immobilization and followed as an observation group. Chung and colleges 148 concluded that improved radiological parameters did not correlate with improved function.
However, Hooper and colleagues149 found that active elderly patients had better functional scores after operation with a volar locking plate compared to less active patients. This indicates that pre-injury function might be a better indicator for the clinical result than radiological alignment. The active elderly seems to benefit from good alignment, while the less active patients experience almost the same clinical result regardless of alignment.
Further, the threshold between active and less active can be discussed, but the patient´s needs and function are obviously important in the treatment decision process. The Swedish guidelines on treatment of distal radius fractures from 2021 also focus on the patients´
activity level. Treatment recommendations are provided for patients with high, moderate, and low functional requirements, and radiological thresholds for treatment are provided for each group. Adolfsson et al recently published a new scale that assess activity level, the Adolfsson-Björnsson Activity Scale (ABAS). The main purpose was to present a scale to determine the patients´ subjective activity level for patients with upper limb disorders. They believe this can be used to assess the patients´ preinjury function and as a tool in RCTs to ensure comparable groups.150 The importance of preinjury activity level and the relative effect on outcome after different treatment regimens is still, however, largely unknown.
The increased use of VLPs has not been driven by research. Open reduction and internal fixation of fractures is the mainstay of orthopedic treatment. Many surgeons were already used to the volar approach to the distal radius, and volar angulated fractures had been treated with a volar plate before the locking screws were introduced. The volar locking plates offered a possibility for early active motion compared to the previously most used options, CRPP and EF. In addition, the risk of loss of reduction and secondary displacement was decreased. With the volar locking plate, most distal radius fractures could be fixed with the same technique.
DRFs in the elderly population have less stability due to osteoporosis and the risk of displacement is therefore higher. VLP fixation in elderly patients has offered stability until healing. However, to a certain extent, this solved a non-existing problem or at least a minor problem as malunion is better tolerated in elderly than in a younger age group. Further, the VLP offered a method of fixation with less need of controls after surgery. Also, compared to repeated controls to evaluate the degree of redisplacement after a closed reduction, early fixation with a reliable method might seem attempting. The shift towards more invasive methods has in many ways made the treatment of distal radius fractures more streamlined for the surgeon.
There are also other factors that have been important in this treatment shift. The
orthopaedic implant industry has developed and promoted the use of VLP since the start of the century and has definitively contributed to the treatment change. Also, in some
countries, there might be an economic incentive for the surgeon to choose VLP instead of CRPP or EF. 152
I believe that the change of treatment mainly should be attributed to surgeons’ preferences and beliefs. It seems logical to reduce a fracture as accurately as possible and make it heal in that position. However, significant changes in treatment should be backed by research. We now have a lot of research and experience on the use of VLP, also in elderly people. We know that most elderly recover well with non-operative treatment, but we do not know when a VLP makes an advantage compared to simpler and cheaper options. Health care costs should be a part of the treatment-recommendation-equation as the funding is not
unlimited. The classic Latin phrase, “primum, non nocere” or “first, do no harm” must still be remembered. Surgical treatment should provide better result than none-operative
treatment to be justified and the evidence of improved results should be available before changing treatment routines.
13 Conclusions
• Primary closed reduction of displaced fractures in patients ³ 65 years improved average radiological position, also after the immobilization period, and is recommended.
• Non-operative treatment was non-inferior to operation with a volar plate and should be considered as the main treatment option also in independently living patients above 65 years.
• Non-operative treatment was less expensive than surgery with a volar plate the first year after injury
• Despite higher QALY in the operative group during first year after injury, non-operative treatment was considered cost effective
• In a group of working elderly, operation might be cost effective
• Some patients might benefit from early operation, especially those with a special need of a fast recovery
• As Colles claimed, we found almost normal range of motion after non-operative treatment of displaced fractures. However, Colles also believed that as long the fracture was treated properly, “the limb will at some remote period again enjoy perfect freedom in all its motions, and be completely exempt from pain; the
deformity, however, will remain undiminished “. Unfortunately, no known treatment provides perfect function in all patients.
