Diao E

This issue of The American Journal of Orthopedics has several very interesting articles for the upper extremity surgeon. The first one that I would like to talk about is “Trends in Thumb Carpometacarpal Interposition Arthroplasty in the United States, 2005–2011” by Dr. Werner and colleagues (pages 363-368). This is a condition that has deep penetration in the US population. As a group, surgical treatments have been evolving, with a number of innovations over the last few decades. Like many things in orthopedics, it is not easy to get “head to head” comparisons between different treatment arms. Nonetheless, although there are some studies that have indicated no particular advantage of 1 mechanism to another, it is interesting as a physician to review this data and follow these trends. This article indicates that, despite lack of strong evidence, individual surgeons have the impression that the operative treatments for basal joint or thumb arthritis are functioning better overall. I share that belief. 

I also enjoyed the article “5 Points on Shoulder Examination of the Overhead Athlete” by Dr. Makhni and Dr. Ahmad (pages 347-352). I think that the care of the musculoskeletal patient is important both in terms of screening and in terms of establishing reasonable indications and goals for rehabilitation as well as for surgical treatment. In this light, I found a lot of illuminating information in this review of the approach to the overhead athlete by these authors with deep experience in this arena. 

The next article that I would like to address is that on thoracic outlet syndrome by Dr. Buller and colleagues (pages 376-382). It has amazed me during my 3 decades in practice how common the condition of thoracic outlet syndrome is and how frequently the diagnosis is made in my own upper extremity practice. Unfortunately, these patients don’t come “labeled,” as this diagnosis remains somewhat mysterious and, certainly, the treatment somewhat controversial. However, identification and recognition of this clinical entity as well as being able to perform an adequate history and do the physical examination maneuvers to elicit the “nerve tension signs” around the thoracic outlet and brachial plexus are important. The descriptions of the history and physical examimation in this article are excellent. Certainly, advanced imaging and diagnostics can be helpful, but I feel that these tests are not adequate as screening tests, and the index of suspicion by you, the clinician, remains paramount in identifying and managing these patients. In my own practice, the vast majority of patients respond to physical therapy and home exercise programs when adequately performed and monitored.

I was fascinated to read Dr. Steve Burkhart’s Neer Guest Lecture, “The Burden of Craft in Arthroscopic Rotator Cuff Repair: Where We Have Been and Where We Are Going” (pages 353-358). He touches on many things in this lecture. Certainly he talks about the innovations that he has been responsible for and how some of these have come about. Interestingly enough, he has views on the role of the private practitioner and those outside of the “shoulder establishment” in contributing to a paradigm shift in treatment from open to arthroscopic techniques, of which he was certainly at the forefront. Additionally, he has some interesting thoughts on the limitations of level I evidence studies. This is a huge issue in orthopedics as it becomes very difficult to try to “randomize” patients into various treatment arms. Most people take their own bodies and the health of their bodies seriously enough to not want to determine treatment with a “flip of the coin.” I think this is quite different than taking a “red pill” or a “blue pill” in a drug study. Dr. Burkhart emphasizes the role of technical expertise as a variable that is not really adequately considered in level I evidence studies, and I wholeheartedly agree with him.

This issue of The American Journal of Orthopedics is rich in terms of its content, and I hope you enjoy reading these articles as much as I have enjoyed commenting on them.  ◾

This issue of The American Journal of Orthopedics has several very interesting articles for the upper extremity surgeon. The first one that I would like to talk about is “Trends in Thumb Carpometacarpal Interposition Arthroplasty in the United States, 2005–2011” by Dr. Werner and colleagues (pages 363-368). This is a condition that has deep penetration in the US population. As a group, surgical treatments have been evolving, with a number of innovations over the last few decades. Like many things in orthopedics, it is not easy to get “head to head” comparisons between different treatment arms. Nonetheless, although there are some studies that have indicated no particular advantage of 1 mechanism to another, it is interesting as a physician to review this data and follow these trends. This article indicates that, despite lack of strong evidence, individual surgeons have the impression that the operative treatments for basal joint or thumb arthritis are functioning better overall. I share that belief. 

I also enjoyed the article “5 Points on Shoulder Examination of the Overhead Athlete” by Dr. Makhni and Dr. Ahmad (pages 347-352). I think that the care of the musculoskeletal patient is important both in terms of screening and in terms of establishing reasonable indications and goals for rehabilitation as well as for surgical treatment. In this light, I found a lot of illuminating information in this review of the approach to the overhead athlete by these authors with deep experience in this arena. 

