The extended flexor carpi radialis approach for partially healed malaligned fractures of the distal radius

Combined approach versus single Henry approach for fixation of die-punch distal radius fractures: a retrospective study

BACKGROUND

Distal radius fracture (DRF) is one of the most common orthopaedic-related traumas. DRF patients with die-punch fractures have a higher risk of loss of reduction, poorer functional outcomes, and increased risk of complications even after open reduction and internal fixation (ORIF). According to the three-column theory, the lunate fossa is an important part of the intermediate column for load bearing. When the distal radius fracture involves the lunate fossa, adequate anatomical reduction can have an important impact on the prognosis of wrist function. Herein, we used the combined volar and dorsal approach, and the dorsal approach was used to assist in bone grafting or dorsal plate fixation in reducing fractures. We compare the combined approach versus the Henry approach for the fixation of die-punch distal radius fractures.

METHODS

We reviewed patients who were admitted for surgery for die-punch fractures from January 2016 to June 2021. The patients were followed-up after surgery to measure and evaluate their Gartland-Werley wrist score, wrist range of motion (ROM), and follow-up imaging data.

RESULTS

There were 21 patients in the volar locking plate (VLP) group and 10 patients in the combined approach group. The majority of fractures in the VLP and combined approach groups were AO B and C fractures, respectively. The cause of injury and AO fracture classification showed significant differences between the two groups, and there was no difference in age or sex between the two groups. There was no significant difference in ROM between the two groups, but the VLP group presented a better Gartland-Werley score and volar tilt angle, and the combined group presented better maintenance in radial height and articular congruity.

CONCLUSIONS

Reduction through the combined palmar and dorsal approach supplemented by bone grafting or dorsal plate fixation is an effective method for the treatment of die-punch distal radius fractures, which provides a new option for the treatment of die-punch fractures.

Effect of Time-To-Surgery on Distal Radius Fracture Outcomes: A Systematic Review

PURPOSE

It remains unclear whether time-to-surgery for distal radius fractures affects clinical, functional, or radiographic outcomes or health care costs/use. This systematic review investigated the outcomes of early versus delayed surgery for closed, isolated distal radius fractures in adult patients.

METHODS

A comprehensive search of MEDLINE, Embase, and CINAHL databases was completed for all original case series, observational studies, and randomized controlled trials reporting clinical outcomes of both early and delayed surgically-treated distal radius fractures from database inception to July 01, 2022. A consistent threshold of two weeks was used to define early versus delayed treatment arms.

RESULTS

Nine studies, including 16 intervention arms and 1,189 patients (858 early, 331 delayed), were included. Mean age was 58 years (range, 33-76). At more than one year, the frequency-weighted mean Disabilities of the Arm, Shoulder, and Hand score was 4 in the early group (n = 208; range, 1-17) and 21 in the delayed group (n = 181; range, 4-27). Range of motion, grip strength, and radiographic outcomes were comparable. The pooled mean complication rate (7% vs 5%) and revision rate (3.6% vs 1%) were very low in both groups.

CONCLUSIONS

A delay in time-to-surgery greater than two weeks for distal radius fractures may be associated with inferior patient-reported outcomes. Early surgery was associated with improved long-term Disabilities of the Arm, Shoulder, and Hand scores. On the basis of the available evidence, range of motion, grip strength, and radiographic outcomes are similar. The complication and revision rates were very low in both groups and comparable.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Technique, Indications and Limitations of a Minimally Invasive Approach to Treat Distal Radius Fractures and Malunions

The minimally invasive flexor carpi radialis approach can be used for volar locking plate fixation of distal radius fractures. It offers the advantage of preserving ligamentotaxis, which facilitates the reduction and the small size of the scar improves the esthetic result of the procedure. It is indicated for extra-articular fractures of the distal radius. In the case of an intra-articular fracture, an arthroscopy may be associated. In the case of a proximal diaphyseal extension of the fracture, a second proximal approach can be added in order to use a longer plate. Relative contraindications are comminuted articular fractures in elderly osteoporotic patients. Functional and radiological results are comparable to those obtained with the extented flexor carpi radialis approach. A conversion of the procedure for a larger incision is always possible in the case of a difficult reduction.

