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49Ann R Coll Surg Engl 2014; 96: 49–54 49
UPPER LIMB
Ann R Coll Surg Engl 2014; 96: 49–54
doi 10.1308/003588414X13824511650254
KEYWORDS
Radius – Internal fracture fi xation – Cartilage fractures – Radiology information systems
Accepted 16 August 2013
CORRESPONDENCE TO
Shelain Patel, SpR in Trauma and Orthopaedics, University College Hospital, 235 Euston Road, London NW1 2BU, UK
T: +44 (0)845 155 5000; E: shelain.patel@doctors.org.uk
Does the DVR® plate restore bony anatomy
following distal radius fractures?
S Patel, PB Menéndez, FS Hossain, HB Colaço, MH Lee, ED Sorene, EJ Taylor
University College London Hospitals NHS Foundation Trust, UK
ABSTRACT
INTRODUCTION Fractures of the distal radius are common. Malreduced fractures are associated with residual functional
defi ciency. There has been a trend over the last few years for using fi xed angle volar locking plates to surgically stabilise this
injury. Our unit uses the DVR® plate (DePuy, Warsaw, IN, US). Nevertheless, it is unknown whether the normal bony anatomy is
recreated or merely restored to acceptable limits with its usage. The aim of this study was to evaluate the reduction achieved
compared with an uninjured population and pre-existing quoted ‘normal’ values. Furthermore, we wanted to identify the per-
centage of cases that were reduced to acceptable limits, and determine whether the grade of the surgeon and fracture type was
a confounding infl uence on this reduction.
METHODS A retrospective review of the 3-month postoperative radiography of 48 eligible patients who underwent open reduc-
tion and internal fi xation of a distal radius fracture with a DVR® plate was undertaken.
RESULTS Volar tilt, radial length and inclination were different to quoted normal values (p<0.01). Despite this, these param-
eters fell within acceptable limits in 46 cases; this was not infl uenced by fracture type or grade of operating surgeon.
CONCLUSIONS The DVR® plate restores the bony anatomy to within acceptable limits in the majority of patients who have
sustained a fracture of the distal radius although of all parameters investigated, the widest variability is seen in volar tilt.
Fractures of the distal radius are common injuries with an
estimated incidence of 71,000 cases in Britain every year.1
Patients of all ages can be affected but the elderly are more
susceptible to injury.2 It has long been recognised that
malreduced fractures are associated with poor long-term
function.3 Consequently, there is an indication to reduce
displaced fractures and surgically stabilise those that are
unstable. The devices used for maintaining reduction sur-
gically include percutaneous wires, external fi xators, in-
tramedullary nails and plates.
The early results of plate fi xation were poor but im-
proved dramatically following the introduction of precon-
toured locking plates. This has been associated with a rise
in popularity with respect to usage. Recent randomised con-
trolled trials have demonstrated better function in the early
postoperative period with this fi xation method than with
other methods such as percutaneous pinning, external fi xa-
tion and radial column plates although long-term function
is comparable.4,5
The DVR® plate (DePuy, Warsaw, IN, US) is a volar lock-
ing plate that was introduced in 2001. It has been shown to
be biomechanically stable and possibly more so than other
similar volar locking plates by other manufacturers.6–8 The
DVR® plate has undergone an evolution in design since fi rst
coming to the market with two rows of screw options now
available (Fig 1) to improve subchondral support. Further-
more, the number of available sizes has been increased
to seven so that it can be used in patients of variable bony
anatomy and size.
The biomechanical merits of plate osteosynthesis, com-
plications and functional outcome are well documented.
There is, however, a paucity of evidence as to what the ex-
pected radiographic parameters are following this fi xation
modality. Our institution always performs open reduction
and internal fi xation rather than closed reduction and per-
cutaneous wire fi xation for all adult patients presenting with
an unstable fracture of the distal radius within two weeks of
the injury. We have used the DVR® plate with two rows of
distal screw options since 2006 and we do not commonly
image both wrists unless there is a suspicion of congenital
abnormal anatomy.
