Open Journal of Orthopedics, 2013, 3, 227-233
http://dx.doi.org/10.4236/ojo.2013.35043 Published Online September 2013 (http://www.scirp.org/journal/ojo) 227
Comparison between Distractor Application on Both
Radial & Ulnar Side and Radial Side Only for Fracture
Distal Radius with Ulnar Styloid Fracture
Ujjal Bhakat1, Arindam Mukherjee2, Ranadeb Bandyopadhyay3
1B. S. Medical College, Bankura, India; 2The Mission Hospital, Durgapur, India; 3Department of Orthopaedics, B. S. Medical Col-
lege, Bankura, India.
Received June 28th, 2013; revised July 29th, 2013; accepted August 14th, 2013
Copyright © 2013 Ujjal Bhakat et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Background: Fracture of distal radius with involvement of the ulnar styloid process is a common clinical problem. It
can be treated conservatively, u sually involving wrist immob ilization in plaster cast or surgically. A key method of sur-
gical fixation is external fixation by distractor. Distractor can be applied either only on the radial side or on both ulnar
and radial sides. Materials and Methods: A prospective randomized and comparative study of 1 year duration was
conducted on 32 patients admitted in the Department of Orthopaedics of BSMC & H in the age group of 20 to 75 years
old with AO types B and C distal radius fracture along with involvement of the ulnar styloid process. The parameters
studied were resto ration of radial len gth, restoration of rad ial angle, intracarpal step-off an d palmar tilt which were sta-
tistically evaluated and Fisher’s exact test was performed. The two tailed P-value was calculated and both the groups
were statistically compared. Results: In our study, 37.5% patients in Group A and 81.25% in Group B had a radial dif-
ference <3 mm which was statistically sig nificant ( Tab le 1 , Chart 1). 43.75% patients in Group A and 87 .5% in Group
B had radial angle <5’ which was significant (Table 2, Chart 2). 31.25% in Group A and 75% had intra carpal step off
<2 mm which was again statistically significant (Table 3, Chart 3). 62.5% had an abnormal palmar tilt in Group A
while only 6.25% had an abnormal palmar tilt in Group B which is extremely statistically sign ificant. On an average, 2
mm of distraction was required in 75% patients of Group A while only 30% patients in Group B required distraction
(Table 4, Chart 4). Conclusion: In our study, the radial difference, radial angle, intra carpal step off and palmar tilt
returned significantly to normal in the patients treated with distractor on radial side only when compared with distractor
application on both radial and ulnar sides for distal radius fracture with ulnar styloid process involvement. Also
post-operative distraction required under image intensifier was higher in the group treated with distractor on either side
than those with distractor only on rad ial side.
Keywords: Fracture Distal Radius; Plaster Cast; Distractor; Radial Length; Radial Angle; Intra Carpal Step Off; Palmar
Tilt; Fischer’s Test; P-Value
1. Introduction
The incidence of distal radius fracture with ulnar styloid
fracture is increasing together with average age of popu-
lation. Intra-articular incongruity is the most probable
cause of unsatisfactory outcome of these fractures in
younger and most active adults. Thus the main goal in
the treatment should be restoration of articular congru-
ence. Persistent intra-articular incongruity has been
shown to cause a 9.9 fold increased risk of radiological
osteoarthritis and restriction of range of motion [1,2].
New implants have been designed to provide stable
and enough fixations for early mobilization after surgery
and to lower complication rates, such as ex ternal fixation
by distractor and internal fixation by Allie’s plate. Distal
radius fracture along with involvement of the ulnar sty-
loid, closed or open, can be treated by distractor applica-
tion on the radial side only. It can also be treated by ap-
plication of distractor on both the radial and ulnar sides
of the affected forearm [3].
Hence we conducted a study in our rural set up to
compare the results of treatment of these fractures by
external fixation with a distractor by either of the two
methods.