Comparison of the conventional Henry approach and trans-flexor carpi radialis approach for the treatment of distal radius fracture: A retrospective cohort study

Few studies have compared the clinical outcomes of the conventional Henry approach and trans-flexor carpi radialis (FCR) approach. The purpose of this study was to compare the clinical and radiologic outcomes of the conventional Henry approach and trans-FCR approach for the treatment of distal radius fractures. We compared 20 wrists that underwent the conventional Henry approach with 20 wrists that underwent the trans-FCR approach for open reduction and internal fixation of distal radius fracture. The clinical and radiological parameters were checked at 3 months, 6 months, and 1 year after surgery. A visual analogue scale score, the modified Mayo wrist score, range of motion, and grip strength were collected. In addition, tenderness in the area of the FCR tendon were assessed. Regarding radiologic evaluations, the radial inclination, radial height, volar tilt, and ulna variance were measured. In the trans-FCR approach group, 15 patients complained of tenderness in the area of the FCR tendon at 3 months after surgery, which was significantly higher than those of conventional Henry approach group (P < .05). In the conventional Henry approach group, the tenderness had resolved spontaneously by 1 year after surgery in 19 patients. The trans-FCR approach can cause discomfort such as tenderness to the area of the FCR tendon compared to the conventional Henry approach, but there is no significant difference in the final clinical and radiologic outcomes.

Corrective Osteotomy of Malunited Fractures of the Distal Radius Using a Combined Surgical Approach

Background: Malunited distal radius (DR) fractures following conservative treatment range from 6% to 80% of clinical observations. Surgical treatment is used to return the articular surface of the radius to original anatomical position and to restore the natural transfer of strength, wrist kinematics, and function of the entire hand. The aim of this research was to study and analyze the results of corrective osteotomy of malunited distal radius fractures using a combined approach. Methods: From 2008 to 2018, 43 patients with malunited DR fractures who underwent surgery using a combined approach were followed up. Long-term results (1 year after surgery) were studied in detail in 32 patients. Indications for surgery were determined taking into account, first, complaints of severe pain in the wrist during exertion, decreased hand strength, and limited mobility of the wrist. Results: Five patients (15.6%) reported a number of minor complications: intra-articular screw placement (2), incorrect reposition (1), transient neuropathy of the superficial branch of the radial nerve (1), and delayed fracture consolidation (1). In addition, another 5 patients reported the progression of wrist arthritis. Suppurations of the surgical wound and malunited fragments were not reported. Conclusions: During reconstructive interventions, a combined approach with palmar plating provides optimal conditions for corrective osteotomy, adequate reposition and plastic repair of the bone defect, and minimization of the number of complications.

Radiographic Outcomes and Complications of Delayed Fixation of Distal Radius Fractures

BACKGROUND

Surgeons are sometimes presented with patients with distal radius fractures who present in a delayed fashion or lose reduction after several weeks of attempted closed management. There are limited studies on delayed surgical treatment of distal radius fractures to assist providers in decision-making.

METHODS

We conducted a matched cohort study to compare radiographic outcomes and complications for patients with a distal radius fracture treated with delayed (3-5 weeks) or early (0-2 weeks) surgical fixation. Patients ages 18+ who underwent open reduction and internal fixation of distal radius fractures by a volar approach at 2 Level I trauma centers between 2003 and 2015 were eligible. We measured radiographic outcomes and reviewed medical records to determine operative approach and complications.

RESULTS

There were 25 cases and 50 controls matched for age (18-87), sex, and AO fracture type. The delayed group had surgery at a mean of 24.8 days from injury and the early group at 5.6 days. There was no statistically significant difference between the delayed and early cohorts in radiographic parameters on injury x-rays, in improvement in radiographic parameters on first postoperative x-rays, or in maintenance of radiographic parameters at union.

