1. Combined Dorsal and Volar Plate Fixation of Complex Fractures of the Distal Part of the Radius by David Ring, Karl Prommersberger, and Jesse B. Jupiter J Bone Joint Surg Am Volume 87(1 suppl 2):195-212 September 1, 2005 ©2005 by The Journal of Bone and Joint Surgery, Inc.

2. Figs. 1-A and 1-B Radiographs of a forty-year-old man who sustained a fracture of the left, nondominant wrist in a skiing accident. David Ring et al. J Bone Joint Surg Am 2005;87:195-212 ©2005 by The Journal of Bone and Joint Surgery, Inc.

3. The lateral radiograph also demonstrates substantial metaphyseal comminution. David Ring et al. J Bone Joint Surg Am 2005;87:195-212 ©2005 by The Journal of Bone and Joint Surgery, Inc.

4. Figs. 2-A through 2-T Reprinted with permission of David Ring and Jesse B. Jupiter. David Ring et al. J Bone Joint Surg Am 2005;87:195-212 ©2005 by The Journal of Bone and Joint Surgery, Inc.

5. The fat overlying the pronator quadratus and the flexor pollicis longus are swept ulnarward bluntly. David Ring et al. J Bone Joint Surg Am 2005;87:195-212 ©2005 by The Journal of Bone and Joint Surgery, Inc.

6. The brachioradialis tendon can be released or z-lengthened to facilitate restoration of length and ulnarward inclination of the distal radial articular surface. David Ring et al. J Bone Joint Surg Am 2005;87:195-212 ©2005 by The Journal of Bone and Joint Surgery, Inc.

7. This photograph demonstrates the difficulty involved with aligning and stabilizing these complex fractures. David Ring et al. J Bone Joint Surg Am 2005;87:195-212 ©2005 by The Journal of Bone and Joint Surgery, Inc.

8. The dorsal incision is in line with the third metacarpal and the radial diaphysis (and the Lister tubercle when palpable). David Ring et al. J Bone Joint Surg Am 2005;87:195-212 ©2005 by The Journal of Bone and Joint Surgery, Inc.

9. The development of full-thickness skin flaps protects the radial and ulnar sensory nerve branches and provides broad access to the dorsal surface of the distal part of the radius. David Ring et al. J Bone Joint Surg Am 2005;87:195-212 ©2005 by The Journal of Bone and Joint Surgery, Inc.

10. The extensor pollicis longus is identified, mobilized, and transposed dorsally and radially into the subcutaneous tissues, where it is left at the end of the procedure. David Ring et al. J Bone Joint Surg Am 2005;87:195-212 ©2005 by The Journal of Bone and Joint Surgery, Inc.

11. The fourth dorsal compartment is elevated subperiosteally off of the distal part of the radius, but the attachment of the dorsal capsule to the dorsal fracture fragments is maintained. David Ring et al. J Bone Joint Surg Am 2005;87:195-212 ©2005 by The Journal of Bone and Joint Surgery, Inc.

12. A longitudinal incision of the dorsal capsule has been created, and the dorsal-ulnar distal radial fragments are elevated. David Ring et al. J Bone Joint Surg Am 2005;87:195-212 ©2005 by The Journal of Bone and Joint Surgery, Inc.

13. The forceps (right hand) is elevating the dorsal portion of the scapholunate interosseous ligament, which was avulsed from the scaphoid at the time of the injury. David Ring et al. J Bone Joint Surg Am 2005;87:195-212 ©2005 by The Journal of Bone and Joint Surgery, Inc.

14. The alignment of the volar articular fragments (at the tip of the suction) can be monitored and adjusted through this exposure. David Ring et al. J Bone Joint Surg Am 2005;87:195-212 ©2005 by The Journal of Bone and Joint Surgery, Inc.

15. Impacted central articular fragments are identified, realigned, and supported. David Ring et al. J Bone Joint Surg Am 2005;87:195-212 ©2005 by The Journal of Bone and Joint Surgery, Inc.

