Reduction Loss Despite Adequate Volar Locking Plate Fixation in Distal Radius Fractures: Analysis of Characteristics and Follow-up Management

Abstract

Background

The management of distal radius fractures (DRFs) has evolved with the introduction of volar locking plate (VLP) fixation. Nevertheless, despite the low occurrence rates, reduction loss following VLP fixation has been reported in several studies. Our objective was to determine the incidence and features of reduction loss in patients despite the appropriate application of VLP fixation for DRF.

Methods

This retrospective study was conducted between March 2017 and August 2023, during which a single hand surgeon performed VLP procedures for DRFs. This study included 379 patients (382 wrists) including 3 patients who underwent bilateral surgery. We identified patients who experienced reduction loss after VLP fixation (group 1) and patients without stability problems (group 2) and compared the 2 groups.

Results

The mean age of the patients was 63.5 years, with a standard deviation of 13.8. There were 90 male patients (23.6%) and 289 female patients (75.7%). We identified 14 cases of DRFs, in which reduction loss occurred even after VLP fixation during the follow-up period (group 1, 3.7%). The remaining DRFs were assigned to group 2 (n=368, 96.3%). Among the 14 patients, 7 cases of screw breakage were identified as causing the loss of fracture reduction. As the joint surface collapsed and sank down to the distal row locking screw, 4 cases presented with distal locking screws penetrating into the radiocarpal joint. There were no significant differences between the 2 groups in terms of sex, weight, fracture arm direction, and Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) fracture classification. However, patients in group 1 were statistically significantly older than those in group 2 (average age, 77.5 years vs. 62 years). Among 4 patients experiencing distal screw violation of the radiocarpal joints, 3 underwent partial or complete screw removal immediately after fracture consolidation or union.

Conclusions

While rare, reduction loss remains a potential complication following VLP fixation, especially in elderly patients with intra-articular DRFs. However, with diligent monitoring and timely intervention, such as implant removal if necessary, acceptable outcomes can still be attained.

As South Korea has become a super-aged society, the increase in the elderly population is expected to correspondingly result in a higher incidence of distal radius fractures (DRFs), one of the representative osteoporotic fractures. In terms of treating DRFs, there has been a paradigm shift since the introduction of volar locking plate (VLP) fixation in the early 2000s.¹,²⁾ The distal locking system allows for plate placement on the volar aspect, where the fracture interface typically experiences the majority of tensile force. The anatomically designed volar plate, equipped with a locking system, provides robust holding power, particularly benefiting cases involving senile osteoporotic bone, intra-articular fractures, and even those associated with dorsal comminution.³,⁴,⁵⁾ Furthermore, by incorporating a certain angle adjustment function into the distal row, surgeons can precisely position and stabilize specific fracture fragments by securing the distal screw in the desired direction.²,⁶⁾

The stability provided by VLP enables shorter immobilization periods and quicker returns to work, leading to higher rates of operative treatment. Regarding complications, a large-scale multicenter study found very low incidences, establishing VLP fixation in DRFs as a safe and preferred treatment option, which remains the primary modality to date.⁷⁾ Nevertheless, reduction loss or plate fixation failure, albeit infrequent, has been reported in the literature, with osteoporotic bone and severe fractures being more commonly associated with these events.⁸,⁹,¹⁰⁾ Our objective was to determine the incidence and features of reduction loss despite the appropriate application of VLP fixation in patients with DRFs. Additionally, we attempted to report the authors’ management outcomes following the occurrence of this complication.

METHODS

This retrospective study was conducted between March 2017 and August 2023, during which a single hand surgeon (JKL) performed VLP procedures for DRFs. Approval for this study was obtained from the local Institutional Review Board at 2 separate hospitals where the surgeries were conducted by the same surgeon (IRB No. NHIMC 2023-01-005-003). Informed consent requirement was waived by the Board due to the retrospective design of this study. However, informed consent was obtained from the patient for the use of the postoperative photograph.