The next article that I would like to address is that on thoracic outlet syndrome by Dr. Buller and colleagues (pages 376-382). It has amazed me during my 3 decades in practice how common the condition of thoracic outlet syndrome is and how frequently the diagnosis is made in my own upper extremity practice. Unfortunately, these patients don’t come “labeled,” as this diagnosis remains somewhat mysterious and, certainly, the treatment somewhat controversial. However, identification and recognition of this clinical entity as well as being able to perform an adequate history and do the physical examination maneuvers to elicit the “nerve tension signs” around the thoracic outlet and brachial plexus are important. The descriptions of the history and physical examimation in this article are excellent. Certainly, advanced imaging and diagnostics can be helpful, but I feel that these tests are not adequate as screening tests, and the index of suspicion by you, the clinician, remains paramount in identifying and managing these patients. In my own practice, the vast majority of patients respond to physical therapy and home exercise programs when adequately performed and monitored.

I was fascinated to read Dr. Steve Burkhart’s Neer Guest Lecture, “The Burden of Craft in Arthroscopic Rotator Cuff Repair: Where We Have Been and Where We Are Going” (pages 353-358). He touches on many things in this lecture. Certainly he talks about the innovations that he has been responsible for and how some of these have come about. Interestingly enough, he has views on the role of the private practitioner and those outside of the “shoulder establishment” in contributing to a paradigm shift in treatment from open to arthroscopic techniques, of which he was certainly at the forefront. Additionally, he has some interesting thoughts on the limitations of level I evidence studies. This is a huge issue in orthopedics as it becomes very difficult to try to “randomize” patients into various treatment arms. Most people take their own bodies and the health of their bodies seriously enough to not want to determine treatment with a “flip of the coin.” I think this is quite different than taking a “red pill” or a “blue pill” in a drug study. Dr. Burkhart emphasizes the role of technical expertise as a variable that is not really adequately considered in level I evidence studies, and I wholeheartedly agree with him.

This issue of The American Journal of Orthopedics is rich in terms of its content, and I hope you enjoy reading these articles as much as I have enjoyed commenting on them.  ◾

This issue of The American Journal of Orthopedics has several very interesting articles for the upper extremity surgeon. The first one that I would like to talk about is “Trends in Thumb Carpometacarpal Interposition Arthroplasty in the United States, 2005–2011” by Dr. Werner and colleagues (pages 363-368). This is a condition that has deep penetration in the US population. As a group, surgical treatments have been evolving, with a number of innovations over the last few decades. Like many things in orthopedics, it is not easy to get “head to head” comparisons between different treatment arms. Nonetheless, although there are some studies that have indicated no particular advantage of 1 mechanism to another, it is interesting as a physician to review this data and follow these trends. This article indicates that, despite lack of strong evidence, individual surgeons have the impression that the operative treatments for basal joint or thumb arthritis are functioning better overall. I share that belief. 

I also enjoyed the article “5 Points on Shoulder Examination of the Overhead Athlete” by Dr. Makhni and Dr. Ahmad (pages 347-352). I think that the care of the musculoskeletal patient is important both in terms of screening and in terms of establishing reasonable indications and goals for rehabilitation as well as for surgical treatment. In this light, I found a lot of illuminating information in this review of the approach to the overhead athlete by these authors with deep experience in this arena. 

The next article that I would like to address is that on thoracic outlet syndrome by Dr. Buller and colleagues (pages 376-382). It has amazed me during my 3 decades in practice how common the condition of thoracic outlet syndrome is and how frequently the diagnosis is made in my own upper extremity practice. Unfortunately, these patients don’t come “labeled,” as this diagnosis remains somewhat mysterious and, certainly, the treatment somewhat controversial. However, identification and recognition of this clinical entity as well as being able to perform an adequate history and do the physical examination maneuvers to elicit the “nerve tension signs” around the thoracic outlet and brachial plexus are important. The descriptions of the history and physical examimation in this article are excellent. Certainly, advanced imaging and diagnostics can be helpful, but I feel that these tests are not adequate as screening tests, and the index of suspicion by you, the clinician, remains paramount in identifying and managing these patients. In my own practice, the vast majority of patients respond to physical therapy and home exercise programs when adequately performed and monitored.

