What is the step-by-step procedure for a volar approach with plating for a fracture of the distal end of the radius?

From the Guidelines

The volar approach with plating for distal radius fractures is the recommended procedure, as it provides excellent exposure of the fracture, allows anatomic reduction, and provides stable fixation through a relatively safe interval. The procedure begins with positioning the patient supine with the arm extended on a hand table under general or regional anesthesia, as described in the clinical practice guideline summary management of distal radius fractures 1. After standard prepping and draping, a longitudinal incision is made along the flexor carpi radialis (FCR) tendon, typically 8-10 cm in length. The FCR tendon sheath is opened, and the tendon is retracted ulnarly. The flexor pollicis longus is identified and retracted ulnarly to expose the pronator quadratus.

The pronator quadratus is then incised along its radial border and elevated from the radius, exposing the fracture site. After fracture reduction under fluoroscopic guidance, a volar locking plate is positioned on the volar surface of the distal radius. The plate should be placed proximal to the watershed line to avoid flexor tendon irritation, as supported by the updated clinical practice guideline summary management of distal radius fractures 1. Provisional fixation is achieved with K-wire, followed by placement of distal locking screws into the subchondral bone and proximal screws in the radial shaft.

After confirming proper reduction and hardware placement with fluoroscopy, the pronator quadratus is repaired over the plate when possible. The wound is irrigated and closed in layers, followed by application of a well-padded splint with the wrist in slight extension. Postoperatively, early finger motion is encouraged, with wrist motion typically beginning at 2 weeks. This approach is supported by the American Academy of Orthopaedic Surgeons and the American Society for Surgery of the Hand clinical practice guideline summary management of distal radius fractures 1.

Key considerations for the procedure include:

• Patient selection: The indication for fixation of distal radius fractures is updated to reflect patients under the age of 65, with moderate support for operative fixation in the non-geriatric population and strong evidence that demonstrates surgical fixation in those above 65 years of age does not lead to improved outcomes 1.
• Imaging: The statement designed to guide serial radiographic imaging for patients treated for distal radius fractures has been updated, with no difference exists in outcomes based on frequency of radiographic evaluation for patients treated for distal radius fractures 1.
• Rehabilitation: The use of a home exercise program and supervised therapy following the treatment of distal radius fractures has been unchanged, with inconsistent evidence to support its use, and the need for more investigation into this topic 1.

From the Research

Procedure Overview

The procedure for a volar approach with plating for a fracture of the distal end of the radius involves several steps:

• Preparation of the patient and the operating room
• Administration of anesthesia and positioning of the patient
• Incision and exposure of the fracture site
• Reduction of the fracture and application of the volar plate
• Fixation of the plate to the bone
• Closure of the incision and postoperative care

Step-by-Step Procedure

The step-by-step procedure for a volar approach with plating for a fracture of the distal end of the radius is as follows:

• The patient is positioned in a supine position with the affected arm extended on a radiolucent arm table 2
• A volar incision is made, and the fracture site is exposed 3
• The fracture is reduced, and a volar locking plate is applied to the distal radius 4
• The plate is fixed to the bone using screws, and the fracture is stabilized 3
• The incision is closed, and the patient is taken to the recovery room for postoperative care 2

Considerations and Complications

Considerations and complications for the procedure include:

• The choice of plate fixation should depend on fracture type, patient factors, and surgeon experience 4
• Arthroscopic-assisted volar plating may be useful for intra-articular reduction and treatment of associated soft tissue injuries 5
• Implant removal after volar locking plate fixation may be necessary in some cases, and is not associated with major complications 6
• Complications such as median nerve compression, tendon rupture, arthrosis, and malunion can occur 2

Plate Fixation Options

Plate fixation options for distal radius fractures include:

• Volar plating: has broad applicability and consistent outcomes, and is the most commonly used plate type 4
• Dorsal plating: advantageous for specific fracture patterns, and can provide direct fracture reduction and buttressing 4
• Bridge plating: offers an alternative to external fixation, and can be used for immediate weight bearing 4