Unstable distal radius fractures and the volar locking plate 281 extra-articular distal fractures with a volar locking plate. Patients and methods Fifteen patients with distal radius fractures were trea- ted with the Acu-Loc distal radius plate (Acumed) in the Department of Orthopedic Surgery, Tohoku Kosai Hospital, Japan, from April 2007 to March 2009. The distal ﬁxed-angle screws in the plate are angled 6 degrees distally, precontoured plates are used for the volar distal radius, and the thickness of the plate is 2.5 mm. This plate has a unique screw hole for insertion at the radial styloid (Figure 1). Exclusion criteria included any fracture treated with another volar plate or distal radius fractures extending to the shaft of the radius, and concomitant fractures of the same limb. This study included 3 men and 12 women with an average age of 64.4 years; 5 patients had fractured their dominant wrist, and 10 patients fractured their non-dominant wrist. Altogether 11 fractures were caused by simple falls, 1 occurred following a fall from a height, 1 while skiing, 1 from a motorcycle accident, and 1 while dancing socially. Fractures were classiﬁed using the AO classiﬁcation system (11): 1 fracture was extra-articular (AO-type A) and 14 fractures were complete intra-articular (AO-type C). There were no partial intra-articular fractures (AO-type B) (Table I). Preoperative, immediate postoperative, and ﬁnal follow-up volar tilt, radial inclination, and ulnar A B variance were measured radiographically. Subjective and objective functional results were graded using modiﬁcation of the demerit point system of Saito and Cooney’s scoring system (12). Subjective evalu- ation consisted of pain, disability, lassitude of wrist, restricted activity, and limitation of motion. Objective evaluation consisted of range of motion of the wrist and forearm, grip power, and complications such as nerve injury, ﬁnger contracture, tendon irritation, and development of osteoarthritis. All procedures were performed under general anes- thesia with upper arm tourniquet. The distal radius was exposed by a palmar approach along the ﬂexor carpi radialis tendon. After release of the pronator quadratus muscle from its radial insertion, the frac- ture site and palmar surface of the distal radius were exposed. Fracture reduction was veriﬁed with the image intensiﬁer. Provisional Kirschner wires were used occasionally. We usually used a condylar stabilizing technique (13). In the condylar stabilizing technique, the plate and drill guide/K-wire or locking pin construct is called the ‘reduction maneuver’. The reduction maneuver is pushed up and rotated, so that each articular fragment is reduced, and the clamp is used to maintain reduction. The reduction maneuver is lined up with the radial shaft, and then the fracture is reduced in anatomical position (epiphyseal ﬁxation ﬁrst, reduction second). Next, the length of the radius is adjusted for proper ulnar variance by pushing the plate distally to restore the distal radio-ulnar congruity and to apply adequate tension on the triangular Figure 1. A: The distal ﬁxed-angle screws are angled 6 degrees distally; precontoured plates are used for the volar distal radius. B: This plate has a unique screw hole for insertion at the radial styloid, and the thickness of the plate is 2.5 mm.