Abstract
Background Open reduction and internal fixation of distal radius fractures is one of the most common procedures performed in wrist surgery. The use of volar locking plate has gained increasing interest in the past decade. Epiphyseal fixation can be done either with locking screws or smooth locking pegs, with no evidence supporting the use of one rather than the other.
Purpose The aim of this study is to compare the stability of distal radius fixation by volar locking plate using locking screws or smooth locking pegs.
Methods Adult patients with A2–A3 AO fractures treated with a volar plate with locking screws only or smooth locking pegs only were retrospectively included. Radiographic assessment was performed to evaluate extra-articular parameters in the intraoperative postreduction and fixation period and after bony healing. Forty-seven distal radius fractures were included.
Results Twenty-four fractures had fixation with locking screws and 23 had fixation with smooth locking pegs. For both groups, all radiographic parameters measured showed a statistically significant difference between the intraoperative postreduction and fixation period and the remote postoperative period after union of the fracture ( p < 0.05) attesting a slight loss of reduction. Nevertheless, there were no significant differences between the groups in radiographic extra-articular parameters.
Conclusion This clinical study shows that there is no difference in stability fixation between locking screws or smooth locking pegs in A2–A3 distal radius fractures.
Clinical Relevance The use of smooth locking pegs only for epiphyseal fixation appears to be safe in volar plating of A2–A3 distal radius fractures in adult patients and could be an alternative to locking screws. More clinical data are needed to confirm these results.
Level of Evidence Level III; retrospective comparative study.
Keywords: distal radius fracture, extra-articular, volar locking plate, smooth locking peg, locking screw
Introduction
Distal radius fractures are among the most common of all fractures, with an overall rate incidence of 20 to 32 per 10,000 person-years 1 2 and with an extra-articular AO type A fractures reported as the most common among all age groups. 1 Among surgical treatment options for displaced distal radius fracture, volar fixed-angle plates have become increasingly popular and are considered as a good option to restore and maintain anatomy including dorsally displaced fractures. 3 Screws or pegs that lock into the plate can be used for distal fixation and the use of screws or pegs is usually the surgeon's preference. Smooth pegs are intended for subchondral support and some surgeons find pegs safer in the subchondral position because of the perceived concern of screw thread penetration into the joint. 4 Pegs have a larger core diameter and are likely to resist bending stress better than screws; however, screws may provide better grip on individual bone fragments 5 and allow direct purchase on bone fragment. Smooth locking pegs are easier and quicker to insert but could be more difficult to remove compare with locking screws. 6
Most of biomechanical studies that compare stability between locking screws and smooth locking pegs found that the use of locking screws optimize construct stability, 4 7 8 but a more recent study showed no significant differences in stiffness and failure load. 9 One clinical study has compared the stability fixation between locking screws or smooth locking pegs in intra-articular distal radius fractures and no significant difference was found. 10 To our knowledge, there is no clinical study that compares the stability fixation in extra-articular distal radius fractures.
The aim of this study is to assess the stability of fixation after volar plating of extra-articular distal radius fracture with either locking screws or locking pegs.
Methods
In a retrospective comparative study, we identified, in hospital medical files, patients who underwent volar locking plating fixation for extra-articular distal radius fractures with a volar distal radius (VDR) plate (Acu-Loc 2 proximal Volar Distal Radius plate, Acumed [Hillsboro, Oregon]) during more than 2 years period (January 2017–April 2019). The research was completed in accordance with the Declaration of Helsinki after obtaining the approval of our Institutional Review Board.
Inclusion criteria for this study were (1) patients older than 18 years, (2) types A2 and A3 fracture of the AO/ASIF classification system extra-articular distal radius fracture, (3) no fracture of the distal ulna other than the styloid, and (4) internal fixation with an Acu-Loc 2 proximal VDR plate, either with all locking screws or all smooth locking pegs in the distal portion of the plate.
Exclusion criteria for this study were (1) A1 fracture (radial styloid avulsion fracture) and intra-articular distal radius fractures types B and C fracture of the AO/ASIF classification system, (2) internal fixation with a combination of locking screws and smooth locking pegs, (3) use of a Acu-Loc 2 proximal VDR plate combined with an extension plate, and (4) use of an Acu-Loc 2 standard VDR plate.
There was no randomization to the use of pegs or screws. All procedures were performed by specialists experienced hand surgeons. The use of smooth locking pegs was in the preference of one of the senior hand surgeons (Y.R.). The use of locking screws was in accordance with the three other senior hand surgeons' preference (T.P., F.A., and D.T.).