Comparison between Distractor Application on Both Radial & Ulnar Side and Radial Side
Only for Fracture Distal Radius with Ulnar Styloid Fracture
228
2. Materials and Methods
A prospective randomized and comparative study was
conducted on the patients admitted in the Department of
Orthopaedics of BSMC & H. Our study population
mainly consisted 32 patients (16 in each group) aged be-
tween 20 to 75 years old, of either sex with distal radius
intra-articular fracture (AO types B and C), along with
involvement of the ulnar styloid process. The study pe-
riod was about 1 year from October 2010 to September
2011. Eligibility criteria for the patients included in the
study were as follows: 1) Patients who were in the age
group of 20 to 75 years of either sex, 2) distal radius in-
tra-articular fracture along with involvement of the ulnar
styloid process without any systemic or psychiatric ill-
ness, 3) patients fit for anaesthesia.
The parameters studied were radiographic parameters:
1) Restoration of radial length (within 3 mm of contra-
lateral side), 2) restoration of radial angle (<5 degrees), 3)
intracarpal step-off (<2 mm) and 4) palmar tilt (0 de-
grees).
After obtaining ethical clearance from the institutional
Ethics committee, study was conducted among the study
populations after obtaining written informed consent in
accordance with the Ethical standards of the 1964 Dec-
laration of Helsinki as revised in 2000. The relevant in-
formation collected by using a pre-designed proforma
including history, general and systemic examination find-
ings. Initial radiograph of the wrist joint was conducted
besides routine pre anesthetic investigations. The 32 pa-
tients were divided in to two groups, 16 in each. The pa-
tients under group A were treated by distractor applica-
tion on both the radial and ulnar sides, while group B
were treated with distractor application on the radial side
only. The patients were followed up with radiographs at
2 weeks apart. Distraction was done in only those with
persistent deformity under image intensifier. The dis-
tractor was maintained for 6 weeks on an average till
bony union was eviden t on skiagram. Following removal
of the distractor, the patients were advised active and
passive range of motion exercises of the wrist joint. Pa-
tients were followed up at every 2 weeks. Radiographs
were obtained again at the end of 12 weeks for compari-
son. The number of patients with restoration of radial
length (within 3 mm of the contralateral side), radial an-
gle (<5 degrees), intracarpal step-off (<2 mm) and pal-
mar tilt (0 degrees) in each group were evaluated and
Fisher’s exact test was performed. The two tailed P-value
was calculated and both the groups were statistically
compared.
3. Results
The 32 patients under the study were divided into 2
groups (16 in each).
Group A-distractor application on both the radial and
ulnar side of the forearm (Figures 1- 5).
Group B-distractor application on the radial side of the
forearm only (Figures 6-10).
In both Groups A and B, 10 were males and 6 were
females.
In either groups, 9 were AO type B and 7 were AO
type C.
Figure 1. Post operative clinical photograph of distractor
application on both radial & ulnar side.
Figure 2. Pre-operative skiagram of wrist showing forearm
A-P view.

Comparison between Distractor Application on Both Radial & Ulnar Side and Radial Side
Only for Fracture Distal Radius with Ulnar Styloid Fracture 229
Figure 3. Pre-operative skiagram of wrist showing forearm
lateral view.
The results were statistically analyzed using Fisher’s
exact test and the two tailed P valu e was evaluated.
In our study, 37 .5% (6 of 16) patien ts in Group A had
a radial difference <3 mm while 62.5% (10 of 16) had
radial difference >3 mm. In Group B, 81.25% (13 of 16)
had a radial difference <3 mm whereas 18.75% (3 of 16)
had a difference >3 mm which was significant (P-value
0.0290) (Table 1, Chart 1). 43.75% (7 of 16) patients
had radial angle <5’ while 56.25% (9 of 16) had radial
angle >5 ’ in Group A. I n Group B, 87.5 % (14 of 16) h ad
radial angle <5’ while 12.5% (2 of 16) had >5’ which
was significant (P-value 0.0233) (Table 2, Chart 2).
31.25% (5 of 16) had intra carpal step off <2 mm and
68.75% (11 of 16) had step off >2 mm in Group A. In
Group B, 75% (12 of 16) had intra carpal step off <2 mm
while 25% (4 of 16) had step off >2 mm which was
Figure 4. Post operative skiagram of wrist showing forearm
with distractor on both radial and ulnar side A-P view.
again significant statistically (P-value 0.0320) (Table 3,
Chart 3). 62.5% (10 of 16) had an abnormal palmar tilt
in Group A while only 6 .25% (1 of 16) had an abnormal
palmar tilt in Group B which is extremely statistically
significant (P-value 0.0021) (Table 4, Chart 4).