14 Suggestions for further research
The small differences in many outcome scores might indicate that the real difference in outcome is neglectable but might also indicate a shortcoming of the scores. To improve the treatment for distal radius fractures, I think we need to investigate the patients with the less favorable results to try to understand why they experience inferior result. Also, not enough is known about the patients’ experience. Their priorities, the need to be involved in the treatment, the need for information and their emphasis on treatment results should be further investigated.
We still do not know why malalignment is better tolerated in elderly. One reason might be that the deformity in osteoporotic bone develop differently compared to non-osteoporotic bone, usually in younger patients. The deformity might be analyzed not only by angulation of the distal fragment and radial shortening, but for rotation and ad latus, for example with 3D CT compared to a mirror CT of the opposite side. A comparison to younger patients’
deformity could be performed.
Further, most elderly patients treated non-operatively do not suffer from marked pain 1-2 weeks after injury. However, a subgroup of patients with more than usual pain should probably be followed closely to investigate if this predisposes for later inferior results. There might be several reasons for early pain. Some of these patients probably have a too tight cast, and a change of cast might resolve the problem. Further, an evolving CTS or CRPS might be a reason for early pain and should be looked for. Continuous pain after 1-2 weeks might in some cases indicate that the patient tolerate displacement poorly, and it would be interesting to investigate early operative fixation and early mobilization in this group.
We know that the activity level among the patients over 65 years vary extensively. Low activity level and low demands might explain why some patients are satisfied despite gross displacement, whereas active and healthy elderly might not tolerate a non-anatomic position worse. 149 Therefore, a registration of activity level before and after injury compared to functional outcome scores might give new information on the correlation between activity and outcome, and this should be reviewed more thoroughly.
Further, the finding of difference in QALY between the operative and non-operative group has not been reported by others, therefore it would be interesting to see if the finding is reproducible and if the difference continue after 12 months follow-up. A continued difference would probably change the conclusion in the cost-benefit analysis.
15 References
1. A C. On the fracture of the carpal extremity of the radius. Edinburg Medical and Surgical Journal. 1814;3(1):368-371.
2. Porter R. Hospitals and surgery. In: Porter R. The Cambridge History of Medicine.
Cambridge University Press; 2006.
3. Fernandez DL, Jupiter JB. Fractures of the Distal Radius. Springer Science &
Business Media; 2012.
4. Diaz-Garcia RJ, Chung KC. The Evolution of Distal Radius Fracture Management: A Historical Treatise. Hand Clinics. 2012;28(2):105-111.
doi:10.1016/j.hcl.2012.02.007.
5. Snow SJ. Surgery and Anaesthesia: Revolutions in Practice. In: Schlich T. The Palgrave Handbook of the History of Surgery. Palgrave Macmillan; Springer. 2017.
6. Worboys M. The History of Surgical Wound Infection: Revolution or Evolution? In:
Schlich T. The Palgrave Handbook of the History of Surgery. Palgrave Macmillan;
Springer. 2017.
7. Bartoníček J. Early history of operative treatment of fractures. Archives of
Orthopaedic and Trauma Surgery. 2010;130(11):1385-1396. doi:10.1007/s00402-010-1082-7.
8. GBD 2019 Fracture Collaborators. Global, regional, and national burden of bone fractures in 204 countries and territories, 1990-2019: a systematic analysis from the Global Burden of Disease Study 2019. Lancet Healthy Longev. 2021;2(9):e580-e592. doi:10.1016/S2666-7568(21)00172-0.
9. Court-Brown CM, Caesar B. Epidemiology of adult fractures: A review. Injury.
2006;37(8):691-697. doi:10.1016/j.injury.2006.04.130.
10. Johnell O, Kanis J. Epidemiology of osteoporotic fractures. Osteoporos Int. 2005;16
11. Bartl R, Bartl C. The Osteoporosis Manual. Prevention Diagnosis and Management.
Springer; 2019. doi:10.1007/978-3-030-00731-7.