‘Normal’ values for the volar tilt (VT), radial length
(RL) and radial inclination (RI) of the distal radius were
described originally in 1962 by Scheck as 11º, 12mm and
Volume 96 Issue 1.indb 49Volume 96 Issue 1.indb 49 06/12/13 3:39 pm06/12/13 3:39 pm
50 Ann R Coll Surg Engl 2014; 96: 49–54
PATEL MENÉNDEZ HOSSAIN COLAÇO LEE SORENE
TAYLOR
DOES THE DVR® PLATE RESTORE BONY ANATOMY FOLLOWING
DISTAL RADIUS FRACTURES?
23º respectively.9 A subsequent pooled analysis of multi-
ple studies has demonstrated the mean values to be 14.5º,
13.5mm and 25.4º respectively10 although it is the former set
of values that continue to be quoted widely in the literature.
The aims of this study were to: (1) evaluate the reduction
at three months following surgery against that at the end
of the procedure, against a group of uninjured wrists and
against both sets of pre-existing quoted ‘normal’ values to
determine whether these can be achieved using the DVR®
plate; (2) identify the percentage of cases that were reduced
to acceptable limits; and (3) determine whether the grade of
surgeon and fracture complexity were a confounding infl u-
ence on this reduction.
Methods
A retrospective analysis was undertaken of all patients with
a fracture of the distal radius between 2008 and 2009 who
underwent open reduction and internal fi xation with a
DVR® plate. We identifi ed 60 cases but excluded those pa-
tients whose fractures were stabilised with supplementary
fi xation (n=2), those lost to follow-up by the evaluation stage
(n=3) and those who had a previous distal radius fracture
(n=3) or inadequate radiography (n=4).
This left 48 cases in 48 patients (19 male, 29 female,
mean age: 51.2 years, age range: 19–85 years). All fracture
patterns were described according to the Arbeitsgemein-
schaft für Osteosynthesefragen (AO) classifi cation (type A:
13 cases, mean age: 38.3 years, age range: 19–79 years; type
B: 9 cases, mean age: 48.2 years, age range: 21–72 years;
type C: 26 cases, mean age: 59.1 years, age range: 21–85
years) and all procedures were performed within two weeks
of injury by either a consultant (19 cases), a registrar with
consultant supervision (4 cases) or a registrar independ-
ently (25 cases). The uninjured population with which these
patients were compared as part of the analysis consisted of
48 wrists in 46 patients who presented to our clinic with a
history of minor trauma to the upper limb and in whom no
radiological abnormality was identifi ed.
Operative technique
All cases were operated on in a standardised manner under
general anaesthesia and with a tourniquet infl ated around
the affected limb at 250mmHg for the duration of the opera-
tion. The distal radius was approached through the bed of
the fl exor carpi radialis tendon and the operation performed
as per the recommended operative technique. The fracture
was identifi ed and reduced under fl uoroscopy guidance.
The plate was then positioned on the radial shaft, secur-
ing it initially using the central sliding hole. The decision
to release the brachioradialis tendon to facilitate fracture
reduction on to the plate was made by the operating sur-
geon. All available peg holes were then fi lled to maintain
fracture reduction and prevent redisplacement. After secur-
ing the plate to the shaft with the fi nal screws, the wound
was closed and dressed in a bulky bandage.
Figure 1 Standardised three-month postoperative posteroanterior (A) and lateral (B) radiography of a fractured distal radius that has
been stabilised with a DVR® plate
Volume 96 Issue 1.indb 50Volume 96 Issue 1.indb 50 06/12/13 3:39 pm06/12/13 3:39 pm
51Ann R Coll Surg Engl 2014; 96: 49–54
PATEL MENÉNDEZ HOSSAIN COLAÇO LEE SORENE
TAYLOR
DOES THE DVR® PLATE RESTORE BONY ANATOMY FOLLOWING
DISTAL RADIUS FRACTURES?
Postoperative protocol
Clinical and radiographic follow-up occurred at 2, 6 and 12
weeks following surgery, and thereafter based on clinical
need. For weeks 2–6, patients were given a Futuro® splint
(3M, Bracknell, UK) for support that could be removed
for exercises with our hand therapists. Discontinuation of
the splint was advised routinely at week 6 and further su-
pervised exercised was dependent on residual functional
defi cit.
Radiographic assessment
Posteroanterior and lateral radiography was used to assess
VT, RL and RI, with all values determined by two observers
(SP and PBM). Intraoperative radiography was performed
and further images were collected at least three months
postoperatively to allow for any potential loss of fracture
position. The fi rst ten cases of three-month postoperative
radiography were used for interobserver variability, show-
ing good agreement (kappa = 0.91).
