Thompson vs. Henry Approach for Radial Shaft Fractures

1. Henry Approach (Anterior/Volar Approach)

Interval

• Between brachioradialis (radial nerve) and flexor carpi radialis / pronator teres (median nerve)
• Deeper interval: between pronator teres and the radius

Patient Position

• Supine, arm on a hand table, forearm supinated

Incision

• Longitudinal incision along the volar forearm from the biceps tendon distally toward the radial styloid
• Length adjusted based on fracture location

Steps

1. Identify and protect the radial artery (lies between BR and FCR)
2. Retract the radial artery medially or laterally as needed
3. Identify and protect the superficial branch of the radial nerve (lies under BR)
4. Pronate the forearm to expose the proximal radius
5. Supinate to expose the distal radius

Structures at Risk

Best For

• Distal 2/3 of the radial shaft
• When the volar surface needs plating
• Galeazzi fractures (distal radius + DRUJ disruption)
• Revision surgery or when dorsal scarring exists
• Fractures associated with volar soft tissue injury

2. Thompson Approach (Posterior/Dorsal Approach)

Interval

• Between extensor carpi radialis brevis (radial nerve) and extensor digitorum communis (posterior interosseous nerve)

Patient Position

• Supine with arm across the chest, or prone — forearm in pronation

Incision

• Longitudinal incision along the dorsal forearm from the lateral epicondyle toward Lister's tubercle

Steps

1. Develop the interval between ECRB and EDC
2. Identify and protect the PIN — it crosses the proximal radius through the supinator muscle
3. To safely expose the proximal radius, pronate the forearm to move the PIN away
4. Alternatively, the supinator is split longitudinally with PIN identified and retracted

Structures at Risk

Best For

• Proximal 1/3 of the radial shaft
• Monteggia fracture variants involving the proximal radius
• When the dorsal surface needs plating
• Cases where the Henry approach would require excessive pronator teres dissection

Head-to-Head Comparison

Key Clinical Pearls

• The PIN is the most feared structure in the Thompson approach. To protect it:
  • Pronate the forearm to rotate PIN anteriorly, away from the field
  • Always identify PIN before using retractors proximally
  • Do not use electrocautery near it
• In the Henry approach, the radial artery must be identified before deep dissection. Its accidental ligation can cause ischemia distally.
• For both-bone forearm fractures (radius + ulna), the ulna is typically approached via a direct posterior approach over the subcutaneous border, while the radius uses either Henry or Thompson depending on fracture level.
• Plate placement: The volar surface of the radius is flatter and more ideal for low-profile implants in the Henry approach; the Thompson approach places the plate on the dorsal radius which has a more curved surface.