Surgical Technique
The distal radius was exposed through a modified Henry's approach, and the pronator quadratus muscle was release to expose the fracture site. The fracture was reduced and the proximal VDR plate was placed, and locking pegs or locking screws were placed to fix the subchondral bone. No additional bone grafting or bone substitute was used. No splint was applied, and immediate active and active-assisted motions were allowed after surgery in all patients. Passive motion was allowed 6 weeks after surgery.
Assessment
Radiographic parameters including volar tilt, radial inclination, radial height, and ulnar variance were measured according to Kreder et al. 11
Other radiographic measurements recorded were the average distance between the locking screws/locking pegs and the fracture line, and the average distance between the locking screws/locking pegs and the subchondral bone. The average length of the locking screws/locking pegs was classified into four categories: bicortical (screws/pegs penetrating the dorsal cortex); full length (average length ≥95%); ≥75% (average length between 75 and 95%), and ≥ 50%(average length between 50 and 75%). The presence of intra-articular locking screws/locking pegs and the presence of loosening around locking screws/locking pegs were also assessed at the last follow-up. All initial radiographic measurements were performed on intraoperative fluoroscopy after reduction and definitive fixation with volar locking plating. All final radiographic measurements were performed on standard wrist radiographs.
Statistical Analysis
Descriptive statistics in terms of mean, standard deviation, median percentiles, and ranges were calculated for all the parameters recorded in the study. Normal distribution of the continues parameter were tested by Kolmogorov–Simonov's test. As a result of this test, differences between the groups (smooth locking pegs vs. locking screws) were calculated by t -test or Mann–Whitney's U test. Differences between the groups according to categorical parameter were tested by Fisher's exact test.
Repeated measure analysis was used to test the changes between remote postoperative versus per operative radiographic measurements according to groups (smooth locking pegs vs. locking screws) for each of the four parameters: volar tilt, radial inclination, radial height, and ulnar variance. A p < 0.05 was consider as significant. IBM SPSS Statistics for Windows, Version 27.0 was used for all statistical analysis.
Results
Over more than 2 years period (27 months), 47 fractures in 45 patients fulfilled the inclusion criteria. Twenty-four fractures were fixed with locking pegs (group A) and 23 were fixed with locking screws (group B). In group A, there were 10 (42%) A2 fractures and 14 (58%) A3 fractures according to AO/ASIF classification. In group B, there were 11 (48%) A2 fractures and 12 (52%) A3 fractures. The mean follow-up period between the index surgery and follow-up X-ray was 8.76 months (range: 3–41.8 months). Bony union was achieved in all patients at the last follow-up. There were no differences in demographic variables between the two groups ( Table 1 ).
Table 1. Preoperative demographic variables.
| Variables | All cases (group A+ group B) | Group A (peg) | Group B (screw) | p -Value |
|---|---|---|---|---|
| Number of patients | 45 | 24 | 21 | |
| Number of fractures | 47 | 24 | 23 | |
| Mean age (y), mean (SD) | 54.5 (16.6) | 56.9 (17.8) | 51.7 (15.2) | p = 0.30 |
| Age ≤65 y (%) | 32 (71) | 15 (62.5) | 17 (81) | p = 0.20 |
| Age ≥65 y (%) | 13 (29) | 9 (37.5) | 4 (19) | |
| Gender (%) | ||||
| Female | 34 (76) | 18 (75) | 16 (76) | p = 1.00 |
| Male | 11 (24) | 6 (25) | 5 (24) | |
| Affected wrist (%) | ||||
| Right | 21 (45) | 9 (37.5) | 12 (52) | p = 0.38 |
| Left | 26 (55) | 15 (62.5) | 11 (48) | |
| Bilateral fractures (%) | ||||
| Bilateral | 2 (4) | 0 | 2 (9.5) | p = 0.21 |
| Unilateral | 43 (96) | 24 (100) | 19 (90.5) | |
| AO classification simplified (%) | ||||
| A2 | 21 (45) | 10 (42) | 11 (48) | p = 0.77 |
| A3 | 26 (55) | 14 (58) | 12 (52) | |
| AO classification (%) | ||||
| A2 | ||||
| A2.2 | 20 (43) | 10 (42) | 10 (43.5) | |
| A2.3 | 1 (2) | 0 | 1 (4) | |
| A3 | ||||
| A3.1 | 3 (6) | 0 | 3 (13) | |
| A3.2 | 16 (34) | 9 (37.5) | 7 (30) | |
| A3.3 | 7 (15) | 5 (21) | 2 (9) | |
| Mean days between fracture and surgery, median (IQR: 25–75%) | 7 (3–15.8) | 7.5 (4–15.8) | 7 (3–15) | p = 0.74 |
| Median follow-up (mo) (IQR: 25–75%) | 5.3 (3.4–11.7) | 5.7 (4.0–11.7) | 5.3 (3.4–9.5) | p = 0.28 |
| Mean follow-up (range) | 8.76 (3–41.8) | 10.9 (3–41.8) | 6.54 (3–18.9) | |
Abbreviations: IQR, interquartile range; SD, standard deviation.