12. Wilcke MKT, Hammarberg H, Adolphson PY. Epidemiology and changed surgical treatment methods for fractures of the distal radius: a registry analysis of 42,583 patients in Stockholm County, Sweden, 2004–2010. Acta Orthopaedica.
2013;84(3):292-296. doi:10.3109/17453674.2013.792035.
13. Lofthus CM, Frihagen F, Meyer HE, Nordsletten L, Melhuus K, Falch JA.
Epidemiology of distal forearm fractures in Oslo, Norway. Osteoporos Int.
2007;19(6):781-786. doi:10.1007/s00198-007-0499-5.
14. Støen RO, Nordsletten L, Meyer HE, Frihagen JF, Falch JA, Lofthus CM. Hip fracture incidence is decreasing in the high incidence area of Oslo, Norway. Osteoporos Int.
2012;23(10):2527-2534. doi:10.1007/s00198-011-1888-3.
15. Solvang HW, Nordheggen RA, Clementsen S, Hammer O-L, Randsborg P-H.
Epidemiology of distal radius fracture in Akershus, Norway, in 2010-2011. J Orthop Surg Res. 2018;13(1):199–7. doi:10.1186/s13018-018-0904-0.
16. Rundgren J, Bojan A, Mellstrand Navarro C, Enocson A. Epidemiology, classification, treatment and mortality of distal radius fractures in adults: an observational study of 23,394 fractures from the national Swedish fracture register. BMC Musculoskelet Disord. 2020;21(1):88-89. doi:10.1186/s12891-020-3097-8.
17. Bregni M, Cahueque M, Cobar A. Historical Perspective of Distal Radius Fracture Classifications in the Twentieth Century. J Clin Exp Orthop. 2016;02(03):1-6.
doi:10.4172/2471-8416.100026.
18. Kleinlugtenbelt YV, Groen SR, Ham SJ, et al. Classification systems for distal radius fractures. Acta Orthopaedica. 2017;88(6):681-687.
doi:10.1080/17453674.2017.1338066.
19. Luokkala T, Laitinen MK, Hevonkorpi TP, Raittio L, Mattila VM, Launonen AP. Distal radius fractures in the elderly population. EFORT Open Reviews. 2020;5(6):361-370. doi:10.1302/2058-5241.5.190060.
20. Mulders MAM, Rikli D, Goslings JC, Schep NWL. Classification and treatment of distal radius fractures: a survey among orthopaedic trauma surgeons and
residents. Eur J Trauma Emerg Surg. 2017;43(2):239-248. doi:10.1007/s00068-016-0635-z.
21. Meinberg EG, Agel J, Roberts CS, Karam MD, Kellam JF. Fracture and Dislocation Classification Compendium-2018. J Orthop Trauma. 2018;32 Suppl 1:S1-S170.
doi:10.1097/BOT.0000000000001063.
22. Andersen DJ, Blair WF, Steyers CM, Adams BD, el-Khouri GY, Brandser EA.
Classification of distal radius fractures: an analysis of interobserver reliability and intraobserver reproducibility. Journal of Hand Surgery. 1996;21(4):574-582.
doi:10.1016/s0363-5023(96)80006-2.
23. Bergvall M, Bergdahl C, Ekholm C, Wennergren D. Validity of classification of distal radial fractures in the Swedish fracture register. BMC Musculoskelet Disord.
2021;22(1):587-589. doi:10.1186/s12891-021-04473-5.
24. Gliatis JD, Plessas SJ, Davis TR. Outcome of distal radial fractures in young adults. J Hand Surg Br. 2000;25(6):535-543. doi:10.1054/jhsb.2000.0373.
25. Wilcke MKT, Abbaszadegan H, Adolphson PY. Patient-perceived outcome after displaced distal radius fractures. A comparison between radiological parameters, objective physical variables, and the DASH score. Journal of Hand Therapy.
