Volar Approach to Distal Radius Fractures

doi:10.1016/j.jhsa.2008.04.018

The Journal of Hand Surgery

Volume 33, Issue 6, July–August 2008, Pages 958-965

https://doi.org/10.1016/j.jhsa.2008.04.018 Get rights and content

The volar approach to the distal radius fracture is an important exposure in the treatment of these fractures, particularly with the growing enthusiasm for fixed-angle volar plating. With reports in the literature documenting complications associated with external fixation and dorsal plating, the volar approach has become ever more popular. Moreover, advancements in locking plate technology have expanded the indications for palmar plating beyond volar shear and volarly displaced fractures to include unstable intra-articular distal radius fractures. The surgical approach remains the same as when Henry recommended the interval between the flexor carpi radialis and the radial artery. Critical elements of the surgical technique include releasing the brachioradialis, gaining exposure all the way to the sigmoid notch, and building the intra-articular reduction, beginning with the intermediate column and moving radially. The relevant anatomy, indications and contraindications, postoperative care, and a pertinent case presentation are discussed.

Section snippets

Indications and Contraindications

The indications for use of the volar approach to the distal radius have expanded with the proliferation of volar fixed-angle plates. The classic indications for volar plating include the volar articular shear fracture—the eponymous “volar Barton” fracture, and the volarly displaced extra-articular fracture or “Smith fracture.” However, with the availability of locking screw technology, fractures that classically have been treated with a dorsal approach or with external fixation now can be

Surgical Anatomy

The volar approach of Henry uses the interval between the FCR and the radial artery to gain access to the distal radius. Structures most directly at risk during the dissection include the superficial palmar cutaneous branch of the median nerve and the radial artery. If the dissection stays maintained to the radial side of the FCR, the palmar branch of the median nerve is not likely to be injured. Therefore, the nerve does not need to be identified formally during the approach. If a carpal

Surgical Technique

An incision is made overlaying the FCR tendon (Fig. 1). The interval of the dissection will proceed between the FCR and the radial artery in order to avoid injury to the palmar cutaneous branch of the median nerve, which lies just ulnar to the FCR (Fig. 2). This nerve does not need to be identified if the dissection is maintained to the radial side of the FCR. The FCR tendon sheath is incised sharply in a longitudinal direction, and the FCR can be retracted ulnarly. The radial artery is

Postoperative Care and Rehabilitation

For more stable fractures, the wrist is placed into a prefabricated wrist splint. If the fracture has an unstable DRUJ or a high-energy mechanism, a sugar tongue splint is placed with the forearm maintained in approximately 60° of supination. The patient can initiate gentle finger range-of-motion exercises in the splint during the period leading up to the first postoperative visit. The sutures are removed 10–14 days after surgery. A customized, well-padded orthoplastic wrist splint is fashioned

Clinical Case

The patient is a 45-year-old right-handed registered nurse who sustained a fall onto an outstretched hand. She was seen and evaluated in our emergency room. X-rays demonstrated an intra-articular distal radius fracture (Fig. 11A). After administration of a hematoma block, a reduction maneuver was performed, and the patient was placed into a well-molded sugar tongue splint. She followed up in the clinic, and after discussing all treatment options, she elected to proceed with surgical management

Pearls and Pitfalls

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The key to a successful reduction is rebuilding the fractured radius, beginning with the volar lunate facet and then moving dorsally and radially.
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Releasing the brachioradialis aids in the restoration of radial inclination (Fig. 4).
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Plate positioning should always be gauged fluoroscopically while applying a traction reduction maneuver, to avoid underestimating the true radial length (Fig. 8).
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The 20° lateral tilt view is critical for ensuring that the distal screws or pegs are extra-articular and

Complications

Complications of volar plating of the distal radius include loss of fixation, injury to the palmar cutaneous branch of the median nerve, postoperative carpal tunnel syndrome, extensor tendon rupture, and postoperative loss of motion. Loss of fixation can occur catastrophically, particularly if care is not taken to reduce and capture the volar lunate facet fragment with the plate's more ulnar locking screws. If the mechanism of injury involves one of high energy, or if symptoms of carpal tunnel

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Cited by (70)