CONCLUSION

We did not find significant differences in radiographic outcomes or complication rates between patients with delayed versus early surgical treatment for distal radius fracture. Providers treating patients with late presentation or late displacement have the option of surgical fixation beyond the first few weeks after injury.

LEVEL OF EVIDENCE

III (Retrospective matched cohort study).

Minimally invasive anterior plate osteosynthesis of the distal radius: A 710 case-series

INTRODUCTION

Since the 2000s, internal fixation of distal radius fracture by volar locking plate on an extended flexor carpi radialis (FCR) approach has become the gold standard.

OBJECTIVE

The present study aimed to assess medium-term results of minimally invasive plate osteosynthesis (MIPO) in distal radius fracture.

MATERIAL AND METHODS

The series comprised of 710 cases (512 female; mean age, 58 years). The 15mm approach was on the lateral edge of the FCR. The plate was slipped under the pronator quadratus. Closure used intradermal running suture without drain or orthosis.

RESULTS

At a mean 7 months' follow-up, mean scar length was 17mm (range, 10-40mm), pain 1.13/10 (0-8), Quick-DASH 13.28 (0-86.36), and patient-rated wrist evaluation (PRWE) 11.48 (0-91). Compared to contralateral values, mean flexion was 87.23%, extension 88.52%, pronation 96.17%, supination 93.41%, and grip strength 79.68%. Hardware was removed in 45.92% of cases. There were 16 cases of secondary displacement, with 4 revision procedures, one of sepsis at 6 months, 10 of complex regional pain syndrome, and 14 of median nerve paresthesia, with 4 carpal tunnel release procedures.

DISCUSSION

The minimally invasive FCR approach can be used for volar plate fixation of distal radial fracture. It has the advantage of conserving ligamentotaxis, facilitating reduction and improving scar esthetics. The incision can be extended if need be.

LEVEL OF EVIDENCE

III; single-centre retrospective study.

Minimally invasive internal fixation for extra-articular distal radius fracture: Comparison between volar plate and intramedullary nail

INTRODUCTION

There are numerous internal fixation techniques for distal radius fracture, using pins, plates or nails. Some authors have developed minimally invasive procedures. The aim of the present study was to compare two minimally invasive internal fixation techniques for unstable extra-articular distal radius fracture in women over 50 years of age: volar plate (minimally invasive plate osteosynthesis: MIPO), and intramedullary nail.

HYPOTHESES

The main study hypothesis was that the incision scar left by minimally invasive internal fixation is smaller using MIPO than an intramedullary nail. The secondary hypotheses were that the two techniques do not differ in terms of pain, functional score, strength, range of motion and radiologic indices.

MATERIAL AND METHOD

The series comprised nineteen A2.2 and one A2.1 fractures in 20 female patients with a mean age of 72 years. The first 10 (group 1) received minimally invasive internal fixation of the distal radius by MIPO, and the other 10 (group 2) by intramedullary nail locked onto the distal radius epiphysis and diaphysis.

RESULTS

The main study hypothesis was confirmed: the incision scar left by minimally invasive internal fixation was smaller using MIPO than an intramedullary nail (mean, 14.3mm vs. 32.8mm). Some of the secondary hypotheses were also confirmed: there were no differences between the two techniques in terms of pain at 6 months, QuickDASH, PRWE (Patient-Reported Wrist Evaluation), range of motion or ulnar variance; two were not confirmed: pain at 6 weeks was less with intramedullary nails, and palmar slope was better with MIPO.

DISCUSSION AND CONCLUSION

The main study hypothesis was confirmed: the incision scar left by minimally invasive internal fixation was smaller using MIPO than an intramedullary nail. In conclusion, the present findings showed that internal fixation of unstable extra-articular fracture in over 50-year-olds gave better clinical results at 6 weeks using an intramedullary nail, while MIPO required smaller incision.

LEVEL OF EVIDENCE

III, retrospective study.