The average distance between locking pegs/locking screws and fracture line was 5.68 ± 2.31 mm in group A and 6.17 ± 2.82 mm in group B. The average distance between locking pegs/locking screws and subchondral bone was 3.82 ± 1.1 mm in group A and 3.64 ± 1.50 mm in group B. There was no significant difference for these two parameters. Regarding the average length of locking pegs/locking screws, there was a significant difference between the two groups ( p < 0.05) with more fractures fixed with a full-length peg in group A (20 fractures [83%]) compare with group B (7 fractures [30%]), and more fractures fixed with a ≥75% length screws in group B (16 fractures [70%]) compare with group A (4 fractures [17%]) ( Table 2 ).
Table 2. Pegs and screws intraoperative characteristics between the groups.
| All cases (group A + group B) | Group A (peg) | Group B (screw) | p -Value | |
|---|---|---|---|---|
| Distance pegs/screws fracture line (mm), mean (SD) | 5.92 (2.6) | 5.68 (2.31) | 6.17 (2.82) | p = 0.52 |
| Distance pegs/screws subchondral bone (mm), mean (SD) | 3.73 (1.30) | 3.82 (1.1) | 3.64 (1.50) | p = 0.65 |
| Length of pegs/screws | ||||
| Full length (%) | 27 (57) | 20 (83) | 7 (30) | p < 0.0001 |
| ≥75% length (%) | 20 (43) | 4 (17) | 16 (70) | |
Abbreviation: SD, standard deviation.
No intra-articular pegs or screws were noted, and no loosening around pegs or screws were noted at the last follow-up. There was no revision surgery.
Regarding radiographic parameters, intraoperative postreduction and fixation volar tilt averaged 5.79 ± 5.10 degrees in group A and 6.48 ± 3.6 degrees in group B. Radial inclination averaged 22.5 ± 3.0 degrees in group A and 23.7 ± 3.3 degrees in group B. Radial height averaged 10.6 ± 2.2 mm in group A and 11.64 ± 1.8 mm in group B. Ulnar variance averaged −0.23 ± 1.47 mm in group A and −0.81 ± 1.08 mm in group B. For both groups, all radiographic parameters measured showed a statistically significant displacement between the intraoperative postreduction and fixation period and the postoperative period after union of the fracture ( p < 0.05). However, there were no significant differences between the two groups between delta values of all radiographic parameters ( Table 3 ). There was no influence on the delta values of all radiographic parameters in the two groups, whether the length of the locking pegs/locking screws used for epiphyseal fixation was full length or ≥75% length. In addition, demographic parameters such as age, gender, and AO fracture group did not have any influence on the delta values of all radiographic parameters in the two groups. Overall, no statistically significant difference was found between the two groups.
Table 3. Intraoperative postreduction and fixation (intraoperative) and remote postoperative radiographic parameters between the groups.
