart. Data analysis was done using MS EXCEL and Statistical Package for Social Sciences (IBM SPSS Statistics version 22 for Windows, Somers NY, USA). Categorical data was represented in the form of frequencies and proportions. Chi-Square test was used as a test of significance for qualitative data. Continuous data were represented as means and standard deviation. P < 0.05 was considered statistically significant after assuming all the rules of statistical tests. The assessment was done at 12 weeks' postoperative and was recorded. DASH scores were graded as follows: 0–15: Excellent, 16–35: Good, 36–50: Fair, >50: Poor.

Details of procedure

All patients were operated on under the regional block. Tourniquet was used in all the surgeries. Patients were put on a supine position with the affected arm resting against the arm board. The modified volar Henry approach was used in all our cases. The modified Henry approach uses the plane between the flexor carpi radialis tendon and the radial artery. The classical Henry approach goes between the brachioradialis and the radial artery, i.e., radial to the radial artery. The modified approach is ulnar to the radial artery. Wrists were immobilized in a below-elbow splint for 4 weeks. Fracture union was assessed by bridging the Callus across the fracture site on both anteroposterior and lateral radiographs and a painless fracture site during stress-related activities. All patients were started with range of motion (ROM) exercises of the wrist joint at an average of 6 weeks.


  Results Top


Demographics

Thirty patients admitted to our hospital with distal radius fractures and conducted VALCP during the study period were assessed retrospectively. The average age of the patients was 37.3 ± 12.2 years. The median age of patients was 33.5 years. Twenty patients were males, while 10 were females.

Mode of injury

RTA was the mode of injury in 20 patients (66.7%) while low energy fall was recorded for 10 (33.3%) patients. The mean age of patients admitted due to RTA was 35.45 years, while the mean age of patients admitted with low energy falls was 41 years. Nineteen patients had fractures in the left wrist, while 11 patients had fractures in the right wrist.

Classification of fractures

We used Müller AO classification to classify the fractures. 3.3% had A2 type, 10% had B1 and B2 type, respectively, 16.7% had B3 type, 30% had C1 type, 23.3% had C2 type and 6.7% had C3 type fractures. 26.7% of patients had associated injuries mainly seen in RTAs group. Demographic data and fracture patterns have been summarized in [Table 1].
Table 1: Demographic data and fracture pattern in our study

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DASH Score

Patient-reported functional outcomes were assessed using the disabilities of the arm, shoulder, and hand (DASH) score. All patients obtained a satisfactory outcome. In our study 53.3% had excellent, 36.7% had good and 10% had fair results. DASH scores at 1 year follow-up are summarized in [Table 2].
Table 2: Descriptive statistics of Disability of Shoulder, Arm, and Hand scores at one year follow-up

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Functional outcome

Movement of the fractured wrist was significantly better at 12 weeks' postoperative follow-up. In our study, the majority of patients had dorsiflexion up to 80° (36.7%), palmar flexion up to 80° (43.3%), radial deviation 20° in 56.7%, ulnar deviation 30° in 40%, supination of 80° in 36.7% and pronation of 80° in 60% of patients. Functional outcomes with respect to the DASH score were significant (P < 0.05) for all the functional outcome aspects of the surgery which have been summarized and represented in [Table 3] and [Figure 1].
Table 3: Functional outcome comparison with respect to Disability of Shoulder, Arm, and Hand score results

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Figure 1: Functional outcome comparison with respect to DASH score results. DASH: Disabilities of the arm, shoulder and hand

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Radiological outcome

Forty percent of patients had a palmar tilt (PT) of 10°, 33.3% of patients had a radial inclination (RI) of 20°, 50% of patients had an ulnar variance (UV) of–2 mm, and 33.3% of patients had a radial length (RL) of 10 mm. In our study, there was no statistically significant difference in mean RI (P = 0.744), UV (P 0.076), and RL (P = 0.213) with respect to results. Mean PT was low among those with fair outcomes and high among those with good outcomes. There was a statistically significant difference in PT with respect to results with P = 0.026. The radiological outcome comparison with respect to DASH score results have been summarized and represented in [Table 4] and [Figure 2].
Table 4: Radiological outcome comparison with respect to Disability of Shoulder, Arm, and Hand score results

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Figure 2: Radiological outcome comparison with respect to DASH score results. DASH: Disabilities of the arm, shoulder and hand

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DASH SCORE with respect to results. In the study, there was a statistically significant difference (P < 0.001) in the mean DASH score with respect to Results. The mean DASH score was low in subjects with excellent results and high among those with fair results, the same has been summarized and represented in [Table 5] and [Figure 3].
Table 5: Disability of Shoulder, Arm, and Hand score with respect to functional and radiological outcome results

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Figure 3: DASH score with respect to functional and radiological outcome results. DASH: Disabilities of the arm, shoulder and hand

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Postoperative complications

In this study, we have records of postoperative complications in three patients (10%). One patient had wrist arthritis as the patient had neglected the surgeon's advice about rehabilitative exercises, particularly given that the fracture was AO C3 type. One patient had Complex Regional Pain Syndrome, who was treated conservatively. One patient had developed a skin infection, which was controlled with regular dressings and antibiotics.