Data

Three orthopedic surgeons (SK, SWL, and CKL) and 1 orthopedic nurse (YYK) conducted data collection to improve accuracy under the supervision of the first author of this study (CHO). During the study period, a total of 423 operatively treated DRFs were identified. Patients under 18 years old were excluded (n = 5). We focused solely on VLP fixation for DRFs and excluded other treatment modalities: closed pinning or screw fixation alone (n = 6, 1.4%), dorsal plate fixation (n = 6, 1.4%), and combined volar and dorsal plate fixation (n = 5, 1.2%). Since our study specifically targeted reduction loss, patients lost to follow-up before bony union were excluded (n = 19, 4.5%). Ultimately, 379 patients and 382 wrists (including 3 patients who underwent bilateral surgery) were included in this study.

Investigation of Patient Characteristics, Fracture-Related Factors, and Operation-Related Factors

Patient characteristics were investigated, including age, sex, height, weight, and body mass index (BMI). Fracture-related factors included the side of the fractured arm, the presence of an accompanying distal ulnar fracture, and the classification of DRF according to the Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) classification system based on plain x-ray and computed tomography. Operation-related factors included the product company and specific name of the plate used during the procedure.

Postoperative Assessment: Definition of Variables, Associated Problems, and Follow-up Management

We conducted radiologic measurements, including radial height, radial inclination, volar tilting, and ulnar variance at the time of initial x-ray, immediate postoperative assessment, and final follow-up evaluation. Additionally, we investigated the number of distal locking screws fixed and the distal dorsal cortical distance (DDD), measured from the tip of the most distal screw to the dorsal rim of the distal radius.²⁾ If patients underwent bone mineral density (BMD) assessment during the follow-up period, we included this information in our investigation. During the follow-up period, our attention was directed towards identifying reduction loss and any subsequent associated complications. Reduction loss was defined as fracture displacement exceeding 2 mm in height or a 10° change in angulation.¹⁰⁾

Furthermore, we investigated subsequent associated complications, including implant failure, joint violation by distal locking screws, delayed or nonunion, flexor or extensor tendon rupture by an implant, and arthritic changes in the final outcome. Implant failure of the VLP was defined as plate breakage or bending, or screw breakage or loosening.¹⁰⁾ Given the time required for fracture healing, delayed union was identified when the fracture line remained clearly visible without undue separation of the fragments for over 4 months following the operation.¹¹⁾ Nonunion was determined by the cessation of fracture healing, necessitating a revision operation that included bone grafting.¹²⁾ In cases where differences of opinion arose among investigators, the first author (CHO), who was not involved in the surgery, made the final decision.

Group Comparison

We identified patients who experienced reduction loss after VLP fixation, categorizing them as group 1, while patients without stability problems were categorized as group 2. We compared basic characteristics including age, sex, weight, height, and BMI between the 2 groups. Additionally, we compared the fractured arm, AO-OTA fracture classification, and the presence of combined distal ulnar fractures.

Further Treatment for Complications and Final Outcome

In group 1, we conducted further investigations into the treatment administered after reduction loss occurred. As final outcomes, we assessed the final pain levels using a visual analog scale (VAS) and evaluated the range of motion (ROM), including volar flexion and dorsiflexion.

Statistics

Before performing comparisons, each variable underwent a normality test (Shapiro-Wilk test). Continuous variables with a positive normality are presented as the mean and standard deviation (SD), while continuous variables with a negative normality are presented as the mean and interquartile range. Categorical values are expressed as numbers and percentages. Single comparisons of continuous values were conducted using the Wilcoxon rank sum test, while categorical values were compared using Pearson’s chi-square test or Fisher’s exact test. For comparison of radiologic parameters, the Friedman test was employed. A significance level of p < 0.05 was considered statistically significant.

RESULTS

The mean age was 63.5 years, with an SD of 13.8. There were 90 male patients (23.6%) and 289 female patients (75.7%). Fractures occurred in 182 right wrists (47.6%). Distal ulnar fractures were combined in 254 wrists (66.5%). Patients were followed up postoperatively for an average of 242 days. Regarding the inserted plate, the surgeon utilized products from 4 manufacturers. Among them, the distal radius system from Deputy Synthes was most commonly used (328 wrists, 85.9%), followed by Aptus (49 wrists, 12.8%).

Characteristics of Reduction Loss (Group 1)

We identified 14 cases of DRFs in which reduction loss occurred even after VLP fixation during the follow-up period, categorizing them into group 1 (n = 14, 3.7%). The remaining DRFs were assigned to group 2 (n = 368, 96.3%). Reduction loss was identified during outpatient follow-up after discharge from the hospital, with the majority being detected during follow-up plain x-ray around 2 weeks postoperatively (Table 1).