Enhanced Approaches to the Treatment of Distal Radius Fractures
2023, Hand Clinics
Complications Following Volar Locking Plate Fixation of Distal Radius Fractures in Adults: A Systematic Review of Randomized Control Trials
2023, Journal of Hand Surgery
The purpose of this study was to assess the incidence of postoperative complications following volar locking plate (VLP) fixation of distal radius fractures (DRFs).
A search using keywords and subject headings to represent the concepts of volar plating and radius fractures was generated. Databases such as MEDLINE (Ovid), Embase (Elsevier), Scopus (Elsevier), and SPORTDiscus (EBSCO) were searched from inception to November 24, 2021, for randomized controlled trials that reported complications following DRF treated with VLP. Inclusion criteria were studies with adult patients (aged ≥18 years) randomized to VLP fixation without other concomitant surgical interventions, with a minimum follow-up of 3 months. Study sample characteristics and post-surgical complications were extracted. The Cochrane Risk of Bias tool was used to evaluate quality of evidence.
Of the 4,059 articles identified using the search strategy, 1,778 titles/abstracts and 856 full-text articles were screened for inclusion, of which 35 articles were included for data extraction. Overall, 1,419 patients with a DRF were randomized to VLP fixation. The mean age was 60.3 years. The overall complication rate was 30.8% following VLP fixation, with 12.4% being major complications. The most common complications were median nerve-related (7.1%) and hardware removal (6.8%), secondary to other complications. Tenosynovitis was the most common tendon-related complication (3.4%). Other complications included complex regional pain syndrome (2.4%), malunion (1.3%), superficial wound infections (1.9%), and tendon rupture (1.3%).
A meta-analysis of high-quality studies that discuss the complications after VLP fixation for DRF showed an overall complication rate of 30.8%. VLP may be related to more hardware-related complications than those previously reported.
Therapeutic II.
Evaluation of the Distal Extent of Visualization Using Volar Approaches for Fixation of Distal Radius Fractures
2023, Journal of Hand Surgery
Distal radius fractures may include difficult-to-treat fractures of the volar ulnar corner, colloquially termed as the “critical corner.” These fragments are problematic because they are often missed, and their fixation is difficult. We aimed to compare the distal extent of the exposure of the volar surface of the distal radius between the classic Henry approach and the extended flexor carpi radialis (EFCR) approach.
Thirteen matched-pair specimens were randomized to receive either the Henry approach or the EFCR approach to the volar distal radius. A mini Hohmann retractor provided retraction at the level of the critical corner. The force needed to attain a standardized angle of retraction at 60° was measured. A 0.062-inch Kirschner wire was placed at the most distal and most ulnar point that was visible from a position directly above the incision. Each distal radius was removed from the specimens. A digital caliper was used to measure the distance from the pin hole to the articular margin of the lunate fossa, along a line parallel to the long axis of the radius.
The pin was significantly closer to the articular margin in the EFCR approach (mean, 2.94 ± 1.69 mm) than in the Henry approach (mean, 9.70 ± 2.70 mm).
Our results demonstrated significantly more distal visualization of the volar distal radius in the EFCR approach compared to the Henry approach.
Adequate exposure of the volar surface of the distal radius is crucial for assessment and fixation of the volar ulnar corner. Complete visualization of the volar ulnar corner improves surgeons’ ability to detect a volar marginal fragment and adequately fix this fragment.
Predictors of Acute Carpal Tunnel Syndrome Following ORIF of Distal Radius Fractures: A Matched Case–Control Study
2019, Journal of Hand Surgery Global Online
Citation Excerpt :
Odumala et al11 found that patients receiving prophylactic CTR were twice as likely as patients who did not undergo release to develop “median nerve dysfunction as an acute complication.” Others advocated prophylactic release only in the presence of described risk factors for developing acute CTS, such as highly displaced or comminuted fracture fragments before reduction and high-energy injury mechanisms.5,13 We confined our investigation to factors predicting the development of acute CTS within the 3 weeks after DRFx-ORIF.
Acute carpal tunnel syndrome (CTS) can develop after distal radius fractures (DRFx), necessitating urgent carpal tunnel release (CTR). This complication has not been specifically investigated after open reduction internal fixation (ORIF) of DRFx (DRFx-ORIF). Identifying risk factors would allow for better definition of the indications for prophylactic CTR at the time of DRFx-ORIF.
We reviewed the records of 1,750 patients who underwent DRFx-ORIF at 2 level I trauma centers over 90 months. Of these patients, 10.7% underwent simultaneous CTR with DRFx-ORIF. Twenty patients who developed acute CTS within 3 weeks after DRFx-ORIF were identified. A case-controlled methodology was used; each patient was matched with 4 control patients who were treated with DRFx-ORIF but did not develop acute CTS on the operative limb. Differences between cases and controls were evaluated via univariable logistic regression modeling. Multivariate analysis was not performed because of the relatively small size of the cohort.