I was fascinated to read Dr. Steve Burkhart’s Neer Guest Lecture, “The Burden of Craft in Arthroscopic Rotator Cuff Repair: Where We Have Been and Where We Are Going” (pages 353-358). He touches on many things in this lecture. Certainly he talks about the innovations that he has been responsible for and how some of these have come about. Interestingly enough, he has views on the role of the private practitioner and those outside of the “shoulder establishment” in contributing to a paradigm shift in treatment from open to arthroscopic techniques, of which he was certainly at the forefront. Additionally, he has some interesting thoughts on the limitations of level I evidence studies. This is a huge issue in orthopedics as it becomes very difficult to try to “randomize” patients into various treatment arms. Most people take their own bodies and the health of their bodies seriously enough to not want to determine treatment with a “flip of the coin.” I think this is quite different than taking a “red pill” or a “blue pill” in a drug study. Dr. Burkhart emphasizes the role of technical expertise as a variable that is not really adequately considered in level I evidence studies, and I wholeheartedly agree with him.

This issue of The American Journal of Orthopedics is rich in terms of its content, and I hope you enjoy reading these articles as much as I have enjoyed commenting on them.  ◾

The treatment for distal radius fractures has changed significantly over time. Initially, distal radius fractures were treated as relatively innocuous injuries that befell the elderly and the comparatively inactive, and casts were the mainstay of treatment. However, closer scrutiny of the clinical results revealed a myriad of problems with these treatments, including “cast disease,” stiffness, inability to hold skeletal position, and soft-tissue compromise that affected the overall function of the wrist and hand.

Additional techniques to improve results included the “pins and plaster” technique, with the introduction of 2 pins in the radius and metacarpals to retard collapse of the fracture while in the cast. This was in some sense an early version of external fixation, with pins giving support to the unstable wrist and the body of the cast serving as the external support. There was further evolution of the adaptation of early versions of external fixation used for the lower extremity towards the treatment of the distal radius. For example, when I was a resident at Massachusetts General Hospital, we routinely applied femoral distractors as external fixation devices for selected distal radius fractures. This was a time when more specific anatomic devices and implants were not yet available.

External fixation evolved,¹ and distal radius–specific systems, with enhanced ability to adjust and achieve reduction, became available in the late 1980s. At the same time, distal radius fracture plating evolved from simple “stamped metal” plates with screws that merely fit in the screw holes, to more highly engineered implants with screws that engaged the plate at a fixed angle, much like the blade plate
technology used for lower extremity fractures.² Over time, the volar fixed-angle plating system supplanted the other treatments and emerged as a popular treatment method.

Use of Kirschner wires or simple pins has been promoted in the past for treatment of distal radius fractures. In France, Kapandji³ described the use of “intra-focal
pinning.” In this technique, smooth Kirschner wires are introduced in the fracture site itself, and then using leverage so that the pins act like “crowbars,” the distal fragment that is malpositioned becomes adjusted into a more anatomic position.³ Kapandji’s treatment can be very effective in achieving reduction; however, as there is no fixation into the distal fragment, this technique has limitations in maintaining the reduction until healing has occurred. Interfragmentary pinning from the dorsal radial and dorsal ulnar aspects were nicely described by Clancey.⁴ I have found great utility in combining the Kapandji intra-focal techniques to achieve reduction with Clancey pin fixation or distal radius plating to maintain reduction.

I was intrigued with the article by Drs. Siegall and Ziran, “En Bloc Joystick Reduction of a Comminuted Intraarticular Distal Radius Fracture: A Technical Trick,” in this month’s issue of The American Journal of Orthopedics. In their technique, the authors introduced a series of parallel pins or screws below the articular surface from radius to ulna in parallel fashion to provide provisional fixation for the intra-articular components of their complex fracture. Once having done so, they felt more secure in manipulating the distal radius component en bloc; in fact, they used strapping to provide distal traction on the external protruding portion of the pins to help achieve and maintain reduction for their definitive fixation. Drs. Siegall and Ziran describe the use of either Kirschner wires or plating to provide definitive fixation. In the example cited, they performed (via an open method) both the scaffolding and plating without the need of an assistant to hold or maintain the reduction during the osteosynthesis. I can envision adapting the technique they describe to percutaneous treatments for placement of the scaffolding pins, and even the Kapandji/Clancey pins under fluoroscopic guidance or arthroscopeassisted placement.