A Novel Technique for Correcting Radial Length and Translation in Distal Radius Fractures

We describe a novel technique in correcting distal radius fractures deformed with significant shortening or coronal plane translation in both the acute or chronic setting. The technique involves using a modified push-pull device to assist the surgeon in correcting length and/or translation of the articular block without the use additional hardware outside of the volar plate.

The minimally invasive approach for distal radius fractures and malunions

This article reviews the author's currently used minimal invasive approach for volar plating of distal radius fractures. A single longitudinal incision of 1.5 cm is drawn on the lateral aspect of the flexor carpi radialis tendon in order to insert a plate under the pronator quadratus. With the wrist flexed, the plate is applied on the anterior cortex of the radius to reduce the fracture. This approach offers the advantage of preserving ligamentotaxis, which facilitates the reduction, and the small scar improves the cosmetics. It is mainly indicated for extra-articular and simple intra-articular fractures of the distal radius. Relative contraindications are comminuted articular fractures in elderly osteoporotic patients. Functional and radiological results are comparable with those obtained with an extended flexor carpi radialis approach. My colleagues and I have used it for more than 2000 cases since 2012. This technique requires practise. Attempted conversion to a larger incision is possible in case of difficulty, but this is seldom necessary.

The minimally invasive flexor carpi radialis approach: a new perspective for distal radius fractures

The minimally invasive flexor carpi radialis approach can be used for volar locking plate fixation of distal radius fractures. After 15-mm incision on the lateral aspect of the FCR tendon and all structures but the radial artery are reclined ulnarly, a plate is inserted under the pronator quadratus just proximal to the "watershed line." The distal epiphyseal screws are put in place, and the proximal part of the plate is exposed by flexion of the wrist to put in place the proximal screws. No drainage or postoperative immobilization is used. It offers the advantage of preserving ligamentotaxis which facilitates the reduction, and the small size of the scar improves the esthetic result of the procedure. It is indicated for extra-articular fractures of the distal radius. In the case of an intraarticular fracture, an arthroscopy may be associated. In the case of a proximal diaphyseal extension of the fracture, a second proximal approach can be added in order to use a longer plate. Relative contraindications are comminuted articular fractures in elderly osteoporotic patients. Functional and radiological results are comparable to those obtained with the extented flexor carpi radialis approach. A conversion of the procedure for a larger incision is always possible in the case of a difficult reduction.

The role of brachioradialis release during AO type C distal radius fracture fixation

INTRODUCTION

Open reduction and internal fixation of distal radius fractures often necessitates release of the brachioradialis from the radial styloid. However, whether this common procedure makes the reduction and fixation easier and affects the elbow function has not been fully understood.

HYPOTHESIS

Brachioradialis (BR) release during volar plate fixation for type C distal radius fractures makes internal reduction and fixation easier, and it does not adversely affect wrist or elbow function.

MATERIAL AND METHODS

A total of 74 patients treated with 2.4mm volar locking compression column plate (VCP) were analyzed for type C distal radius fractures prospectively. The patients were divided into two groups, group A with BR release and group B without BR release. The two groups were compared in terms of "internal reduction and fixation time" during the operation, wrist and elbow function including the scores of Gartland and Werley (G-W), Patient-related wrist evaluation score (PRWE), Mayo Elbow Performance Score (MEPS), the Disabilities of the arm, shoulder, and hand (DASH) and a Visual analog scale (VAS) for pain at 6 and 12 months postoperatively. The radial inclination angle, palmar tilt angle and ulnar variance were also measured from the radiographs.

RESULTS

According to the follow-up of the 74 patients, no significant differences were observed between the two groups on MEPS, DASH, G-W, PRWE, VAS and radiological outcomes at 6 and 12 months postoperatively. Mean time of reduction and internal fixation was significantly shorter in group A than that in group B.

CONCLUSION

Release of the BR for type C distal radius fractures facilitated the surgical procedure and did not adversely affect elbow and wrist function.

LEVEL OF EVIDENCE

II, prospective comparative study.