Table 1. Comparison between Groups.

Variable		Group 1 (n = 14)	Group 2 ( n = 368)	p-value
Age (yr)		77.5 (69.0–86.0)	62.0 (56.0–73.0)	0.001*
Sex				0.593
	Female	12 (85.7)	279 (75.8)
	Male	2 (14.3)	89 (24.2)
Weight (Kg)		58.1 (52.0–61.3)	60.0 (53.0–68.0)	0.422
Height (m)		1.52 (1.48–1.62)	1.59 (1.53–1.65)	0.029*
Body mass index (kg/m2)		25.4 (22.4–26.0)	23.8 (21.6–26.0)	0.517
Fracture direction				0.536
	Left	9 (64.29)	192 (52.17)
	Right	5 (35.71)	176 (47.83)
AO/OTA classification				0.060
	A2	0	41 (11.14)
	A3	0	49 (13.32)
	B2	0	9 (2.45)
	B3	0	25 (6.79)
	C1	1 (7.14)	59 (16.03)
	C2	6 (42.86)	113 (30.71)
	C3	7 (50.00)	72 (19.57)
Ulnar fracture combined				0.912
	None	4 (28.57)	124 (33.70)
	Yes	10 (71.43)	244 (66.30)
Total follow-up period (day)		134.5 (85.0–304.0)	227.0 (98.0–339.0)	0.458

Values are presented as median (range) or number (%).

AO/OTA: Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association.

^*Statistically significant, p < 0.05.

In group 1, there were 12 female patients and 2 male patients with an average age of 77.5 years. Regarding fracture classification, all patients had AO/OTA type C fractures (1 C1, 6 C2, and 7 C3). Among the 14 patients, 7 cases of screw breakage were identified as causing the loss of fracture reduction. Initially, none of the cases had distal locking screws violating the radiocarpal joint. However, as the joint surface collapsed and sank down to the distal row locking screw, 4 cases presented with distal locking screws penetrating into the radiocarpal joint. Other associated problems included 1 patient reporting delayed union and another patient presenting with radiolunate joint arthritis on final plain x-ray. There were no cases of nonunion or tendon rupture (flexor or extensor) despite the reduction loss. The average number of distal locking screws was 4.6 (ranging, 4–6), and the average DDD was 4.4 mm.

Initially, after the DRFs, the average radial height, radial inclination, volar tilting, and ulnar variance values were 5.4 mm, 8.3°, –8.9° (dorsal tilting), and 5.0 mm, respectively. Following reduction and VLP fixation, these figures improved to 11.1 mm, 20.4°, 8.8°, and 0 mm, respectively. However, due to reduction loss during the follow-up, the final average figures were measured as 9.3 mm, 16.3°, 0.2°, and 4.2 mm on the final plain x-ray. All radiologic parameters showed significant statistical differences in Friedman comparison depending on the measurement time (p < 0.001). Among the 14 patients, 8 underwent BMD evaluation. The average spine and femur T-scores were –2.4 and –2.6, respectively. Six patients were diagnosed with osteoporosis and 2 with osteopenia.

Group Comparison

There were no significant differences between the 2 groups in terms of sex, weight, fracture arm direction, AO-OTA fracture classification, and the presence of a distal ulnar fracture accompanying the fracture. However, in the comparison of age, the average age of 77.5 years in group 1 was statistically significantly higher than that in group 2, which was 62 years. Additionally, the average height of group 1 was significantly shorter than that of group 2 (Table 2).

Table 2. Characteristics and Associated Complications of Patients with Reduction Loss Despite Volar Locking Plate Fixation in Distal Radius Fracture.