In our study, on an average 2 mm of distraction was

Comparison between Distractor Application on Both Radial & Ulnar Side and Radial Side
Only for Fracture Distal Radius with Ulnar Styloid Fracture
230
Figure 5. Post operative skiagram of wrist showing forearm
with distractor on both radial and ulnar side lateral view.
Figure 6. Post operative clinical photograph of distractor
application on radial side.
Figure 7. Pre-operative skiagram of wrist showing forearm
A-P view.
Figure 8. Pre-operative skiagram of wrist showing forearm
lateral view.

Comparison between Distractor Application on Both Radial & Ulnar Side and Radial Side
Only for Fracture Distal Radius with Ulnar Styloid Fracture 231
Figure 9. Post operative skiagram of wrist showing forearm
with distractor on radial side A-P view.
Figure 10. Post operative skiagram of wrist showing fore-
arm with distractor on radial side lateral view.
Table 1. Restoration of radial length.
Radial length
difference <3 mm Radial length difference >3 mm P-value
Group A6 10
Group B13 3 0.0290
Chart 1. Restoration of radial length to within 3 mm of
contra-lateral normal side.
Table 2. Radial angle.
Radial angle <5’ Radial angle >5’ P-value
Group A 7 9
Group B 14 2 0.0233
Chart 2. Restoration of radial angle to <5 degrees.
required in 75% patients of Group A while only 30%
patients in Group B required distraction.
4. Discussion
Fracture of distal radius along with fracture ulnar styloid
process usually is classified as either extra-articular or
intra-articular. Numerous eponyms are applied to frac-
tures in this region [2]. The most used AO classification
divides distal radius fractures in three groups and three

Comparison between Distractor Application on Both Radial & Ulnar Side and Radial Side
Only for Fracture Distal Radius with Ulnar Styloid Fracture
232
Table 3. Intra-carpal step off.
Intra-carpal
step off <2 mm Intra-carpal step off >2 mm P-value
Group A 5 11
Group B 12 4 0.0320
Chart 3. Intra-carpal step off.
Table 4. Palmar tilt.
Normal palmar tilt
(0 degree ) Abnormal palmar tilt P-value
Group A 6 10
Group B 15 1 0.0021
Chart 4. Palmar tilt.
subgroups. Groups A1-3 include extra-articular fractures,
Groups B1-3 include partly intra-articular fractures such
as volar and dorsal Barton fractures and Groups C1-3 in-
clude completely intra-articular fractures [4]. 76% to 91%
of fractures of young adults with residual intra-articular
incongruity showed arthritis 7 years after the injury com-
pared to 11% of fractures with congruous joint.
Dorsal angulation of radiocarpal joint surface worsens
functional outcome considerably when it exceeds 20 de-
grees [3]. 38 years after the injury, each ten degrees of
dorsal angulation diminishes volar flexion by three de-
grees [4]. Dorsal angulation exceeding 20 degrees caused
a 6 and 8 degrees loss of volar flexion 3 and 7 years after
the injury respectively [4-7]. Radial shortening of more
than 4 mm associates with decreased forearm rotation at
3 years follow-up [8,9].
So the main goal of treatment is to maintain the ar-
ticular congruity and anatomical restoration of fracture
site by different methods of treatment like external fixa-
tion by distractor or by conservative methods. This study
compares the result outcome of treatment of distal radius
fracture by distractor application on both radial and ulnar
sides of the forearm and distractor application on only
radial side of the forearm [10].
In our study, 37.5% patients in Group A had a radial
difference <3 mm wh ile in Group B 81.25% had a radial
difference <3 mm which was statistically significant (Ta-
ble 1, Chart 1). 43.75% patients had radial angle <5’ in
Group A while in Group B, 87.5% had radial angle <5’
which was significant (Table 2, Chart 2). 31.25% had
intra carpal step off <2 mm in Group A. In Group B,
75% had intra carpal step off <2 mm which was again
statistically significant (Tab le 3, Chart 3). 62.5% had an
abnormal palmar tilt in Group A while only 6.25% had
an abnormal palmar tilt in Group B which is extremely
statistically significant (Table 4, Chart 4). On an aver-
age, 2 mm of distraction was required in 75% patients of
Group A while only 30% patients in Group B required
distraction.