2007;20(4):290–8–quiz299. doi:10.1197/j.jht.2007.06.001.
26. Finsen V, Rod O, Rød K, Rajabi B, Alm-Paulsen PS, Russwurm H. The relationship between displacement and clinical outcome after distal radius (Colles') fracture. J Hand Surg Eur Vol. 2013;38(2):116-126. doi:10.1177/1753193412445144.
27. Knirk JL, Jupiter JB. Intra-articular fractures of the distal end of the radius in young adults. Journal of Bone and Joint Surgery. 1986;68(5):647-659.
28. Ng CY, McQueen MM. What are the radiological predictors of functional outcome following fractures of the distal radius? J Bone Joint Surg Br. 2011;93(2):145-150.
doi:10.1302/0301-620X.93B2.25631.
29. Prommersberger K-J, Fernandez DL. Nonunion of distal radius fractures. Clin Orthop Relat Res. 2004;419(419):51-56. doi:10.1097/00003086-200402000-00009.
30. Stirling PHC, Oliver WM, Ling Tan H, et al. Patient-reported outcomes after
corrective osteotomy for a symptomatic malunion of the distal radius. Bone Joint J.
2020;102-B(11):1542-1548. doi:10.1302/0301-620X.102B11.BJJ-2020-0848.R3.
31. Andreasson I, Kjellby-Wendt G, Fagevik-Olsén M, Aurell Y, Ullman M, Karlsson J.
Functional outcome after corrective osteotomy for malunion of the distal radius: a randomised, controlled, double-blind trial. Int Orthop. 2020;44(7):1353-1365.
doi:10.1007/s00264-020-04605-x.
32. Lafontaine M, Hardy D, Delince P. Stability assessment of distal radius fractures.
Injury. 1989;20(4):208-210. doi:10.1016/0020-1383(89)90113-7.
33. Nesbitt KS, Failla JM, Les C. Assessment of instability factors in adult distal radius fractures. Journal of Hand Surgery. 2004;29(6):1128-1138.
doi:10.1016/j.jhsa.2004.06.008.
34. Hove LM, Solheim E, Skjeie R, Sörensen FK. Prediction of secondary displacement in Colles' fracture. J Hand Surg Br. 1994;19(6):731-736.
doi:10.1016/0266-7681(94)90247-x.
35. Mackenney PJ, McQueen MM, Elton R. Prediction of instability in distal radial fractures. Journal of Bone and Joint Surgery. 2006;88(9):1944-1951.
doi:10.2106/JBJS.D.02520.
36. Wadsten MÅ, Sayed-Noor AS, Englund E, Buttazzoni GG, Sjödén GO. Cortical comminution in distal radial fractures can predict the radiological outcome: a
cohort multicentre study. Bone Joint J. 2014;96-B(7):978-983. doi:10.1302/0301-620X.96B7.32728.
37. Makhni EC, Taghinia A, Ewald T, Zurakowski D, Day CS. Comminution of the dorsal metaphysis and its effects on the radiographic outcomes of distal radius fractures.
J Hand Surg Eur Vol. 2010;35(8):652-658. doi:10.1177/1753193409338750.
38. Lichtman DM, Bindra RR, Boyer MI, et al. Treatment of distal radius fractures.
Journal of the American Academy of Orthopaedic Surgeons. 2010;18(3):180-189.
doi:10.5435/00124635-201003000-00007.
39. Arora R, Lutz M, Deml C, Krappinger D, Haug L, Gabl M. A Prospective Randomized Trial Comparing Nonoperative Treatment with Volar Locking Plate Fixation for Displaced and Unstable Distal Radial Fractures in Patients Sixty-five Years of Age and Older. The Journal of Bone and Joint Surgery-American Volume.
2011;93(23):2146-2153. doi:10.2106/JBJS.J.01597.