16. The volar plate can assist with realignment of the volar articular fragments. David Ring et al. J Bone Joint Surg Am 2005;87:195-212 ©2005 by The Journal of Bone and Joint Surgery, Inc.

17. When the proximal portion of the plate is brought down to bone, the alignment of the volar articular fragments is improved. David Ring et al. J Bone Joint Surg Am 2005;87:195-212 ©2005 by The Journal of Bone and Joint Surgery, Inc.

18. The radial styloid fragment may benefit from a separate fixation device specifically to control it. David Ring et al. J Bone Joint Surg Am 2005;87:195-212 ©2005 by The Journal of Bone and Joint Surgery, Inc.

19. With the radial styloid and the volar fragments realigned and stabilized, the metaphyseal and articular defects are more obvious. David Ring et al. J Bone Joint Surg Am 2005;87:195-212 ©2005 by The Journal of Bone and Joint Surgery, Inc.

20. The impacted central articular fragments are replaced and are supported by the angular stable screws and by bone placed into the metaphyseal defect. David Ring et al. J Bone Joint Surg Am 2005;87:195-212 ©2005 by The Journal of Bone and Joint Surgery, Inc.

21. Prior to repositioning and fixation of the dorsal ulnar fragments, the scapholunate ligament is reattached to the scaphoid with use of a suture anchor. David Ring et al. J Bone Joint Surg Am 2005;87:195-212 ©2005 by The Journal of Bone and Joint Surgery, Inc.

22. The dorsal cortex with the dorsal articular margin is then repositioned and is repaired with a dorsal plate. David Ring et al. J Bone Joint Surg Am 2005;87:195-212 ©2005 by The Journal of Bone and Joint Surgery, Inc.

23. The traction across the external fixator is diminished so that the extrinsic extensor and flexor tendons are not excessively tight. David Ring et al. J Bone Joint Surg Am 2005;87:195-212 ©2005 by The Journal of Bone and Joint Surgery, Inc.

24. Figs. 3-A and 3-B Radiographs made after operative fixation of the fracture demonstrated in Figures 1-A, 1-B, 2-A, 2-B, 2-C, 2-D, 2-E, 2-F, 2-G, 2-H, 2-I, 2-J, 2-K, 2-L, 2-M, 2-N, 2-O, 2-P, 2-Q, 2- R, 2-S, 2-T. David Ring et al. J Bone Joint Surg Am 2005;87:195-212 ©2005 by The Journal of Bone and Joint Surgery, Inc.

25. The lateral radiograph demonstrates the support of the articular surface by multiple fixed-angle subchondral screws. David Ring et al. J Bone Joint Surg Am 2005;87:195-212 ©2005 by The Journal of Bone and Joint Surgery, Inc.

26. Figs. 4-A through 4-F Long-term follow-up radiographs of a case similar to that shown in Figures 1-A, 1-B, 3-A, 3-B. David Ring et al. J Bone Joint Surg Am 2005;87:195-212 ©2005 by The Journal of Bone and Joint Surgery, Inc.

27. This lateral radiograph shows somewhat less comminution than that seen in Figures 1-A, 1-B, 3- A, 3-B. David Ring et al. J Bone Joint Surg Am 2005;87:195-212 ©2005 by The Journal of Bone and Joint Surgery, Inc.

28. The described operative technique was used. David Ring et al. J Bone Joint Surg Am 2005;87:195-212 ©2005 by The Journal of Bone and Joint Surgery, Inc.

29. The external fixator was left in place for four weeks. David Ring et al. J Bone Joint Surg Am 2005;87:195-212 ©2005 by The Journal of Bone and Joint Surgery, Inc.

30. An anteroposterior radiograph made after implant removal demonstrates a reasonably good articular surface given the complexity of the initial articular injury. David Ring et al. J Bone Joint Surg Am 2005;87:195-212 ©2005 by The Journal of Bone and Joint Surgery, Inc.

31. There is a slight dorsal tilt of the articular surface. David Ring et al. J Bone Joint Surg Am 2005;87:195-212 ©2005 by The Journal of Bone and Joint Surgery, Inc.