Despite the popularity and utility of volar fixed-angle plating techniques to treat distal radius fractures, there remain certain situations in which these techniques are faced with challenges. Certainly one of them is the more complex intra-articular fracture with multiple components, or in the very distal fracture patterns in which there is limited bone for the surgeon to use in providing distal screw fixation in the plating systems. Additionally, the nascent malunion presents some challenges as well in terms of performing a “takedown” of the partially healed fracture without destroying the soft, partially healed distal bone that contains the all-important articular component. These are the instances where supplemental techniques such as the one described by Drs. Siegall and Ziran, as well as the
Kapandji and Clancey techniques, have their greatest utility and appeal. Despite one’s wishes and best efforts, some distal radius fractures are not easily reconstructable. In these cases, use of external fixation or temporary arthrodesis
dorsal plating with subsequent plate removal^5,6 can be the best reconstructive option and a great “bailout.” The prepared surgeon should have these supplemental techniques in their armamentarium to be able to adapt to the conditions that present themselves in the operating room and to do the best job they can for the patient.

References
1. Agee JM. External fixation. Technical advances based upon multiplanar
ligamentotaxis. Orthop Clin North Am. 1993;24(2):265-274.
2. Orbay JL, Fernandez DL. Volar fixed-angle plate fixation for unstable
distal radius fractures in the elderly patient. J Hand Surg Am. 2004;29(1):96-102.
3. Kapandji A. Internal fixation by double intrafocal plate. Functional treatment
of non articular fractures of the lower end of the radius (author’s transl) [in French]. Ann Chir. 1976;30(11-12):903-908.
4. Clancey GJ. Percutaneous Kirschner-wire fixation of Colles fractures. A prospective study of thirty cases. J Bone Joint Surg Am. 1984;66(7):1008-1014.
5. Burke EF, Singer RM. Treatment of comminuted distal radius with the use of an internal distraction plate. Tech Hand Up Extrem Surg. 1998;2(4):248-252.
6. Ruch DS, Ginn TA, Yang CC, Smith BP, Rushing J, Hanel DP. Use of a distraction plate for distal radial fractures with metaphyseal and diaphyseal comminution. J Bone Joint Surg Am. 2005;87(5):945-954.

The treatment for distal radius fractures has changed significantly over time. Initially, distal radius fractures were treated as relatively innocuous injuries that befell the elderly and the comparatively inactive, and casts were the mainstay of treatment. However, closer scrutiny of the clinical results revealed a myriad of problems with these treatments, including “cast disease,” stiffness, inability to hold skeletal position, and soft-tissue compromise that affected the overall function of the wrist and hand.

Additional techniques to improve results included the “pins and plaster” technique, with the introduction of 2 pins in the radius and metacarpals to retard collapse of the fracture while in the cast. This was in some sense an early version of external fixation, with pins giving support to the unstable wrist and the body of the cast serving as the external support. There was further evolution of the adaptation of early versions of external fixation used for the lower extremity towards the treatment of the distal radius. For example, when I was a resident at Massachusetts General Hospital, we routinely applied femoral distractors as external fixation devices for selected distal radius fractures. This was a time when more specific anatomic devices and implants were not yet available.

External fixation evolved,¹ and distal radius–specific systems, with enhanced ability to adjust and achieve reduction, became available in the late 1980s. At the same time, distal radius fracture plating evolved from simple “stamped metal” plates with screws that merely fit in the screw holes, to more highly engineered implants with screws that engaged the plate at a fixed angle, much like the blade plate
technology used for lower extremity fractures.² Over time, the volar fixed-angle plating system supplanted the other treatments and emerged as a popular treatment method.

Use of Kirschner wires or simple pins has been promoted in the past for treatment of distal radius fractures. In France, Kapandji³ described the use of “intra-focal
pinning.” In this technique, smooth Kirschner wires are introduced in the fracture site itself, and then using leverage so that the pins act like “crowbars,” the distal fragment that is malpositioned becomes adjusted into a more anatomic position.³ Kapandji’s treatment can be very effective in achieving reduction; however, as there is no fixation into the distal fragment, this technique has limitations in maintaining the reduction until healing has occurred. Interfragmentary pinning from the dorsal radial and dorsal ulnar aspects were nicely described by Clancey.⁴ I have found great utility in combining the Kapandji intra-focal techniques to achieve reduction with Clancey pin fixation or distal radius plating to maintain reduction.