The development of acute CTS after DRFx surgical treatment resulted in 1.1% of patients returning to the operating room for an urgent second surgery. Three statistically significant risk factors for the development of acute CTS after DRFx-ORIF were identified via univariable analysis. Open fractures, AO C-type DRFx, and any intervening surgical procedure between injury and DRFx-ORIF were associated with greater relative odds of developing acute CTS.
Patients with open fractures, AO C-type DRFx, and any intervening surgical procedure are at increased risk for developing acute CTS after DRFx-ORIF and warrant consideration for prophylactic release at the time of DRFx-ORIF.
Therapeutic III.
Effects of Volar Tilt, Wrist Extension, and Plate Position on Contact Between Flexor Pollicis Longus Tendon and Volar Plate
2017, Journal of Hand Surgery
Volar plates positioned at, or distal to, the watershed line have been shown to have a higher incidence of attritional rupture of the flexor pollicis longus (FPL). In this study, we aimed to evaluate the effect of wrist extension and volar tilt on the contact between the plate and the FPL tendon in a cadaver model. We hypothesized that, following volar plate application, loss of native volar tilt increases the contact between the FPL and the plate at lower degrees of wrist extension.
A volar locking plate was applied on 6 fresh-frozen cadavers. To determine the contact between the plate and the FPL tendon, both structures were wrapped with copper wire and circuit conductivity was monitored throughout wrist motion. A lateral wrist radiograph was obtained at each circuit closure, indicating tendon-plate contact. Baseline measurements were obtained with plate positioned at Soong grades 0, 1, and 2. An extra-articular osteotomy was made and contact was recorded at various volar tilt angles (+5°, 0°, –5°, –10°, –15°, and –20°) in 3 different plate positions. A blinded observer measured the degree of wrist extension on all lateral radiographs. Data were analyzed using linear mixed-effects regression model.
Plates placed distal to the watershed line had the most contact throughout wrist range of motion. Significantly, less wrist extension was required for contact in wrists with neutral or dorsal tilt and in distally placed volar plates. Volar tilt, wrist extension, and plate position were 3 independent risk factors determining contact between plate and tendon.
Loss of volar tilt, increased wrist extension, and higher Soong grade plate position result in greater contact between wire-wrapped FPL tendon and plate.
The FPL/plate contact chart generated in this study may be used to assess the risk of rupture in the clinical setting.
The role of brachioradialis release during AO type C distal radius fracture fixation
2017, Orthopaedics and Traumatology: Surgery and Research
Open reduction and internal fixation of distal radius fractures often necessitates release of the brachioradialis from the radial styloid. However, whether this common procedure makes the reduction and fixation easier and affects the elbow function has not been fully understood.
Brachioradialis (BR) release during volar plate fixation for type C distal radius fractures makes internal reduction and fixation easier, and it does not adversely affect wrist or elbow function.
A total of 74 patients treated with 2.4 mm volar locking compression column plate (VCP) were analyzed for type C distal radius fractures prospectively. The patients were divided into two groups, group A with BR release and group B without BR release. The two groups were compared in terms of “internal reduction and fixation time” during the operation, wrist and elbow function including the scores of Gartland and Werley (G-W), Patient-related wrist evaluation score (PRWE), Mayo Elbow Performance Score (MEPS), the Disabilities of the arm, shoulder, and hand (DASH) and a Visual analog scale (VAS) for pain at 6 and 12 months postoperatively. The radial inclination angle, palmar tilt angle and ulnar variance were also measured from the radiographs.
According to the follow-up of the 74 patients, no significant differences were observed between the two groups on MEPS, DASH, G-W, PRWE, VAS and radiological outcomes at 6 and 12 months postoperatively. Mean time of reduction and internal fixation was significantly shorter in group A than that in group B.
Release of the BR for type C distal radius fractures facilitated the surgical procedure and did not adversely affect elbow and wrist function.
II, prospective comparative study.

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Surgical techniqueVolar Approach to Distal Radius Fractures

Section snippets

Indications and Contraindications

Surgical Anatomy

Surgical Technique

Postoperative Care and Rehabilitation

Clinical Case

Pearls and Pitfalls

Complications

J Hand Surg

J Hand Surg

J Hand Surg

J Hand Surg

Incidence of limb fracture across Europe: results from the European Prospective Osteoporosis Study (EPOS)

Osteoporos Int

Surgical technique
Volar Approach to Distal Radius Fractures