VT was defi ned as the angle created between the articu-
lar surface of the distal radius and a line perpendicular to
the long axis of the radius as witnessed on lateral radiog-
raphy. RL was defi ned as the distance between the tip of
the radial styloid process and the distal articular surface of
the ulna in a direction perpendicular to the long axis of the
radius. RI was defi ned as the angle created between a line
joining the tip of the radial styloid and the ulnar corner of
the articular surface, and a line perpendicular to the long
axis of the radius.
Statistical analysis
Descriptive statistics were applied to describe the basic
characteristics of the datasets. A two-sample unpaired t-
test was used for comparing the uninjured population with
the three-month postoperative radiography, a two-sample
paired t-test for comparing the intraoperative radiography
with the three-month postoperative radiography and a one-
sample t-test for comparing the three-month postoperative
radiographic parameters with normal values quoted in the
literature to determine whether normal anatomy was recre-
ated.
A one-way analysis of variance and covariance was used
to determine whether these values differed depending on
the grade and supervision of the operating surgeon, the type
of the fracture as defi ned by the AO classifi cation or the in-
teraction between them. A chi-squared test was used to see
whether complications varied according to the grade of the
operating surgeon. All analyses were performed using the
XLSTAT module (Addinsoft, Paris, France) for Excel® (Mi-
crosoft, Redmond, WA, US), with statistical signifi cance set
at p<0.05.
Results
Comparison with normal values
Radiographic assessment at three months demonstrated
that the mean VT achieved was 8.8º (standard deviation
[SD]: 5.5º, range: -6–20º), the mean RL was 11.0mm (SD:
1.7mm, range: 7–15mm) and the mean RI was 21.0º (SD:
3.4º, range: 13–27º) (Table 1). Comparison of all values with
normal values demonstrated that the difference was statisti-
cally signifi cant for all parameters (Table 2).
Comparison with uninjured wrists
The uninjured group was noted to have a mean VT of 8.5º
(SD: 5.8º; range: -5–20º), a mean RL of 11.3mm (SD: 1.8mm,
Table 1 The number of patients and radiographic parameters (mean, range) by different grades of surgeon and fracture types
AO fracture type Operating surgeon Overall
Consultant Registrar with consultant
supervision
Registrar
An=3
VT: 6.0º (0–9º)
RL: 11.3mm (10–14mm)
RI: 23.3º (21–27º)
n=2
VT: 3.5º (-6–13º)
RL: 12.5mm (10–15mm)
RI: 22.0º (21–23º)
n=8
VT: 9.8º (4–14º)
RL: 11.2mm (9–13mm)
RI: 21.9º (16–26)
n=13
VT: 8.0º (-6–14º)
RL: 11.4mm (9–15mm)
RI: 22.2º (16–27º)
Bn=2
VT: 7.0º (5–9º)
RL: 11.5mm (11–12mm)
RI: 22.0º (22–22º)
n=1
VT: 2.0º (N/A)
RL: 11.0mm (N/A)
RI: 15.0º (N/A)
n=6
VT: 7.8º (-5–13º)
RL: 10.7mm (7–15mm)
RI: 22.0º (18–26º)
n=9
VT: 7.0º (-5–13º)
RL: 10.9mm (7–15mm)
RI: 21.2º (15–26º)
Cn=14
VT: 10.5º (0–20º)
RL: 10.8mm (8–13mm)
RI: 19.6º (16–24º)
n=1
VT: 9.0º (N/A)
RL: 14.0mm (N/A)
RI: 24.0º (N/A)
n=11
VT: 8.9º (-2–16º)
RL: 10.6mm (9–13mm)
RI: 20.9º (13–25º)
n=26
VT: 9.8º (-2–20º)
RL: 10.8mm (8–14mm)
RI: 20.3º (13–25º)
Overall n=19
VT: 9.4º (0–20º)
RL: 11.0mm (8–14mm)
RI: 20.4º (16–27º)
n=4
VT: 4.5º (-6–13º)
RL: 12.5mm (10–15mm)
RI: 20.8º (15–24º)
n=25
VT: 8.9º (-5–16º)
RL: 10.8mm (7–15mm)
RI: 21.5º (13–26º)
n=48
VT: 8.8º (-6–20º)
RL: 11.0mm (7–15mm)
RI: 21.0º (13–27º)
AO = Arbeitsgemeinschaft für Osteosynthesefragen; VT = volar tilt; RL = radial length; RI = radial inclination
Volume 96 Issue 1.indb 51Volume 96 Issue 1.indb 51 06/12/13 3:39 pm06/12/13 3:39 pm
52 Ann R Coll Surg Engl 2014; 96: 49–54
PATEL MENÉNDEZ HOSSAIN COLAÇO LEE SORENE
TAYLOR
DOES THE DVR® PLATE RESTORE BONY ANATOMY FOLLOWING
DISTAL RADIUS FRACTURES?
