Surgical Approaches for Plating of Distal Radius Fractures

There are two main open approaches used for plate fixation of the distal radius, chosen based on fracture pattern/displacement, plus fragment-specific and bridging techniques for special situations.

1. Volar (Henry) Approach - for Volar Locked Plating

This is now the most commonly used approach for the majority of distal radius fractures.

Indications: unstable extra-articular fractures (Colles-type), volar shear (Smith/Barton) fractures, most complete articular fractures, and combined distal radius/ulna fractures. Also used for corrective osteotomy in malunion - Rockwood and Green's Fractures in Adults, 10th ed; Miller's Review of Orthopaedics, 9th ed.

Technique:

Skin incision along the FCR (flexor carpi radialis) tendon
Interval developed between the FCR tendon and the radial artery (classic Henry interval), or alternatively through the floor of the FCR tendon sheath
The pronator quadratus is elevated off the radius (radially-based flap) to expose the fracture and volar plate position
Plate is seated at or proximal to the "watershed line" (the distal-most ridge of the volar radius) to minimize flexor tendon irritation
Reduction is largely fluoroscopically guided since the articular surface is not directly visualized through this approach
Fixed-angle and variable-angle locking plate systems are both available; variable-angle plates give more flexibility for complex intra-articular patterns (e.g., lunate facet fragments)
If very small/comminuted distal fragments exist, specialized volar rim plates are used, though these carry higher rates of tendon irritation
In patients with a concurrent scaphoid fracture or carpal tunnel syndrome, the volar incision can be extended to address both through one approach (requires mobilizing the FCR tendon and releasing the transverse carpal ligament)

Key complications:

Flexor tendon injury when plate is placed distal to the watershed line - most commonly FPL, then FDP of the index finger
Extensor tendon injury (usually EPL) from an overly long dorsal screw penetrating the dorsal cortex
Routine pronator quadratus repair has no proven clinical benefit on outcomes (supported by recent meta-analysis of RCTs, PMID 37482790), and a 2024 systematic review found no significant difference in outcomes between pronator quadratus-preserving vs. pronator quadratus-dissecting volar approaches (PMID 38678106)

2. Dorsal Approach - for Dorsal Plating

Indications: dorsally displaced fractures with dorsal bony defects, dorsal shearing fractures, die-punch fractures, and severely comminuted articular fractures where direct articular visualization is needed - Campbell's Operative Orthopaedics, 15th ed; Miller's Review of Orthopaedics.

Technique:

Approach is developed between the third and fourth extensor compartments (extensor pollicis longus and extensor digitorum communis)
Allows direct visualization of the articular reduction, an advantage over the volar approach
Historical disadvantage: extensor tendon irritation/rupture from prominent dorsal hardware - lower-profile fragment-specific dorsal plates have reduced this risk

3. Fragment-Specific Fixation

Uses multiple small, low-profile plates/pins targeted to individual fracture fragments (e.g., the volar-ulnar "critical corner" fragment)
Technically demanding but useful for highly comminuted intra-articular patterns not well controlled by a single volar plate
A recent RCT (150 patients) cited in Campbell's found standard volar locked plating had radiographic/clinical outcomes similar to fragment-specific fixation for comminuted intra-articular fractures

4. Bridge (Distraction) Plating

Alternative to external fixation for highly comminuted, unstable fractures or elderly patients with severe osteoporosis; allows earlier weight-bearing through the limb
Technique: plate spans from the radial shaft to the second or third metacarpal, holding length via ligamentotaxis while the fracture heals
Can be combined with volar plating for the articular component
Higher risk of EPL tendon entrapment when secured to the third metacarpal vs. index metacarpal
Disadvantage: requires a second procedure to remove the plate at 8-12 weeks

Below is a systematic review specifically comparing dorsal bridge plating outcomes if you want to go deeper on that technique: this 2024 review (PMID 38967772) evaluated dorsal bridge plating results in distal radius fractures and may be worth checking if bridge plating is your specific interest.

Sources: Rockwood and Green's Fractures in Adults, 10th ed.; Campbell's Operative Orthopaedics, 15th ed.; Miller's Review of Orthopaedics, 9th ed.

Let me know if you'd like a deeper dive into one specific approach (e.g., step-by-step volar Henry approach with preoperative checklist, or dorsal bridge plating technique) - the textbooks have detailed preoperative planning checklists and intraoperative steps I can pull in full.

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