40. Combined Randomised and Observational Study of Surgery for Fractures in the Distal Radius in the Elderly (CROSSFIRE) Study Group, Lawson A, Naylor JM, et al.
Surgical Plating vs Closed Reduction for Fractures in the Distal Radius in Older Patients: A Randomized Clinical Trial. JAMA Surg. 2021;156(3):229-237.
doi:10.1001/jamasurg.2020.5672.
41. Hassellund SS, Williksen JH, Laane MM, et al. Cast immobilization is non-inferior to volar locking plates in relation to QuickDASH after one year in patients aged 65 years and older: a randomized controlled trial of displaced distal radius fractures.
Bone Joint J. 2021;103-B(2):247-255. doi:10.1302/0301-620X.103B2.BJJ-2020-0192.R2.
42. Alemdaroğlu KB, Iltar S, Aydoğan NH, Say F, Kilinç CY, Tiftikçi U. Three-point index in predicting redisplacement of extra-articular distal radial fractures in adults.
Injury. 2010;41(2):197-203. doi:10.1016/j.injury.2009.08.021.
43. Martinez-Mendez D, Lizaur-Utrilla A, de-Juan-Herrero J. Intra-articular distal radius
volar plating. J Hand Surg Eur Vol. 2017;43(2):142-147.
doi:10.1177/1753193417727139.
44. Mulders MAM, Walenkamp MMJ, van Dieren S, Goslings JC, Schep NWL, VIPER Trial Collaborators. Volar Plate Fixation Versus Plaster Immobilization in
Acceptably Reduced Extra-Articular Distal Radial Fractures: A Multicenter Randomized Controlled Trial. The Journal of Bone and Joint Surgery-American Volume. 2019;101(9):787-796. doi:10.2106/JBJS.18.00693.
45. Egol KA, Walsh M, Romo-Cardoso S, Dorsky S, Paksima N. Distal radial fractures in the elderly: operative compared with nonoperative treatment. The Journal of Bone and Joint Surgery-American Volume. 2010;92(9):1851-1857.
doi:10.2106/JBJS.I.00968.
46. Arora R, Gabl M, Gschwentner M, Deml C, Krappinger D, Lutz M. A comparative study of clinical and radiologic outcomes of unstable colles type distal radius fractures in patients older than 70 years: nonoperative treatment versus volar locking plating. J Orthop Trauma. 2009;23(4):237-242.
doi:10.1097/BOT.0b013e31819b24e9.
47. Anzarut A, Johnson JA, Rowe BH, Lambert RGW, Blitz S, Majumdar SR. Radiologic and patient-reported functional outcomes in an elderly cohort with conservatively treated distal radius fractures. Journal of Hand Surgery. 2004;29(6):1121-1127.
doi:10.1016/j.jhsa.2004.07.002.
48. Clement ND, Duckworth AD, Court-Brown CM, McQueen MM. Distal radial fractures in the superelderly: does malunion affect functional outcome? ISRN Orthop. 2014;2014:189803. doi:10.1155/2014/189803.
49. Handoll HH, Huntley JS, Madhok R. External fixation versus conservative treatment for distal radial fractures in adults. Cochrane Bone, Joint and Muscle Trauma Group, ed. Cochrane Database of Systematic Reviews. 2007;61(6):528–3.
doi:10.1002/14651858.CD006194.pub2.
50. Handoll HH, Vaghela MV, Madhok R. Percutaneous pinning for treating distal radial fractures in adults. Cochrane Bone, Joint and Muscle Trauma Group, ed. Cochrane Database of Systematic Reviews. 2007;70(2):119-174.
doi:10.1002/14651858.CD006080.pub2.
51. Handoll HHG, Huntley JS, Madhok R. Different methods of external fixation for treating distal radial fractures in adults. Cochrane Database Syst Rev.
2008;(1):CD006522. doi:10.1002/14651858.CD006522.pub2.
52. Handoll HHG, Watts AC. Bone grafts and bone substitutes for treating distal radial fractures in adults. Cochrane Database Syst Rev. 2008;(2):CD006836.
doi:10.1002/14651858.CD006836.pub2.