Radiological results

Sample X-ray images of two patients are illustrated in [Figure 4] and [Figure 5]. The Range of Movement (ROM) achieved at the end of follow up in the male and female patient has been shown in [Figure 6] and [Figure 7].
Figure 4: 2.3.B.3 fracture of wrist as per AO classification. Fracture fixation with bicolumnar distal radius variable angle LCP

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Figure 5: 2.3.C.2 fracture of wrist as per AO classification. Fracture fixation with bicoulmnar distal radius variable angle LCP

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Figure 6: Range of movements achieved at the end of follow up in a male patient

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Figure 7: Range of movements achieved at the end of follow up in a female patient

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  Discussion Top


Distal radius fractures that involve the volar rim are a medical and surgical challenge. In patients suffering from these fractures, it is extremely important to restore the lunate facet as it is indispensable to maintaining length, alignment, and stability of the wrist joint. ORIF using plates for distal radius fractures is a superior modality of treatment compared to other modes of treatment, it restores the anatomy of the wrist joint and helps in faster rehabilitation with good clinical outcomes.[8] Volar variable angle locking compression plates are the recent technological advances that have revolutionized this field. Volar plating provides anatomic reduction and improved stability, especially with AO C2/C3 fracture types with reduced rehabilitation time and early return to routine activities/work. Although locking plate technology provides increased angular stability and has strength advantages over traditional support plating techniques.[9] STo date, traditional locked fixation has not offered the ability to alter fixation to accommodate specific variations in fracture patterns to capture and stabilize comminuted fragments. This is because fixed locked plates rely on the predetermined screw path, which does not take into account the individual anatomy of the fracture fragments at hand or the variation in plate placement, due to which the volar fixed-angle locking plates allow the screws to be inserted in a predefined direction, and they do not take into account the individual fracture types and any variability in the positioning of the plate.[10],[11]

In this context, newer technologies like variable-angle locking plates are advantageous. They provide greater flexibility and the advantage of allowing fragment-specific capture or avoiding intra-articular placement of screws. These plates can be placed proximal to the watershed line and they are still able to engage those fragments. The bi-cortical purchase is another critical point in the management of complex fracture patterns and it can be achieved with flexible plate positioning in variable angle plates. The various fracture lines (proximal/distal and medial/lateral) are accommodated due to the flexibility offered by the variable angle system.[12],[13]

Kanabar et al.[14] reported that early mobilization in fractures treated with volar fixed locking plates does not lead to a decrease in the radiological parameters achieved at the final follow-up. In our study, we mobilized the patients with wrist ROM exercises approximately at around 6 weeks in all the patients.[14]

Khatri et al.[15] reported 65.22% of patients had excellent results and 34.78% of patients had good results in their study on 23 patients with unstable distal end radius fractures treated with a volar variable angle plate.[15] Rao et al.[16] reported 66.6% excellent results, 23.33% good results, and 10% fair results in 28 patients with distal end radius fractures treated with a volar variable angle plate.[16] Both the studies used Gartland and Werley scoring system to grade the outcome. Dabash et al.[17] reported that 63.7% of their patients had excellent outcomes, whereas 13.6% and 22.7% of their patients had good and fair outcomes respectively in their study.[17] We used the DASH score and subsequently had 53.3% excellent, 36.7% good, and 10% results. DASH scores of varies studies in comparison to ours study has been summarized in [Table 6].
Table 6: Disability of Shoulder, Arm and Hand scores of varies studies in comparison to ours study

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JR Fowler et al.[18] and Ilyas in their study on 39 patients of distal end radius fractures treated with VALCP found the average DASH scoring to be 6. Marlow et al.[19] conducted a study on 65 patients of distal end radius fractures who were treated with VALCP, had an average DASH score of 20.14.[19] Mulders et al.[20] reported an average DASH score of 9 in their study. Toon et al.[21] have reported an average DASH score of 17.4. Ermutlu et al.[22] in their study have reported DASH score average of 16. In our study, the average DASH score was 15.415. Average DASH scores in comparison to average DASH score in our study has been shown in [Table 7].
Table 7: Average Disability of Shoulder, Arm and Hand scores in comparison to average Disability of Shoulder, Arm, and Hand score in our study