range: 7–16mm) and a mean RI of 24.3º (SD: 5.6º, range:
14–28º), with VT and RL remaining statistically different
(p=0.02 and p=0.04 respectively); no difference was noted
for RI (p=0.07).
Comparison with intraoperative values
The mean intraoperative VT was 12.7º (SD: 0.8º, range:
8–17º), the mean RL was 13.1mm (SD: 2.7mm, range:
5–18mm) and the mean RI was 21.4º (SD: 3.6º, range: 13–
28º). No statistical difference was noted when comparing
these with the three-month postoperative values (p=0.87,
p=0.91 and p=0.61 respectively).
Comparison with acceptable values
Comparison with the radiographic criteria for acceptable
healing of a distal radial fracture11 demonstrated that VT
and RL were corrected for all patients but two patients had
RIs of 13.0º and 14.4º, which thus approached an acceptable
value but did not reach it (Table 3).
Infl uence of fracture type and surgeon grade
Univariate and covariate analysis determined that neither
fracture type, surgeon grade or the interaction between
them affected VT (p=0.36, p=0.28 and p=0.67 respectively),
RL (p=0.57, p=0.17 and p=0.71 respectively) or RI (p=0.25,
p=0.63 and p=0.36 respectively).
Complications
Follow-up of patients at 12 months determined that 9 pa-
tients had complications attributable to surgery, with 3 in
the group where the consultant was the primary surgeon,
2 where the surgeon was a registrar operating under con-
sultant supervision and 4 in the group where the registrar
was operating independently; this was not statistically sig-
nifi cant (p=0.32). Two patients had chronic regional pain
syndrome: one suffered with a palsy of the sensory branch
of the median nerve that had reversed by three months and
one with a superfi cial wound infection that was treated suc-
cessfully with oral antibiotics. Five patients required re-
moval of the plate: two for poor plate positioning causing
either joint or soft tissue impingement, one for placement of
an intra-articular screw and two for fracture collapse with
secondary joint impingement.
Discussion
This study demonstrates that so-called normal values of dis-
tal radial anatomy are not replicated when using the DVR®
plate to treat unstable fractures of the distal radius with re-
spect to VT, RL or RI. Despite this, the reduction achieved
fell within acceptable limits in most cases irrespective of
fracture complexity and the DVR® plate can be used by sur-
geons of differing experience without compromising this. Of
note, however, is that the complication rate in our series
approached one in fi ve cases, which reinforces the need for
suitable training and patient selection.
This study was limited by its use of plain radiography as
a measure of radiographic parameters. Although radiogra-
phy was standardised, it is well recognised that rotation of
the forearm, which could occur, may affect these param-
eters with pronation of 10º decreasing the apparent VT, RL
and RI by 4.4º, 1.6mm and 2.8º respectively.12 There is conse-
quently an argument for computed tomography assessment
over plain radiography since it is more reliable for quantify-
ing displacement.13 Unfortunately, our retrospective design
did not allow for computed tomography in the present study.
Furthermore, consideration would need to be given to the
additional radiation exposure in any prospective study.