53. Hevonkorpi TP, Launonen AP, Huttunen TT, Kannus P, Niemi S, Mattila VM.
Incidence of distal radius fracture surgery in Finns aged 50 years or more between 1998 and 2016 - too many patients are yet operated on? BMC Musculoskelet Disord. 2018;19(1):70-76. doi:10.1186/s12891-018-1983-0.
54. Mellstrand-Navarro C, Pettersson HJ, 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(7):963-969.
doi:10.1302/0301-620X.96B7.33149.
55. de Putter CE, Selles RW, Polinder S, Panneman MJM, Hovius SER, van Beeck EF.
Economic impact of hand and wrist injuries: health-care costs and productivity costs in a population-based study. The Journal of Bone and Joint Surgery-American Volume. 2012;94(9):e56–1–7. doi:10.2106/JBJS.K.00561.
56. de Putter CE, Selles RW, Polinder S, et al. Epidemiology and health-care utilisation of wrist fractures in older adults in The Netherlands, 1997-2009. Injury.
2013;44(4):421-426. doi:10.1016/j.injury.2012.10.025.
57. Rundgren J, Bojan A, Mellstrand Navarro C, Enocson A. Epidemiology, classification, treatment and mortality of distal radius fractures in adults: an
register. BMC Musculoskelet Disord. 2020;21(1):88-89. doi:10.1186/s12891-020-3097-8.
58. Handoll HH, Madhok R. Closed reduction methods for treating distal radial fractures in adults. Cochrane Database Syst Rev. 2003;(1):CD003763.
doi:10.1002/14651858.CD003763.
59. Handoll HH, Madhok R. Conservative interventions for treating distal radial fractures in adults. Cochrane Database Syst Rev. 2003;(2):CD000314.
doi:10.1002/14651858.CD000314.
60. Vang Hansen F, Staunstrup H, Mikkelsen S. A comparison of 3 and 5 weeks immobilization for older type 1 and 2 Colles' fractures. J Hand Surg Br.
1998;23(3):400-401. doi:10.1016/s0266-7681(98)80067-3.
61. Bentohami A, van Delft EAK, Vermeulen J, et al. Non- or Minimally Displaced Distal Radial Fractures in Adult Patients: Three Weeks versus Five Weeks of Cast
Immobilization-A Randomized Controlled Trial. J Wrist Surg. 2019;8(1):43-48.
doi:10.1055/s-0038-1668155.
62. Søsborg-Würtz H, Corap Gellert S, Ladeby Erichsen J, Viberg B. Closed reduction of distal radius fractures: a systematic review and meta-analysis. EFORT Open
Reviews. 2018;3(4):114-120. doi:10.1302/2058-5241.3.170063.
63. van Geel TACM, van Helden S, Geusens PP, Winkens B, Dinant G-J. Clinical subsequent fractures cluster in time after first fractures. Ann Rheum Dis.
2009;68(1):99-102. doi:10.1136/ard.2008.092775.
64. Johansson H, Siggeirsdóttir K, Harvey NC, et al. Imminent risk of fracture after fracture. Osteoporos Int. 2017;28(3):775-780. doi:10.1007/s00198-016-3868-0.
65. Lorentzon M. Treating osteoporosis to prevent fractures: current concepts and future developments. J Intern Med. 2019;285(4):381-394. doi:10.1111/joim.12873.
66. Black DM, Rosen CJ. Clinical Practice. Postmenopausal Osteoporosis. N Engl J Med.
2016;374(3):254-262. doi:10.1056/NEJMcp1513724.
67. Abimanyi-Ochom J, Watts JJ, Borgström F, et al. Changes in quality of life associated with fragility fractures: Australian arm of the International Cost and Utility Related to Osteoporotic Fractures Study (AusICUROS). Osteoporos Int.
2015;26(6):1781-1790. doi:10.1007/s00198-015-3088-z.