No	Sex	Age (yr)	Weight (cm)	Height (m)	AO/OTA classification	Reduction loss
						Detection time (postoperative days)	Associated problem
							Implant failure	Penetrating joint by screw	Delayed union	Nonunion	Tendon rupture	Arthritis
1	M	59	65.6	1.71	C2	27	1	0	0	0	0	0
2	F	64	78.0	1.52	C3	14	1	0	0	0	0	0
3	M	69	82.0	1.75	C2	10	0	0	0	0	0	0
4	F	76	55.3	1.46	C1	17	0	1	0	0	0	1
5	F	88	60.0	1.52	C3	12	1	1	0	0	0	0
6	F	79	52.0	1.62	C2	15	-	-	-	-	-	-
7	F	76	59.2	1.54	C3	11	1	1	0	0	0	0
8	F	71	61.3	1.52	C2	125	0	0	0	0	0	0
9	F	89	50.0	1.48	C3	9	1	1	0	0	0	0
10	F	80	57.0	1.51	C3	14	0	0	0	0	0	0
11	F	89	60.0	1.52	C3	15	0	0	0	0	0	0
12	F	83	36.0	1.42	C2	33	1	0	0	0	0	0
13	F	86	54.0	1.45	C3	17	0	0	0	0	0	0
14	F	48	52.0	1.64	C2	285	1	0	1	0	0	0
Total	M: 2, F: 12	75.5*	58.7*	1.55*		43.1*	7†	4†	1†	0†	0†	1†

AO/OTA: Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association.

^*Reported as average value. ^†Reported as sum value.

Follow-up Management

Among patients experiencing distal screw violation of the radiocarpal joints, we recommended screw removal once the fracture site had consolidated or achieved union, mostly after a postoperative period of 4 weeks. Two patients underwent only problematic screw removal under local anesthesia at postoperative 30 and 163 days, with no further treatment. One patient requested total implant removal at 45 days after the initial VLP fixation. Another patient refused screw removal due to old age (89 years) and lack of severe symptoms. Upon learning of the reduction loss, 1 patient elected to change hospitals and subsequently underwent implant removal at another hospital after the fracture had healed.

Despite the reduction loss, we recommended observation in the remaining patients with or without immobilization. Eventually, every patient achieved bony union, and the initial treatment was successful. One patient requested implant removal at 223 days after the initial operation despite the lack of related clinical symptoms. We recommended implant removal for another patient at 452 days after the initial operation, as the patient presented with dorsal tilting and plate protrusion (Soong grade 2), raising concerns about flexor tendon rupture.

The average pain score on the VAS at the final follow-up was 0.8 (range, 0–3). Additionally, the average ROM at the final outpatient follow-up was 59° for volar flexion and 65° for dorsiflexion (Table 3). The pre- and postoperative progress and management of several cases in group 1 where reduction was lost are summarized in figures (Figs. 1, 2, 3).

Table 3. Follow-up Management and Final Result of X-Ray and Pain VAS.

No	Follow-up management (time from initial operation, day)	Final x-ray parameter				Final pain VAS	Note
		Radial tilting	Radial height	Volar tilting	Ulnar variance
1	Total implant removal (n = 223)	10.0	18.0	12.0	9.0	0
2	Observation	8.0	15.0	–2	11.0	1
3	Observation	19.9	36.5		5.4	1
4	Partial screw removal (n = 30)	7.0	16.0	5.0	–2	0	Fig. 1
5	Partial screw removal (n = 163)	3.0	3.0	–11	3.5	1
6	Screw removal recommended						Other hospital follow-up
7	Total implant removal (n = 45)	10.7	20.9	–10.6	4.9	1
8	Total implant removal (n = 452)	14.5	24.6	0	8.0	0
9	Screw removal recommended but refused by the patient	6.0	14.0	0	2.5	3
10	Observation	12	23	5	1.5	1
11	Observation	6	13	–4	0.3	1	Fig. 2
12	Observation	6	9	–7	2.4	0
13	Observation	4	6	–6	1.5	2
14	Observation	14	23	10	0.5	0	Fig. 3
Average		9.3	16.3	0.2	4.2	0.8

VAS: visual analog scale.

Fig. 1. Case description (no. 4). A 76-year-old female patient was brought to the emergency room after a fall resulting in trauma to her right wrist. (A, B) Imaging studies, including x-ray and computed tomography scans, revealed a displaced intra-articular fracture. (C) The patient underwent open reduction and volar locking plate fixation. (D-F) Upon outpatient follow-up on the seventeenth day after surgery, anteroposterior and lateral x-ray revealed reduction loss and distal locking screw joint violation. Immobilization with an arm splint was maintained until postoperative day 30, during which consolidation was observed without further displacement of the fracture site. (G, H) Consequently, only the 2 problematic screws were extracted under local anesthesia. (I) Following this intervention, fracture union was achieved, and the patient exhibited good wrist range of motion at the final follow-up.