Comparison of outcomes between partially healed and acute metaphyseally malaligned distal radial fracture treated by palmar locking plate fixation

BACKGROUND

The purpose of this study was to determine whether a partially healed (surgical delay of 2-6 weeks) metaphyseally malaligned distal radius fracture (DRF) treated using the extended palmar approach with palmar locking plate fixation has poorer clinical or radiological outcomes than those of acute (surgical delay of ≤2 weeks) metaphyseally unstable DRF treated by palmar locking plate fixation.

METHODS

We identified 24 patients (Group A) who were treated with palmar locking plate for a partially healed (surgical delay of 2-6 weeks) metaphyseally malaligned DRF. We selected 48 patients (Group B) who were treated with palmar locking plate among the acute (surgical delay of ≤2 weeks) metaphyseally unstable DRF to be individually matched in a 1:2 ratio for sex, age, and fracture type. The two study groups were compared with respect to clinical and radiological parameters. The clinical parameters examined were; wrist range of motion (flexion, extension, supination, and pronation), grip strength, and Disabilities of Arm, Shoulder and Hand (DASH) scores. Radiological measurements included radial inclination, palmar angulation, and ulnar variance.

RESULTS

The wrist flexion and grip strength were significantly greater in group B than group A at 3 months postoperatively. However, wrist ranges of motion, grip strengths, and DASH scores were not significantly different at 1 year postoperatively. Radiographic evaluation demonstrated no intergroup difference in terms of radial inclination, palmar angulation, or ulnar variance at 1 year postoperatively.

CONCLUSIONS

Partially healed metaphyseally malaligned healed DRFs had inferior clinical outcomes to acute metaphyseally unstable DRFs in an early postoperative period, however, achieved similar clinical outcomes at 1 year postoperatively when treated using palmar locking plate fixation.

Intra-articular comminution worsens outcomes of distal radial fractures treated by open reduction and palmar locking plate fixation

We studied 50 patients with AO type C2 distal radial fractures and 35 with AO type C3 distal radial fractures treated by open reduction and palmar locking plate fixation. At 3-month clinical assessments, mean wrist flexion arcs, grip strengths and disabilities of the arm, shoulder and hand scores were significantly better for AO type C2 fractures. At 2-year post-operative clinical assessments, mean disabilities of the arm, shoulder and hand scores were significantly better for AO type C2 fractures than for AO type C3 fractures. At 2-year radiographic examinations, anterior angulations, ulnar variances and arthritis grades were also significantly better for AO type C2 fractures. This study showed that AO type C3 distal radial fractures, which have intra-articular comminution, had poorer clinical and radiographic outcomes than AO type C2 fractures, despite open reduction and palmar locking plate fixation.

LEVEL OF EVIDENCE

IV.

[Descriptive, radiographic, topographic and functional anatomy applied to distal radius fractures]

Extensive anatomical knowledge is needed in order to correctly treat distal radius fractures: normal and pathological osteology of the distal radius, distal radio-ulnar joint and radiocarpal joint-both on the descriptive and functional level-the neurovascular and muscular environments of the distal radius-which are essential to the surgical approaches-and the angles that need to be restored during the reduction. All of these concepts are broached in this article.

The EFCR Approach and the Radial Septum-Understanding the Anatomy and Improving Volar Exposure for Distal Radius Fractures: Imagine What You Could Do With an Extra Inch

Locked volar plating is the most common surgical procedure to address distal radius fractures. The extended flexor carpi radialis approach continues to be an excellent method for visualizing distal radius fractures and applying a volar plate. A new understanding of the anatomy allows for better visualization and reduction of the many different distal radius fracture patterns surgeons commonly see. Within the extended flexor carpi radialis approach, we describe the radial septum in further detail including the anatomy which comprises the radial septum triangle. Knowledge of this area allows for better visualization, more anatomic reductions, and fewer complications.