| Variables | All cases (group A + group B) | Group A (peg) | Group B (screw) | p -Value | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Intraoperative period Mean (SD) |
Remote postoperative period Mean (SD) |
Differences between periods a b | Intraoperative period mean (SD) | Remote postoperative period mean (SD) | Differences between periods a b | Intraoperative period mean (SD) | Remote postoperative period mean (SD) | Differences between periods a b | ||
| Volar tilt (deg) | 6.13 (4.42) | 5.17 (4.50) | −0.95 ([−1.57]–[−0.35]) |
5.79 (5.10) | 4.35 (5.08) | −1.44 ([−2.62]–[−0.26]) |
6.48 (3.6) | 6.04 (3.73) | −0.45 ([−0.71]–[−0.18]) |
P
1
= 0.019
P 2 = 0.002 P 3 = 0.52 |
| Radial inclination (deg) | 23.06 (3.22) | 22.38 (3.3) | −0.67 ([−0.91]–[−0.44]) |
22.5 (3.0) | 21.7 (2.9) | −0.73 ([−1.13]–[−0.32]) |
23.7 (3.3) | 23.06 (3.6) | −0.62 ([−0.89]–[−0.35]) |
P
1
= 0.001
P 2 < 0.001 P 3 = 0.86 |
| Radial height (mm) | 11.13 (2.06) | 10.43 (2.04) | −0.70 ([−0.97]–[−0.43]) |
10.6 (2.2) | 9.93 (1.9) | −0.71 ([−1.15]–[−0.27]) |
11.64 (1.8) | 10.96 (2.11) | −0.68 ([−1.02]–[−0.35]) |
P
1
= 0.003
P 2 < 0.001 P 3 = 0.95 |
| Ulnar variance (mm) | −0.51 (1.31) | 0.04 (1.37) | 0.55 (0.34–0.75) |
−0.23 (1.47) | 0.28 (1.5) | 0.51 (0.24–0.78) |
−0.81 (1.08) | −0.21 (1.22) | 0.60 (0.32–0.88) |
P
1
< 0.001
P 2 < 0.001 P 3 = 0.20 |
Abbreviation: SD, standard deviation.
Differences between periods = remote postoperative period − intraoperative period.
Differences between periods are in median (interquartile range: 25–75%).
Notes: P 1 = difference between remote postoperative period versus intraoperative period in group A (peg). P 2 = difference between remote postoperative period versus intraoperative period in group B (screw). P 3 = difference between delta value between group A (peg) versus group B (screw).
Discussion
Among distal radius volar plates available, most of the manufacturers offer locking screws and smooth locking pegs for distal fixation. Secondary displacement with loosening of the distal screws and intra-articular screw penetration has been observed specifically in osteopenic bone. There has been some clinical studies which support the use of smooth locking pegs for subchondral fixation with potential less concern of screw thread penetration into the radiocarpal joint. 12 13 Nevertheless, there are few clinical comparative studies. One clinical study compared screw and peg fixation for intra-articular distal radius fracture and found no difference. 10 In our clinical study, we evaluated stability of fixation after volar plating of extra-articular distal radius fracture (AO A2–A3) with either locking screws only or smooth locking pegs only and like Boretto et al, we found no difference between the two groups.
Few biomechanical studies comparing the properties of pegs and screws using an A3 extra-articular distal radius fracture model typically support screw fixation over pegs. However, different results are observed depending on axial or torsional compression protocols. Weninger et al reported no difference concerning axial stiffness in a saw bone model between threaded screws and smooth pegs distal fixation; nevertheless, threaded locking screws were mechanically superior to smooth locking pegs alone under torsional loading. 8 In a cadaveric model, Mehling et al found a statistically significant difference between pegs and screws with regard to the stiffness of torsion after 1,000 cycles of axial and torsional loading in favor of screw fixation in both cases. 7 Yao et al in a cadaveric model found no difference in stiffness and failure load between the two constructs in axial load, but torsional loading was not evaluated. 9
Regarding intra-articular distal radius fracture, Boretto et al found no difference in a retrospective clinical study including adult patients with AO C2–C3 fractures treated with a volar plate with locking smooth pegs or locking screws. 10 In a synthetic anatomic radius models of an AO C3 intra-articular distal radius fractures, Martineau et al compared different combination of peg and screw and not a construct with peg only or screw only. The authors found that the use of locking screws as opposed to smooth locking pegs, particularly subchondral and in the ulnar side of the lunate fragment, optimizes construct stability. 4 However, they note that it is likely that all volar locking constructs used for distal radius fracture treatment tested in their study would withstand light active motion that is on average 250 N.