The second potential limitation of the study relates to
the use of expected values against which radiographic pa-
rameters were compared rather than patients’ contralateral
uninjured wrists. While it may be expected that a patient’s
own anatomy would be a better comparison, the mean
difference of 2.5º for VT, 1.5º for RI and 0.5mm for ulnar
variance that has been shown to exist between the wrists
of healthy subjects14 could limit its suitability. This is cor-
roborated by Schuind et al, who compared the variability of
right and left wrists on plain radiography with the variability
of the distribution of those measurements from within the
general population.15 It is noted that although the contral-
ateral uninjured wrist should be used for assessing carpal
measures, the normal side does not provide a better refer-
Table 2 Comparison of obtained radiographic parameters with ‘normal’ values
Study Volar tilt p-value Radial length p-value Radial
inclination
p-value
Scheck, 1962911º 0.007 12mm <0.001 23º <0.001
Mann, 199210 14.5º <0.001 13.5mm <0.001 25.4º <0.001
Table 3 The number and percentage of patients who had radiographic parameters within acceptable limits
Acceptable measurement Number of patients
Volar tilt 15º dorsal tilt – 20º volar tilt 48 (100%)
Radial length >8.5mm 48 (100%)
Radial inclination ≥15º 46 (95.8%)
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53Ann R Coll Surg Engl 2014; 96: 49–54
PATEL MENÉNDEZ HOSSAIN COLAÇO LEE SORENE
TAYLOR
DOES THE DVR® PLATE RESTORE BONY ANATOMY FOLLOWING
DISTAL RADIUS FRACTURES?
ence than normal values obtained from databases for VT, RI
or ulnar variance.
The question of whether volar locking plates offer su-
perior outcomes over other treatment options has been a
recent topic for debate. Direct comparison with percutane-
ous wire fi xation remains diffi cult as this method tends to be
indicated only for extra-articular fractures whereas internal
fi xation methods such as volar locking plates can be used
both for those that do and do not affect articular congruity.
In a specifi c cohort of patients older than 70 years, Aro-
ra et al demonstrated that radiographic parameters were
signifi cantly better in those treated with a locking plate
than in those treated non-operatively.16 It is, however, worth
noting that subjective and functional outcomes did not differ
at a mean follow-up of 4 years and 7 months. When com-
pared with external fi xation, volar locking plates have been
shown to have improved function at three months4 although
this difference was no longer present subsequently, with
either similar or better radiographic outcomes.4,17 These
cumulative fi ndings appear to support the use of volar
locking plates for the treatment of fractures of the distal
radius.
While our study demonstrated a disparity between nor-
mal values and the achieved reduction, the mean values fell
within the accepted limits and this was not infl uenced by the
grade of operating surgeon. However, since we now have
discriminatory scoring and evaluation methods, we recom-
mend these acceptable limits be investigated to see whether
they still hold true. Although traditionally associated with
outcome, there is recent evidence from a number of authors
that in an elderly population aged >65–70 years, radiograph-
ic indices do not correlate with outcome.16,18,19 Taken togeth-
er with the added cost effectiveness of percutaneous wires,20
this suggests that routine volar locking plate fi xation in this
group may not be justifi ed.
The diffi culty in discussing and evaluating volar locking
plates comes from the wide variety of implants available,
and to date, there are no reported human clinical studies
comparing them. First generation DVR® plates, which have
a single row of distal screw holes, have been shown to be
biomechanically superior to non-locking devices such as
percutaneous wires21 or simple plates6 although they are
comparable biomechanically with locking plates from other
manufacturers under physiological loads6,8,22–24 and non-
spanning external fi xators.25 The addition of a second row of
distal screw holes as found in the second generation DVR®
plates does not improve this.7 It is nevertheless worth not-
ing that this design modifi cation was to prevent subchon-
dral collapse, which may be important clinically rather than
biomechanically.
The clinical results of the DVR® plate have been reported
previously in 48 patients with AO type C fractures by Frattini
et al.26 In this subgroup of patients, the radiographic out-
comes were again within acceptable limits with a mean VT
of 10.3º, a mean RL of 9.2mm and a mean RI of 23.2º. This is
comparable with our patients with type C fractures. Howev-
er, it is of note that we have shown acceptable radiographic
parameters can be attained in the majority of patients irre-
spective of fracture type.
Conclusions
We have shown that that the DVR® plate, which is a fi xed
angle volar locking plate, is able to restore the bony anatomy
to within acceptable limits in the majority of patients follow-
ing an unstable fracture of the distal radius. The parameter
that exhibits the widest variability is VT and while the rate
of complication approached one in fi ve cases, most were
attributable to surgically related factors rather than failure
of fi xation, emphasising the need for suitable preoperative
counselling of patients undergoing plate osteosynthesis of
the distal radius irrespective of which implant is used.
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