Distal Radius Fractures: Approaches, Indications, and Techniques

Distal radius fractures remain among the most common fractures of the upper extremity. The indications for operative management continue to evolve based on outcomes from the most recent clinical studies. Advancements over the past decade have expanded the variety of fixation options available; however, the clinical superiority of a particular treatment modality remains without consensus. Each approach requires the use of unique surgical techniques, and the choice of a particular implant system should be based on the surgeon's familiarity with the implant design and its limitations. As our understanding of the management of distal radius fractures improves, so will our indications for each specific treatment modality.

DVR plating of distal radius fractures

Volar plating has become the standard of care for most distal radius fractures. When done for the right indication and with adequate mastering of the technique complication ratio is low. The concept of subchondral support is key in this technique. Osteoporotic patients will especially benefit from this type of fixation which allows early immobilization, quick return to activities of daily living and early good outcome.

Exposure of the forearm and distal radius

Approaches to the forearm use internervous planes to allow adequate bone exposure and prevent muscle denervation. The Henry approach utilizes the plane between muscles supplied by the median and radial nerves. The Thompson approach utilizes the plane between muscles supplied by the radial and posterior interosseous nerves. The distal radius may be approached volarly. The extended flexor carpi radialis approach is useful for intraarticular fractures, subacute fractures, and malunions. The distal radius can be approached dorsally by releasing the third dorsal compartment and continuing the dissection subperiosteally. Choice of approach depends on the injury pattern and the need for exposure.

The effect of brachioradialis release during distal radius fracture fixation on elbow flexion strength and wrist function

PURPOSE

To identify whether brachioradialis (BR) release during volar plate fixation for a distal radius fracture affects elbow flexion strength and wrist function.

METHODS

A total of 42 consecutive patients who were treated by open reduction volar plate fixation for unstable distal radius fractures were enrolled in this study. The BR was not released in 20 of 42 patients (BR preserved group) and was released in 22 patients (BR released group). The primary outcome variable was isokinetic strength and endurance testing of elbow flexion measured by the Cybex isokinetic system 3 months after surgery. Measured at the same time, secondary outcome variables were grip strength, a visual analog scale score for wrist pain, Disabilities of the Arm, Shoulder, and Hand score, and radiographic parameters. We used Mann-Whitney U tests to compare these variables between groups.

RESULTS

Neither elbow flexion strength and endurance nor any of the secondary outcome variables differed significantly between groups.

CONCLUSIONS

Release of the BR during a volar approach for a distal radius fracture did not adversely affect elbow flexion strength and wrist function.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic III.

Outcome of delayed primary internal fixation of distal radius fractures: a comparative study

INTRODUCTION AND AIM

Operative fixation of distal radius fractures using fixed-angle devices has become increasingly common. Although good to excellent results have been reported in acute fractures, little is currently known regarding the fixation of healing displaced distal radius fractures that were presented late. The aim of this study was to evaluate the results of internal fixation of distal radius fractures presented late (>21 days) as compared with an acute-care control group.

METHODS

Forty patients operated on for displaced distal radius fractures, presenting more than 21 days after injury (delayed treatment (DT) group), were compared with 75 age-matched controls with acute fracture repair (≤21 days). The same surgical approach was used in both groups, together with dorsal soft-tissue and brachioradialis release. No osteotomy was required. Direct and indirect reduction aids were used. A fixed-angle device (DVR; Biomet Inc., Warsaw, IN, USA) was used in both groups. Mean follow-up was 3.4 years. Quick DASH (Disabilities of the Arm, Shoulder and Hand) and Short Form 12 scores were used to evaluate outcome, as well as radiographic analysis for Arbeitsgemeinschaft für Osteosynthesefragen(AO)/Orthopaedic Trauma Association(OTA) classification, volar tilt, radial inclination and radial length.