In the present study, we observed a modest loss of reduction after fixation for both groups for all radiographic parameters (volar tilt, radial inclination, radial height, and ulnar variance). There was no difference between delta values in the two groups. These findings are similar with the study of Boretto et al which also found slight loss reduction including intra-articular radiographic parameters and found no difference between the peg and screw groups. 10 This is in accordance with other clinical studies that also observed a loss of reduction after volar locking plate and screw fixation in A2/A3 distal radius fracture with an average loss of radial height of 1.3 mm 14 and in C2/C3 AO distal radius fractures with statistically significant average loss of volar tilt (1.9 degrees) and radial inclination (1.4 degrees). 15
In our study, more fractures were fixed with a full-length device in the peg group. However, no significant differences were observed between delta values of all radiographic parameters within the two groups regarding the length of locking pegs/locking screws (full length or ≥75% length). These results are in accordance with recent biomechanical studies that evaluated construct stability regarding the screws/peg length for distal fixation. Baumbach et al found that 75% distal screw length provides similar primary stability to 100% unicortical screw. 16 Wall et al determined each construct's stiffness in five groups based on distal locking fixation: bicortical locked screws, three lengths of unicortical locked screws (full length, 75% length, and 50% length to dorsal cortex), and unicortical locked pegs. They found no significant difference in any of the groups when comparing volar, and dorsal bending and axial compression during cyclic loading length. However, force needed to displace fracture fragments by 2 mm was significantly less for 50% unicortical screws in comparison to the other groups, and forces for catastrophic failure (defined as complete closure of 1 cm of the osteotomy site) were also lower in both 50% unicortical screws and pegs than in other groups. 17
We did not find any difference between the peg group and the screw group regarding the average distance between locking screws/locking pegs and the fracture line and the average distance between locking screws/locking pegs and subchondral bone. The later was inferior to 4 mm in both groups. This plate positioning was in accordance with the recommendation of Drobetz et al. 18 In a biomechanical study, the authors evaluated construct stability regarding plate positioning. In an AO A3 fracture model in seven pairs of fresh frozen human cadaver radiuses, seven plates were applied subchondrally and seven plates were applied 4.5 to 7.5 mm proximal to the subchondral zone. After loading, radial shortening was significantly greater when the distal screws were placed proximal to the subchondral zone, and rigidity of the plate systems was significantly higher in the subchondral plate-screw-bone constructs.
There are several limitations in the current study. This is a retrospective and nonrandomized study. The fixation by smooth locking peg was according to surgeon's preference and was used by the same surgeon. This can explain the largest number of full-length screws/pegs in the peg group (83%) comparing with the locking screw group (30%). Nevertheless, there was no influence on the delta values of all radiographic parameters if the average length of locking pegs/locking screws used epiphyseal fixation was full length or ≥75% length in the two groups. Another limitation is the collection of radiographic data by three researchers with a potential interobserver variability.
The advantages of the study are the relative homogeneity of the groups regarding demographic, number of patients, type of fracture, and screws/pegs positioning.
Conclusion
Unlike the results of most of biomechanical studies comparing stability fixation between screws and pegs, we found no difference between screws and pegs fixation in volar locking plating of AO A2/A2 extra-articular distal radius fractures while positioning the screws/pegs in the subchondral zone. This is in accordance with conclusions of a previous clinical study in AO C2/C3 intra-articular distal radius fracture. 10 The use of smooth locking pegs only for epiphyseal fixation appears to be safe in volar plating of A2–A3 distal radius fractures in adult patients and could be an alternative to locking screws. More clinical data are needed to confirm these results.
Acknowledgment
The authors would like to thanks Ronit Leiba, biostatistician (MA), for statistical analysis.
Funding Statement
Funding None declared.
Conflict of Interest None declared.
Ethical Approval
Ethical approval was obtained from Institutional Review Board: IRB 0353-20-TLV.