Fig. 2. Case description (no. 11). An 89-year-old female patient presented to the emergency room with painful swelling in her right wrist following a simple fall on the ground. (A, B) X-ray imaging revealed a displaced comminuted intra-articular fracture. (C, D) Subsequently, open reduction and Synthes juxa-articular plate fixation were performed. (E, F) During outpatient follow-up after discharge, anteroposterior and lateral x-rays taken on the fifteenth day after surgery indicated joint space depression with neutral ulnar variance and dorsal tilt compared to the immediate postoperative x-ray. An additional 2-week period of short arm splinting was applied, after which fracture union was achieved without further displacement, concluding treatment 4 months postoperatively.

Fig. 3. Case description (no. 14). A 48-year-old female patient with a history of renal failure presented to the emergency room with painful swelling in both wrists after falling on a slippery road. (A, B) Imaging revealed displaced fractures in both distal radius bones, with the left side being more severely affected. (C, D) Open reduction and volar locking plate fixation were performed on both wrists. In the left wrist, a dorsal cortical defect remained despite proper reduction and fixation. Several distal screws broke as fracture union was delayed. However, at postoperative 4.5 months, the fractures had united without clinical symptoms (visual analog scale score for pain: 0), despite partial implant failure. (E, F). No further treatment was pursued.

DISCUSSION

The authors observed reduction loss in 3.5% of the DRF patients who underwent VLP fixation. These patients were older than the other patient groups, with an average age of 77.5 years. The reduction loss was mostly confirmed on x-ray approximately 2 weeks after surgery (10 out of 14 cases). Although there was no statistical difference, all cases were classified as type C in the AO/OTA fracture classification, with C3 type being the most common. However, only 4 patients (1%) required a second surgery for partial or complete implant removal immediately after fracture consolidation or union. In 2 of the remaining patients, implant removal was performed after a considerable period of time due to patient requests or concerns about tendon rupture, but treatment was able to be completed with a final VAS score of 0.8 in all patients.

The principles of operative management entail achieving anatomic reduction and stable fixation, which in turn facilitate early ROM, thereby resulting in fewer complications. Since the introduction of VLP fixation for DRFs in the year 2000, this approach has provided advantages such as delivering enhanced stability in fixation and reducing complications compared to alternative surgical methods.³,⁴,⁵,¹³⁾

Several studies have concluded that VLPs can help maintain radiographic parameters postoperatively until fracture union.¹⁴,¹⁵⁾ However, between the race of fracture union and implant failure,¹⁶⁾ despite low occurrence rates, reduction loss following VLP fixation has been reported in several studies, with rates ranging from 0% to 12.1%.⁸,¹⁷,¹⁸,¹⁹,²⁰,²¹⁾ Additionally, catastrophic results due to subsequent complications have also been reported.²⁰⁾ Four factors can be considered as potential causes of reduction loss following VLP fixation.

Firstly, the potential factor could be the defect of the instrument used. The authors employed the Deputy Synthes plate in 328 wrists (85.9%) and the Aptus plate in 49 wrists (12.8%). These commercial products were verified in biomechanical tests and were associated with low complications in clinical studies.²²,²³⁾ The authors believe that the probability of instrument defect was very low.

The second issue to consider is the shortage of surgeons, which can result in problems such as incomplete reduction, inappropriate plate positioning, and improper screw fixation. In our study, the operating surgeon was an experienced hand surgeon, chosen based on their expertise level.¹⁹⁾ Our experience showed an overall reduction loss rate of 3.7%, with 4 wrists (1.0%) requiring secondary surgery, consistent with previous reports. Preoperative radiologic parameters were reduced to a level within the normal range, indicating that adequate reduction was achieved with primary operation.