RESULTS

Average age was 53 years in both groups and male to female (M/F) ratio was similar in the study groups. Mean time to surgery was 30 days in the DT group and 8 days in the control group. There were significantly more type C (91.5% vs. 67.5%) fractures in the control group. The average quick DASH score was 27.1 in the DT group as compared with 6.3 in the control group (p<0.03); however, when controlling for two outlier cases with complications (hardware irritation and a sensory neuropathy) there was no significant difference. Volar tilt, radial inclination and length were similar in both groups and were within normal anatomical values.

CONCLUSIONS

Delayed primary operative fixation of displaced unstable distal radial fractures is a viable option for cases that were presented late, with predictable, favourable results. Neither extensile approaches nor formal osteotomies are required.

Intramedullary nail versus volar plate fixation of extra-articular distal radius fractures. Two year results of a prospective randomized trial

BACKGROUND

Intramedullary techniques for stabilization of displaced distal radius fractures are now available. Purported benefits include limited soft tissue dissection while affording sufficient stability to allow early wrist motion. The primary null hypothesis of this randomized trial is that there is no significant difference with respect to functional outcome, pain and disability between patients treated with either 2.4-mm volar locking plate fixation or intramedullary nail fixation of unstable dorsally displaced extra-articular fractures of the distal radius.

METHODS

We conducted a single-centre, parallel-group trial, with unrestricted randomization. Patients with dorsally displaced extra-articular distal radius fractures were randomized to receive volar locking plate (n=72) fixation or intramedullary nailing (n=80). The outcome was measured on the basis of the Gartland and Werley and Castaing score; the pain level; the range of wrist motion; the rate of complications; and radiographic measurements including volar tilt and ulnar variance. Clinical and radiographic assessment was performed at 8 weeks, 6 months, 1 year and 2 years after the operation.

RESULTS

There were no significant differences between groups in terms of range of motion, grip strength or the level of pain during the entire follow-up period (p>0.05). There was no significant difference between treatment groups with respect to volar tilt or ulnar variance (p>0.05). There was no significant difference in the complication rate between groups (p>0.05).

CONCLUSIONS

The present study supports the view that intramedullary nail fixation and volar plate fixation for the treatment of displaced extra-articular distal radius fractures have equivalent radiographic and functional outcomes.

LEVEL OF EVIDENCE

Level I therapeutic study.

Extensile surgical exposures of the radius: a comparative anatomic study

PURPOSE

To evaluate and compare exposures of the radius using 3 surgical approaches. Our hypotheses were that the anterior flexor carpi radialis approach allows greater exposure of the distal radius than does the volar-ulnar approach, and the extensile flexor carpi radialis approach allows comparable proximal and midshaft exposure of the radius compared with the dorsal Thompson approach.

METHODS

We performed anterior and dorsal exposures of the radius on 10 matched pairs of cadavers (20 forearms) randomly assigned to 1 anterior and 1 dorsal approach. We measured and compared the anatomic features and limits of the anterior flexor carpi radialis approach, volar-ulnar approach to the distal radius, and the dorsal Thompson approach.

RESULTS

The anterior flexor carpi radialis approach exposed 3.3 cm of distal radius width, was convertible to an extensile approach proximally, required sacrifice of 3 arterial branches, and was limited by the junction of the radial and ulnar arteries. This approach provided 79% of radius exposure and ended 4.7 cm distal to the radiocapitellar joint. The volar-ulnar approach to the distal radius exposed 3.1 cm of distal radius width. The dorsal Thompson approach sacrificed no arterial branches, provided 69% of radius exposure, was limited by the first compartment distally and the posterior interosseous nerve proximally, and ended within 2.6 cm of the radiocapitellar joint. The posterior interosseous nerve coursed 19, 14, and 6 mm dorsolateral to the distal, middle, and proximal margins, respectively, of the supinator insertion on the radius.

CONCLUSIONS

The volar-ulnar approach provided less access to the radial styloid and was not as extensile as the flexor carpi radialis approach. The Thompson approach provided more proximal exposure than the flexor carpi radialis approach.

CLINICAL RELEVANCE

Improved knowledge of the anatomy, limits of exposure, and comparison of features between approaches to the radius may facilitate surgical planning and exposure.