References
- 1.Bentohami A, Bosma J, Akkersdijk G JM, van Dijkman B, Goslings J C, Schep N WL. Incidence and characteristics of distal radial fractures in an urban population in The Netherlands. Eur J Trauma Emerg Surg. 2014;40(03):357–361. doi: 10.1007/s00068-014-0394-7. [DOI] [PubMed] [Google Scholar]
- 2.Mellstrand-Navarro C, Pettersson H J, Tornqvist H, Ponzer S. The operative treatment of fractures of the distal radius is increasing: results from a nationwide Swedish study. Bone Joint J. 2014;96-B(07):963–969. doi: 10.1302/0301-620X.96B7.33149. [DOI] [PubMed] [Google Scholar]
- 3.Stevenson I, Carnegie C A, Christie E M, Kumar K, Johnstone A J. Displaced distal radial fractures treated using volar locking plates: maintenance of normal anatomy. J Trauma. 2009;67(03):612–616. doi: 10.1097/TA.0b013e3181ad8d4d. [DOI] [PubMed] [Google Scholar]
- 4.Martineau P A, Waitayawinyu T, Malone K J, Hanel D P, Trumble T E. Volar plating of AO C3 distal radius fractures: biomechanical evaluation of locking screw and locking smooth peg configurations. J Hand Surg Am. 2008;33(06):827–834. doi: 10.1016/j.jhsa.2008.01.006. [DOI] [PubMed] [Google Scholar]
- 5.Downing N D, Karantana A. A revolution in the management of fractures of the distal radius? J Bone Joint Surg Br. 2008;90(10):1271–1275. doi: 10.1302/0301-620X.90B10.21293. [DOI] [PubMed] [Google Scholar]
- 6.Gyuricza C, Carlson M G, Weiland A J, Wolfe S W, Hotchkiss R N, Daluiski A. Removal of locked volar plates after distal radius fractures. J Hand Surg Am. 2011;36(06):982–985. doi: 10.1016/j.jhsa.2011.03.032. [DOI] [PubMed] [Google Scholar]
- 7.Mehling I, Klitscher D, Mehling A P et al. Volar fixed-angle plating of distal radius fractures: screws versus pegs–a biomechanical study in a cadaveric model. J Orthop Trauma. 2012;26(07):395–401. doi: 10.1097/BOT.0b013e318225ea46. [DOI] [PubMed] [Google Scholar]
- 8.Weninger P, Dall'Ara E, Leixnering M et al. Volar fixed-angle plating of extra-articular distal radius fractures–a biomechanical analysis comparing threaded screws and smooth pegs. J Trauma. 2010;69(05):E46–E55. doi: 10.1097/TA.0b013e3181c6630e. [DOI] [PubMed] [Google Scholar]
- 9.Yao J, Park M J, Patel C S. Biomechanical comparison of volar locked plate constructs using smooth and threaded locking pegs. Orthopedics. 2014;37(02):e169–e173. doi: 10.3928/01477447-20140124-21. [DOI] [PubMed] [Google Scholar]
- 10.Boretto J G, Pacher N, Giunta D, Gallucci G L, Alfie V, De Carli P. Comparative clinical study of locking screws versus smooth locking pegs in volar plating of distal radius fractures. J Hand Surg Eur Vol. 2014;39(07):755–760. doi: 10.1177/1753193413517806. [DOI] [PubMed] [Google Scholar]
- 11.Kreder H J, Hanel D P, McKee M, Jupiter J, McGillivary G, Swiontkowski M F. X-ray film measurements for healed distal radius fractures. J Hand Surg Am. 1996;21(01):31–39. doi: 10.1016/S0363-5023(96)80151-1. [DOI] [PubMed] [Google Scholar]
- 12.Orbay J L, Fernandez D L. Volar fixed-angle plate fixation for unstable distal radius fractures in the elderly patient. J Hand Surg Am. 2004;29(01):96–102. doi: 10.1016/j.jhsa.2003.09.015. [DOI] [PubMed] [Google Scholar]
- 13.Orbay J L, Fernandez D L. Volar fixation for dorsally displaced fractures of the distal radius: a preliminary report. J Hand Surg Am. 2002;27(02):205–215. doi: 10.1053/jhsu.2002.32081. [DOI] [PubMed] [Google Scholar]
- 14.Cheng M F, Chiang C C, Lin C C, Chang M C, Wang C S. Loss of radial height in extra-articular distal radial fracture following volar locking plate fixation. Orthop Traumatol Surg Res. 2021;107(05):102842. doi: 10.1016/j.otsr.2021.102842. [DOI] [PubMed] [Google Scholar]
- 15.Gruber G, Gruber K, Giessauf C et al. Volar plate fixation of AO type C2 and C3 distal radius fractures, a single-center study of 55 patients. J Orthop Trauma. 2008;22(07):467–472. doi: 10.1097/BOT.0b013e318180db09. [DOI] [PubMed] [Google Scholar]
- 16.Baumbach S F, Synek A, Traxler H, Mutschler W, Pahr D, Chevalier Y. The influence of distal screw length on the primary stability of volar plate osteosynthesis–a biomechanical study. J Orthop Surg Res. 2015;10:139. doi: 10.1186/s13018-015-0283-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Wall L B, Brodt M D, Silva M J, Boyer M I, Calfee R P. The effects of screw length on stability of simulated osteoporotic distal radius fractures fixed with volar locking plates. J Hand Surg Am. 2012;37(03):446–453. doi: 10.1016/j.jhsa.2011.12.013. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Drobetz H, Bryant A L, Pokorny T, Spitaler R, Leixnering M, Jupiter J B. Volar fixed-angle plating of distal radius extension fractures: influence of plate position on secondary loss of reduction–a biomechanic study in a cadaveric model. J Hand Surg Am. 2006;31(04):615–622. doi: 10.1016/j.jhsa.2006.01.011. [DOI] [PubMed] [Google Scholar]