I was intrigued with the article by Drs. Siegall and Ziran, “En Bloc Joystick Reduction of a Comminuted Intraarticular Distal Radius Fracture: A Technical Trick,” in this month’s issue of The American Journal of Orthopedics. In their technique, the authors introduced a series of parallel pins or screws below the articular surface from radius to ulna in parallel fashion to provide provisional fixation for the intra-articular components of their complex fracture. Once having done so, they felt more secure in manipulating the distal radius component en bloc; in fact, they used strapping to provide distal traction on the external protruding portion of the pins to help achieve and maintain reduction for their definitive fixation. Drs. Siegall and Ziran describe the use of either Kirschner wires or plating to provide definitive fixation. In the example cited, they performed (via an open method) both the scaffolding and plating without the need of an assistant to hold or maintain the reduction during the osteosynthesis. I can envision adapting the technique they describe to percutaneous treatments for placement of the scaffolding pins, and even the Kapandji/Clancey pins under fluoroscopic guidance or arthroscopeassisted placement.

Despite the popularity and utility of volar fixed-angle plating techniques to treat distal radius fractures, there remain certain situations in which these techniques are faced with challenges. Certainly one of them is the more complex intra-articular fracture with multiple components, or in the very distal fracture patterns in which there is limited bone for the surgeon to use in providing distal screw fixation in the plating systems. Additionally, the nascent malunion presents some challenges as well in terms of performing a “takedown” of the partially healed fracture without destroying the soft, partially healed distal bone that contains the all-important articular component. These are the instances where supplemental techniques such as the one described by Drs. Siegall and Ziran, as well as the
Kapandji and Clancey techniques, have their greatest utility and appeal. Despite one’s wishes and best efforts, some distal radius fractures are not easily reconstructable. In these cases, use of external fixation or temporary arthrodesis
dorsal plating with subsequent plate removal^5,6 can be the best reconstructive option and a great “bailout.” The prepared surgeon should have these supplemental techniques in their armamentarium to be able to adapt to the conditions that present themselves in the operating room and to do the best job they can for the patient.

References
1. Agee JM. External fixation. Technical advances based upon multiplanar
ligamentotaxis. Orthop Clin North Am. 1993;24(2):265-274.
2. Orbay JL, Fernandez DL. Volar fixed-angle plate fixation for unstable
distal radius fractures in the elderly patient. J Hand Surg Am. 2004;29(1):96-102.
3. Kapandji A. Internal fixation by double intrafocal plate. Functional treatment
of non articular fractures of the lower end of the radius (author’s transl) [in French]. Ann Chir. 1976;30(11-12):903-908.
4. Clancey GJ. Percutaneous Kirschner-wire fixation of Colles fractures. A prospective study of thirty cases. J Bone Joint Surg Am. 1984;66(7):1008-1014.
5. Burke EF, Singer RM. Treatment of comminuted distal radius with the use of an internal distraction plate. Tech Hand Up Extrem Surg. 1998;2(4):248-252.
6. Ruch DS, Ginn TA, Yang CC, Smith BP, Rushing J, Hanel DP. Use of a distraction plate for distal radial fractures with metaphyseal and diaphyseal comminution. J Bone Joint Surg Am. 2005;87(5):945-954.

The treatment for distal radius fractures has changed significantly over time. Initially, distal radius fractures were treated as relatively innocuous injuries that befell the elderly and the comparatively inactive, and casts were the mainstay of treatment. However, closer scrutiny of the clinical results revealed a myriad of problems with these treatments, including “cast disease,” stiffness, inability to hold skeletal position, and soft-tissue compromise that affected the overall function of the wrist and hand.

Additional techniques to improve results included the “pins and plaster” technique, with the introduction of 2 pins in the radius and metacarpals to retard collapse of the fracture while in the cast. This was in some sense an early version of external fixation, with pins giving support to the unstable wrist and the body of the cast serving as the external support. There was further evolution of the adaptation of early versions of external fixation used for the lower extremity towards the treatment of the distal radius. For example, when I was a resident at Massachusetts General Hospital, we routinely applied femoral distractors as external fixation devices for selected distal radius fractures. This was a time when more specific anatomic devices and implants were not yet available.