Regarding plate position, some investigators have recommended placing the plate as distally as possible without crossing the watershed line to position the screws as close as possible to the subchondral bone.²⁴,²⁵⁾ If the plate is placed too proximally, there may be insufficient subchondral support for the distal screw to maintain fracture reduction, especially in osteoporotic bone. This can lead to “lift-off,” where the plate drifts away from the distal end, leading to tendon irritation.⁹⁾ Additionally, Vosbikian et al.²⁾ introduced the concept of DDD, measured from the tip of the most distal screw to the dorsal rim of the distal radius, and recommended keeping it less than 6 mm. In our patients of group 1, the average DDD was 4.4, indicating adequate distal locking screw location with subchondral support. At least 4 distal locking screws were fixed, with an average of 4.6 screws in cases of reduction loss. Previous studies have also reported that the number of distal row screws is not critical, and there is no need for distal double-row screw fixation.²¹,²⁶⁾

The third issue to consider is the patient factor, which encompasses both aspects related to the fracture itself and factors within the patient that may impede fracture union. In group 1, it was observed that the average age of patients was significantly higher than that of the control group, suggesting potentially inferior bone quality. Among the 8 patients in group 1 who underwent BMD testing, 6 were diagnosed with osteoporosis, while the remaining 2 exhibited osteopenia. Coinciding with ours, Earp reported that 8 patients (10.4%) experienced reduction loss with VLP for AO C3 fracture out of 77 total patients.²⁷⁾

In the author’s experience, although the fracture classification did not show a statistically significant difference, all fractures in group 1 were type C AO-OTA, with the most common type being type C3, indicating intra-articular comminution. Although distal locking screws were placed as close as possible to the joint surface, reduction loss occurred in cases within group 1. In some instances, distally supported screws penetrated the radiocarpal joint, necessitating early partial or total distal screw removal. Mignemi et al.⁸⁾ also claimed that the loss of reduction was correlated with initial fracture severity.

The last issue to consider is the impact of external forces on a fixed DRFs. There remains no consensus regarding the optimal immobilization period and the initiation of ROM exercises following VLP fixation in patients undergoing treatment for DRFs. Some studies have supported immediate mobilization after VLP fixation.²⁸⁾ On the other hand, Foo et al.¹⁰⁾ concluded that a longer immobilization period is more beneficial for volar-dorsal metaphyseal comminution. Martinez-Mendez et al.¹⁷⁾ conducted a prospective study of VLP fixation in patients over 60 years old. After 1 week of immobilization, patients began ROM exercises under therapist supervision. However, 12.1% (8/68) experienced reduction loss, indicating that extended immobilization should be considered in patients with osteoporotic bone, even after fixation with a VLP.¹⁷⁾

Initially, the authors permitted gentle ROM exercises by transitioning to a removable brace within a few days after surgery in most early cases. However, after observing instances of reduction loss, we now recommend splinting for up to 4 weeks in cases involving older patients, poor bone quality, or comminuted fractures. Following this revised protocol, we have experienced relatively fewer cases of reduction loss in our later practices compared to the earlier phase. We found that reduction loss was typically identified around 2 weeks after fracture fixation. In patients with advanced age, poor bone quality, or comminuted fractures where there is a risk of reduction loss, the authors recommend more intensive observation for at least 2 weeks after surgery. Additionally, the immobilization period should be extended as necessary.

Anyway, upon confirming reduction loss in group 1, additional immobilization was initiated to prevent further displacement, thereby extending the time required for fracture site consolidation. DRFs typically achieve radiographic union within 6 weeks after surgery, with consolidation occurring earlier.²⁹⁾

After achieving consolidation or union of the fracture site without further displacement, if immediate secondary surgery such as addressing intra-articular screw penetration was necessary, partial or complete removal of metal screws was undertaken. Otherwise, we solely conducted close monitoring while permitting gentle ROM exercises. Following this protocol, the authors encountered 1 case of delayed union but observed no instances of nonunion subsequent to reduction loss. Furthermore, we did not experience secondary flexor or extensor tendon rupture caused by implant-related issues resulting from reduction loss either.

There are several limitations of our study. First, it has a retrospective design. Second, due to the rarity of reduction loss, our small-scale study was unable to adequately address which factors were significantly associated with reduction loss following VLP fixation. Third, although we achieved acceptable clinical results in our patients, the operating surgeon’s approach cannot be universally applied. Nevertheless, we hope that the authors’ experience will be helpful in dealing with situations that may be challenging for a surgeon encountering unfamiliar circumstances. Reduction loss, albeit rare, remains a potential complication following VLP fixation, especially in elderly patients with intra-articular DRFs. However, with diligent monitoring and timely intervention, including implant removal if necessary, acceptable outcomes can still be attained.