68. Ostergaard PJ, Hall MJ, Rozental TD. Considerations in the Treatment of
Osteoporotic Distal Radius Fractures in Elderly Patients. Curr Rev Musculoskelet Med. 2019;12(1):50-56. doi:10.1007/s12178-019-09531-z.
69. Axelsson KF, Johansson H, Lundh D, Möller M, Lorentzon M. Association Between Recurrent Fracture Risk and Implementation of Fracture Liaison Services in Four Swedish Hospitals: A Cohort Study. J Bone Miner Res. 2020;35(7):1216-1223.
doi:10.1002/jbmr.3990.
70. Javaid MK. Efficacy and efficiency of fracture liaison services to reduce the risk of recurrent osteoporotic fractures. Aging Clin Exp Res. 2021;33(8):2061-2067.
doi:10.1007/s40520-021-01844-9.
71. Levin LS, Rozell JC, Pulos N. Distal Radius Fractures in the Elderly. J Am Acad Orthop Surg. 2017;25(3):179-187. doi:10.5435/JAAOS-D-15-00676.
72. Cooney WP, Linscheid RL, Dobyns JH. External pin fixation for unstable Colles' fractures. Journal of Bone and Joint Surgery. 1979;61(6A):840-845.
73. Grana WA, Kopta JA. The Roger Anderson device in the treatment of fractures of the distal end of the radius. Journal of Bone and Joint Surgery. 1979;61(8):1234-1238.
74. Costa ML, Achten J, Parsons NR, et al. Percutaneous fixation with Kirschner wires versus volar locking plate fixation in adults with dorsally displaced fracture of distal radius: randomised controlled trial. BMJ. 2014;349(aug05 2):g4807-g4807.
doi:10.1136/bmj.g4807.
75. Stürmer KM, Letsch R, Koeser K, Schmit-Neuerburg KP. [Treatment of distal radius fracture. Surgical technique: bore wire osteosynthesis]. Langenbecks Arch Chir Suppl II Verh Dtsch Ges Chir. 1990:647-656.
76. Williksen JH, Frihagen F, Hellund JC, Kvernmo HD, Husby T. Volar Locking Plates Versus External Fixation and Adjuvant Pin Fixation in Unstable Distal Radius Fractures: A Randomized, Controlled Study. Journal of Hand Surgery.
2013;38(8):1469-1476. doi:10.1016/j.jhsa.2013.04.039.
77. Hargreaves DG, Drew SJ, Eckersley R. Kirschner wire pin tract infection rates: a randomized controlled trial between percutaneous and buried wires. J Hand Surg Br. 2004;29(4):374-376. doi:10.1016/j.jhsb.2004.03.003.
78. Hollevoet N. Effect of patient age on malunion of operatively treated distal radius fractures. Acta Orthop Belg. 2010;76(6):743-750.
79. Tubeuf S, Yu G, Achten J, et al. Cost effectiveness of treatment with percutaneous Kirschner wires versus volar locking plate for adult patients with a dorsally
displaced fracture of the distal radius: analysis from the DRAFFT trial. Bone Joint J.
2015;97-B(8):1082-1089. doi:10.1302/0301-620X.97B8.35234.
80. Ring D, Jupiter JB, Brennwald J, Büchler U, Hastings H. Prospective multicenter trial of a plate for dorsal fixation of distal radius fractures. Journal of Hand Surgery.
1997;22(5):777-784. doi:10.1016/S0363-5023(97)80069-X.
81. Rozental TD, Beredjiklian PK, Bozentka DJ. Functional outcome and complications following two types of dorsal plating for unstable fractures of the distal part of the radius. Journal of Bone and Joint Surgery. 2003;85(10):1956-1960.
doi:10.2106/00004623-200310000-00014.
82. Orbay JL. The treatment of unstable distal radius fractures with volar fixation.
Hand Surg. 2000;5(2):103-112. doi:10.1142/s0218810400000223.