External fixation evolved,¹ and distal radius–specific systems, with enhanced ability to adjust and achieve reduction, became available in the late 1980s. At the same time, distal radius fracture plating evolved from simple “stamped metal” plates with screws that merely fit in the screw holes, to more highly engineered implants with screws that engaged the plate at a fixed angle, much like the blade plate
technology used for lower extremity fractures.² Over time, the volar fixed-angle plating system supplanted the other treatments and emerged as a popular treatment method.

Use of Kirschner wires or simple pins has been promoted in the past for treatment of distal radius fractures. In France, Kapandji³ described the use of “intra-focal
pinning.” In this technique, smooth Kirschner wires are introduced in the fracture site itself, and then using leverage so that the pins act like “crowbars,” the distal fragment that is malpositioned becomes adjusted into a more anatomic position.³ Kapandji’s treatment can be very effective in achieving reduction; however, as there is no fixation into the distal fragment, this technique has limitations in maintaining the reduction until healing has occurred. Interfragmentary pinning from the dorsal radial and dorsal ulnar aspects were nicely described by Clancey.⁴ I have found great utility in combining the Kapandji intra-focal techniques to achieve reduction with Clancey pin fixation or distal radius plating to maintain reduction.

I was intrigued with the article by Drs. Siegall and Ziran, “En Bloc Joystick Reduction of a Comminuted Intraarticular Distal Radius Fracture: A Technical Trick,” in this month’s issue of The American Journal of Orthopedics. In their technique, the authors introduced a series of parallel pins or screws below the articular surface from radius to ulna in parallel fashion to provide provisional fixation for the intra-articular components of their complex fracture. Once having done so, they felt more secure in manipulating the distal radius component en bloc; in fact, they used strapping to provide distal traction on the external protruding portion of the pins to help achieve and maintain reduction for their definitive fixation. Drs. Siegall and Ziran describe the use of either Kirschner wires or plating to provide definitive fixation. In the example cited, they performed (via an open method) both the scaffolding and plating without the need of an assistant to hold or maintain the reduction during the osteosynthesis. I can envision adapting the technique they describe to percutaneous treatments for placement of the scaffolding pins, and even the Kapandji/Clancey pins under fluoroscopic guidance or arthroscopeassisted placement.

Despite the popularity and utility of volar fixed-angle plating techniques to treat distal radius fractures, there remain certain situations in which these techniques are faced with challenges. Certainly one of them is the more complex intra-articular fracture with multiple components, or in the very distal fracture patterns in which there is limited bone for the surgeon to use in providing distal screw fixation in the plating systems. Additionally, the nascent malunion presents some challenges as well in terms of performing a “takedown” of the partially healed fracture without destroying the soft, partially healed distal bone that contains the all-important articular component. These are the instances where supplemental techniques such as the one described by Drs. Siegall and Ziran, as well as the
Kapandji and Clancey techniques, have their greatest utility and appeal. Despite one’s wishes and best efforts, some distal radius fractures are not easily reconstructable. In these cases, use of external fixation or temporary arthrodesis
dorsal plating with subsequent plate removal^5,6 can be the best reconstructive option and a great “bailout.” The prepared surgeon should have these supplemental techniques in their armamentarium to be able to adapt to the conditions that present themselves in the operating room and to do the best job they can for the patient.

References
1. Agee JM. External fixation. Technical advances based upon multiplanar
ligamentotaxis. Orthop Clin North Am. 1993;24(2):265-274.
2. Orbay JL, Fernandez DL. Volar fixed-angle plate fixation for unstable
distal radius fractures in the elderly patient. J Hand Surg Am. 2004;29(1):96-102.
3. Kapandji A. Internal fixation by double intrafocal plate. Functional treatment
of non articular fractures of the lower end of the radius (author’s transl) [in French]. Ann Chir. 1976;30(11-12):903-908.
4. Clancey GJ. Percutaneous Kirschner-wire fixation of Colles fractures. A prospective study of thirty cases. J Bone Joint Surg Am. 1984;66(7):1008-1014.
5. Burke EF, Singer RM. Treatment of comminuted distal radius with the use of an internal distraction plate. Tech Hand Up Extrem Surg. 1998;2(4):248-252.
6. Ruch DS, Ginn TA, Yang CC, Smith BP, Rushing J, Hanel DP. Use of a distraction plate for distal radial fractures with metaphyseal and diaphyseal comminution. J Bone Joint Surg Am. 2005;87(5):945-954.