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Mengcun Chen et al.[23] reported favorable clinical and radiographic results using the VALCP system compared to the fixed-angle volar rim locking compression plates (FALCP). In their study of 47 cases, Modified Mayo wrist score and DASH scores improved with time postoperatively. Relative wrist ROM was improved in VALCP compared to the FALCP at 12 months. VA-LCP was associated with a decreased incidence of flexor tendon irritation compared to FA-LCP. VA-LCP also better held the volar tilt reduction compared to the FA-LCP. Favorable results were attributed to the VALCP system design with its low profile, anatomic contour, and multiple options for fixation that may decrease the incidence of joint penetration and improve lunate facet stability. Their study recommended that surgeons should consider the V-LCP system as an alternative to conventional plates when treating radius fractures distal to the watershed region.[20]

Khatri et al.[15] in their study reported a complications rate of 21.7%. Anakwe et al.[24] over a 12-month period, treated 21 patients with type C distal radius fractures using locked volar plating and reported a complications rate of 4.8%.[24] Agarwala et al.[25] conducted a study on 25 patients with distal end radius fractures who were treated with a locked compression plate and found a complication rate of 4%.[25] In our study, we report 10% complication rate.

Our retrospective study evaluated the biomechanical outcome in patients with distal radius fractures who were treated with a 2.7 mm Volar Variable angle locking compression plate. A total of 30 patients were included in the study, in the age range of 18 years and above. Patients were assessed using the DASH score and 53.3% of patients had excellent results and 36.7% of patients had good outcome with 10% patients having fair outcomes. Our study signifies the importance of fragment-specific fixation of fractures using volar variable angle locking plate and the results obtained highlight the same. Patients had a good ROM and minimal disabilities at the end of 1 year of follow-up.

Our study has some limitations. First, we recognize the limitations of our retrospective review. We had a limited number of patients' data, which although at par with other published studies, can still be considered suboptimal. Future prospective studies with even longer follow-up period that may capture long-term outcomes including the development of posttraumatic osteoarthritis and flexor tendon rupture is needed.


  Conclusion Top


We would like to stress on the importance of proper reduction and vigilance during the surgery as it technically demanding and chances of misplacement of the screw in the wrist joint space or breakage of the screw is not uncommon. We were also able to mobilize the patients sooner than the other accepted methods of treatment for distal radius fractures. The radiological outcome was overall very satisfactory and the complication rates were minimal. Thereby we would like to conclude that volar variable angle locking plates are superior to various other accepted modalities of treatment for distal end radius fractures.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Jakim I, Pieterse HS, Sweet MB. External fixation for intra-articular fractures of the distal radius. J Bone Joint Surg Br 1991;73:302-6.  Back to cited text no. 1
    
2.
Mellstrand Navarro C, Ahrengart L, Törnqvist H, Ponzer S. Volar locking plate or external fixation with optional addition of k-wires for dorsally displaced distal radius fractures: A randomized controlled study. J Orthop Trauma 2016;30:217-24.  Back to cited text no. 2
    
3.
Harness NG, Jupiter JB, Orbay JL, Raskin KB, Fernandez DL. Loss of fixation of the volar lunate facet fragment in fractures of the distal part of the radius. J Bone Joint Surg Am 2004;86:1900-8.  Back to cited text no. 3
    
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Bakker AJ, Shin AY. Fragment-specific volar hook plate for volar marginal rim fractures. Tech Hand Up Extrem Surg 2014;18:56-60.  Back to cited text no. 4
    
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Park YH, Song JH, Choi GW, Kim HJ. Comparative analysis of clinical outcomes of fixed-angle versus variable-angle locking compression plate for the treatment of Lisfranc injuries. Foot Ankle Surg 2020;26:338-42.  Back to cited text no. 5
    
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Lenz M, Wahl D, Gueorguiev B, Jupiter JB, Perren SM. Concept of variable angle locking – Evolution and mechanical evaluation of a recent technology. J Orthop Res 2015;33:988-92.  Back to cited text no. 6
    
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O'Shaughnessy MA, Shin AY, Kakar S. Stabilization of volar ulnar rim fractures of the distal radius: Current techniques and review of the literature. J Wrist Surg 2016;5:113-9.  Back to cited text no. 7
    
