What is the step-by-step procedure for treating distal radius fractures using a volar (front) plating approach?

From the Guidelines

The volar plating approach for distal radius fractures involves a systematic surgical procedure beginning with patient positioning in supine position with the arm extended on a hand table under general or regional anesthesia. This approach is supported by recent guidelines, including the American Academy of Orthopaedic Surgeons/American Society for Surgery of the Hand clinical practice guideline summary on the management of distal radius fractures 1.

Key Steps in the Procedure

• A longitudinal incision is made along the flexor carpi radialis tendon, typically 6-8 cm in length.
• The surgeon then identifies and retracts the flexor carpi radialis tendon laterally, protecting the median nerve and radial artery throughout the procedure.
• The pronator quadratus muscle is elevated from the radius using an L-shaped incision at its radial border, exposing the fracture site.
• After thorough irrigation and debridement of the fracture hematoma, the fracture is reduced under direct visualization and fluoroscopic guidance.

Fixation and Closure

• Provisional K-wires may be used to maintain reduction temporarily.
• A pre-contoured volar locking plate is positioned on the volar surface of the distal radius, ensuring it sits proximal to the watershed line to avoid flexor tendon irritation.
• The plate is secured with locking and non-locking screws, with care taken to avoid penetrating the dorsal cortex or entering the radiocarpal joint.
• Fluoroscopy confirms proper plate and screw placement, fracture reduction, and restoration of radial height, inclination, and volar tilt.
• The pronator quadratus is then repaired over the plate when possible to provide additional soft tissue coverage.

Post-Operative Care

• The wound is irrigated and closed in layers, followed by application of a sterile dressing and a volar splint with the wrist in slight extension.
• Post-operatively, early finger motion is encouraged, with wrist motion typically beginning at 1-2 weeks based on fracture stability, as supported by the guideline indicating moderate evidence to support treatment of non-geriatric patients 1.
• This approach provides stable fixation through a relatively safe surgical corridor, allowing for early mobilization and better functional outcomes compared to other treatment methods for unstable distal radius fractures.

From the Research

Step-by-Step Procedure for Distal End Radius by Plating Volar Approach

The volar plating approach is a valuable method for treating distal radius fractures, offering broad applicability and consistent outcomes 2. The procedure involves several key steps:

• Preoperative Planning: Careful evaluation of the fracture pattern and patient factors is essential to determine the best approach and type of plate to use 2.
• Surgical Approach: The volar approach can be performed using different methods, including the traditional Henry approach or alternative approaches that spare the pronator quadratus muscle, such as the brachioradialis splitting approach or the volar plating insertion PQ muscle approach 3.
• Exposure and Reduction: The fracture is exposed and reduced, taking care to avoid damage to surrounding tissues and to achieve accurate reduction of the fracture fragments 4.
• Plate Fixation: A volar locking plate is applied to the distal radius, with screws inserted to secure the plate to the bone 5. The use of dorsal tangential views can help avoid screw penetration and minimize the risk of iatrogenic extensor tendon rupture 6.
• Stabilization and Fixation: The fracture is stabilized and fixed using the volar locking plate, with careful attention to the placement of screws and the overall stability of the construct 4.
• Closure and Postoperative Care: The wound is closed, and the patient is managed postoperatively with a focus on pain management, wound care, and early mobilization to promote healing and recovery 3.

Key Considerations and Tips

Several key considerations and tips can help optimize the outcome of volar plating for distal radius fractures:

• Anatomical Understanding: A detailed understanding of the volar distal radius anatomy is essential to facilitate appropriate placement of the volar plate and avoid complications such as flexor tendon rupture 5.
• Plate Selection: The choice of plate should depend on the fracture type, patient factors, and surgeon experience, with volar plating being the most commonly used approach 2.
• Screw Placement: Careful attention to screw placement is critical to avoid complications such as dorsal screw protrusion, with the use of dorsal tangential views recommended to minimize this risk 6.
• Postoperative Management: Early mobilization and rehabilitation are essential to promote healing and recovery, with a focus on pain management and wound care 3.