In conclusion, the results of distractor application for
intra articular distal radius fracture (AO types B and C)
with ulnar styloid involvement on radial side alone are
better than application on both radial & ulnar sides. Fur-
thermore, it is seen that on application of distractor on
either sides of a forearm, there is a chance of collapse of
the radial fracture fragment. This is probably due to ulnar
stretching that distorts the normal anatomical relation
between the two styloids (i.e., the radial styloid being at a
lower level compared to the ulnar styloid). Also, only
30% patients with distractor on radial side required re-
peat distraction at 2 weeks whereas 75% patients with
distractor on both sides necessitated distraction.
Hence distractor applied on radial side only is superior,
less costly as well as less cumbersome to distractor ap-
plied on both radial and ulnar sides.
REFERENCES
[1] J. T. Capo, W. Rossy, P. Henry, R. J. Maurer, S. Naidu
and L. Chen, “External Fixation of Distal Radius Frac-
tures: Effect of Distraction and Duration,” Journal of
Hand Surgery (American Volume), Vol. 34, No. 9, 2009,
pp. 1605-1611.
[2] “Campbell’s: Fracture of Distal Radius: Fracture & Dis-

Comparison between Distractor Application on Both Radial & Ulnar Side and Radial Side
Only for Fracture Distal Radius with Ulnar Styloid Fracture
233
location,” 11th Edition, Mosby Elsevier, 2008, pp. 3441-
3452.
[3] J. Vasenius, “Operative Treatment of Distal Radius Frac-
tures,” Scandinavian Journal of Surgery, Vol. 97, No. 4,
2008, pp. 290-297.
[4] H. J. Kreder, D. P. Hanel, J. Agel, M. McKee, E. H.
Schemitsch, T. E. Trumble and D. Stephen, “Indirect Re-
duction and Percutaneous Fixation versus Open Reduc-
tion and Internal Fixation for Displaced Intra-Articular
Fractures of the Distal Radius: A Randomised, Controlled
Trial,” Journal of Bone and Joint Surgery (British Vol-
ume), Vol. 87, No. 6, 2005, pp. 829-836.
[5] D. S. Ruch, J. Vallee, G. G. Poehling, et al., “Arthro-
scopic Reduction versus Fluoroscopic Reduction in the
Management of Intra-Articular Distal Radius Fractures,”
Arthroscopy, Vol. 20, No. 3, 2004, pp. 225-230.
[6] T. Gausepohl, D. Pennig and K. Mader, “Principles of
External Fixation and Supplementary Techniques Distal
Radius Fractures,” Injury, Vol. 31, Suppl. 1, 2000, pp. 56-
70. doi:10.1016/S0020-1383(99)00264-8
[7] W. Dee, W. Klei n and H. Rieger, “Reduction Techniques
in Distal Radius Fractures,” Injury, Vol. 31, Suppl. 1,
2000, pp. 48-55. doi:10.1016/S0020-1383(99)00263-6
[8] J. Bruske, Z. Niedzwiedz, M. Bednarski, et al., “Acute
Carpal Tunnel Syndrome after Distal Radius Fractures-
Long Term Results of Surgical Treatment with Decom-
pression and External Fixator Application,” Chir Nar-
zadow Ruchu Ortop Pol, Vol. 67, No. 1, 2002, pp. 47-53.
[9] D. T. Hutchinson, K. N. Bachus and T. Higgenbotham,
“External Fixation of the Distal Radius: To Predrill or
Not to Predrill,” Journal of Hand Surgery (American
Volume), Vol. 25, No. 6, 2000, pp. 1064-1068.
doi:10.1053/jhsu.2000.17866
[10] H. J. Kreder, D. P. Hanel, J. Agel, et al., “A Randomized
Controlled Trial of Closed Reduction and Casting versus
Closed Reduction and External Fixation for Distal Radius
Fractures with Metaphyseal Displacement but without
Joint Incongruity,” Orthopaedic Trauma Association 18th
Annual Meeting, 13 October 2002.