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

Volar Plating Approach for Distal Radius Fracture: Step-by-Step Procedure

The volar plating approach is the preferred surgical technique for distal radius fractures due to its ability to provide stable fixation and allow earlier recovery of function in the short term (3 months) compared to other fixation methods. 1

Preoperative Planning

• Obtain proper radiographic evaluation to confirm diagnosis and fracture pattern, including assessment of displacement, dorsal tilt, and presence of intra-articular involvement 2
• Classify the fracture based on displacement (>3mm is significant) and dorsal tilt (>10° is significant) to guide treatment approach 2
• Consider volar locked plating particularly for multi-fragmentary fractures with significant comminution and/or bone loss 3

Surgical Approach

1. Patient Positioning and Anesthesia

   • Position patient supine with the affected arm on a radiolucent hand table 3
   • Apply tourniquet to the upper arm and elevate for hemostasis 3
   • Administer appropriate anesthesia (regional or general) 3

2. Surgical Exposure - Extended FCR Approach

   • Make a longitudinal incision (8-10 cm) along the course of the flexor carpi radialis (FCR) tendon 3
   • Identify and protect the radial artery, which lies lateral to the FCR tendon 3
   • Incise the FCR tendon sheath and retract the tendon ulnarly 3
   • Identify and protect the median nerve, which lies ulnar to the FCR 4
   • Incise the pronator quadratus at its radial border, creating an L-shaped flap for later repair 5
   • Elevate the pronator quadratus from the radius to expose the fracture site 5

3. Fracture Reduction

   • Reduce the fracture under direct visualization and fluoroscopic guidance 5
   • For intra-articular fragments, ensure anatomic reduction of the articular surface 6
   • Temporarily stabilize the reduction with K-wires if needed 4
   • Confirm reduction with fluoroscopy in multiple planes 5

4. Plate Application

   • Select an appropriately sized volar locking plate 5
   • Position the plate on the volar surface of the radius, just proximal to the watershed line 5
   • Secure the plate to the shaft with a non-locking screw through the oblong hole to allow for fine adjustment 5
   • Confirm proper plate position with fluoroscopy 5
   • Insert distal locking screws into the subchondral bone, ensuring they do not penetrate the dorsal cortex or enter the joint 4
   • Complete fixation with additional shaft screws 5
   • Recheck reduction and hardware position with fluoroscopy in multiple planes 5

5. Wound Closure

   • Repair the pronator quadratus over the plate if possible 5
   • Close the wound in layers 5
   • Apply a sterile dressing and a volar splint in neutral position 5

Postoperative Management

• Apply a removable splint for comfort for the first 1-2 weeks 2
• Instruct patients to perform active finger motion exercises immediately following surgery to prevent stiffness 1
• Early wrist motion is not routinely necessary following stable fracture fixation 1
• Radiographic follow-up is recommended at approximately 3 weeks and at the time of immobilization removal 2
• Prescribe a home exercise program for rehabilitation 1

Potential Complications and Prevention

• Transient nerve dysfunction is the most common complication (particularly in early surgeon experience) 4
• Careful identification and protection of neurovascular structures can minimize nerve complications 4
• Avoid placing screws that penetrate the dorsal cortex to prevent extensor tendon irritation 4
• Position the plate proximal to the watershed line to avoid flexor tendon irritation 5
• Surgeon experience significantly reduces complication rates, with the first 30 cases showing higher complication rates 4

Expected Outcomes

• Volar locked plating leads to earlier recovery of function in the short term (3 months) compared to other fixation techniques 1
• Early mobilization after volar plating shows better range of motion in the sagittal plane and grip strength up to 6 months post-surgery 7
• At one year post-surgery, patients with early mobilization show 93% "excellent" and "good" results according to the Green O'Brien score 7