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AO Manual of Surgery Reference. Available from: www.aofoundation.org. [Last accessed on 2022 Jun 07].  Back to cited text no. 8
    
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Schneppendahl J, Windolf J, Kaufmann RA. Distal radius fractures: Current concepts. J Hand Surg Am 2012;37:1718-25.  Back to cited text no. 9
    
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Inagaki K, Kawasaki K. Distal radius fractures-design of locking mechanism in plate system and recent surgical procedures. J Orthop Sci 2016;21:258-62.  Back to cited text no. 10
    
11.
Couzens GB, Peters SE, Cutbush K, Hope B, Taylor F, James CD, et al. Stainless steel versus titanium volar multi-axial locking plates for fixation of distal radius fractures: A randomised clinical trial. BMC Musculoskelet Disord 2014;15:74.  Back to cited text no. 11
    
12.
Neder Filho AT, Mazzer N, Bataglion LR, Pires RE, Macedo AP, Shimano AC. Distal radius fracture fixation using volar plate: A comparative study evaluating the biomechanical behavior of uni and bicortical distal screws. Injury 2021;52 Suppl 3:S38-43.  Back to cited text no. 12
    
13.
Bergsma M, Brown K, Doornberg J, Sierevelt I, Jaarsma R, Jadav B. Distal radius volar plate design and volar prominence to the watershed line in clinical practice: Comparison of Soong grading of 2 common plates in 400 patients. J Hand Surg Am 2019;44:853-9.  Back to cited text no. 13
    
14.
Kanabar P, Mirza S, Hallam P, Cooper A. Volar locking plate for distal radius fractures: Does it do what it says on the box? A radiological review of 170 consecutive distal radius fractures treated with a volar locking plate. In: Orthopaedic Proceedings. Vol. 93. SUPP_I. South West Orthopaedics Society-Barnstable: The British Editorial Society of Bone & Joint Surgery; 2011. p. 12.  Back to cited text no. 14
    
15.
Khatri K, Sharma V, Farooque K, Tiwari V. Surgical treatment of unstable distal radius fractures with a volar variable-angle locking plate: Clinical and radiological outcomes. Arch Trauma Res 2016;5:e25174.  Back to cited text no. 15
    
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Rao MV, Venkatesh P, Kiran GU, Nimbergi SS. A prospective study of surgical management of distal end radius fractures using variable angle locking compression plate. Int J Orthopaed 2019;5:04-7.  Back to cited text no. 16
    
17.
Dabash S, Potter E, Pimentel E, Shunia J, Abdelgawad A, Thabet AM, et al. Radial plate fixation of distal radius fracture. Hand (N Y) 2020;15:103-10.  Back to cited text no. 17
    
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Fowler JR, Ilyas AM. Prospective evaluation of distal radius fractures treated with variable-angle volar locking plates. J Hand Surg Am 2013;38:2198-203.  Back to cited text no. 18
    
19.
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20.
Mulders MA, Walenkamp MM, van Dieren S, Goslings JC, Schep NW, VIPER Trial Collaborators. Volar plate fixation versus plaster immobilization in acceptably reduced extra-articular distal radial fractures: A multicenter randomized controlled trial. J Bone Joint Surg Am 2019;101:787-96.  Back to cited text no. 20
    
21.
Toon DH, Premchand RA, Sim J, Vaikunthan R. Outcomes and financial implications of intra-articular distal radius fractures: A comparative study of Open Reduction Internal Fixation (ORIF) with volar locking plates versus nonoperative management. J Orthop Traumatol 2017;18:229-34.  Back to cited text no. 21
    
22.
Ermutlu C, Mert M, Kovalak E, Kanay E, Obut A, Öztürkmen Y. Management of distal radius fractures: Comparison of three methods. Cureus 2020;12:e9875.  Back to cited text no. 22
    
23.
Chen M, Gittings DJ, Yang S, Liu G, Xia T. Variable-angle locking compression plate fixation of distal radius volar rim fractures. Iowa Orthop J 2019;39:55-61.  Back to cited text no. 23
    
24.
Anakwe R, Khan L, Cook R, McEachan J. Locked volar plating for complex distal radius fractures: Patient reported outcomes and satisfaction. J Orthop Surg Res 2010;5:51.  Back to cited text no. 24
    
25.
Agarwala S, Mohrir GS, Gadiya SD. Functional outcome in distal radius fractures treated with locking compression plate. Bombay Hosp J 2012;54:209-19.  Back to cited text no. 25
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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