Distal Radius ORIF with Volar Locking Plate

Indication. An unstable distal radius fracture in a healthy, active adult — one that falls outside acceptable non-operative parameters after closed reduction — is the core indication for volar locking plate fixation. The procedure is also indicated for open fractures, fractures with acute carpal tunnel syndrome, and polytrauma or bilateral injuries where early mobilisation matters. Acceptable non-operative parameters. In a healthy adult the following radiographic parameters after closed reduction allow cast treatment with acceptable risk of malunion and post-traumatic arthritis. Any deviation beyond these, especially in a young or high-demand patient, favours operative fixation.

The decision in one view. Whatever the pattern, the choice rests on whether the reduction can be held in a cast until union without drifting past the thresholds above.

Contraindications. Absolute: active infection at the surgical site, severe medical comorbidities precluding anaesthesia, and non-ambulatory patients with low functional demand in whom malunion is acceptable. Relative: osteoporosis severe enough to preclude stable fixation (consider augmentation or alternative fixation) and delayed presentation with established malunion (consider corrective osteotomy instead). Why operate — the evidence. The radiographic thresholds that predict cast failure are well defined: radial shortening greater than 2 mm or dorsal tilt greater than 10 degrees after reduction predicts a greater than 50 percent chance of significant displacement at union, and intra-articular incongruity greater than 2 mm is associated with symptomatic arthritis in greater than 40 percent of patients at 5 to 7 years. Modern volar locking plates allow early mobilisation and achieve high rates of anatomic reduction even in osteoporotic bone, with comparative series showing superior radiographic outcomes and faster return to function than external fixation or percutaneous pinning, particularly for intra-articular fractures. Consent specifically for flexor or extensor tendon rupture, median nerve injury, complex regional pain syndrome, intra-articular screw placement, malunion, stiffness, and the possible need for later hardware removal. Setup. Supine on a radiolucent table with the arm abducted on a hand table. An upper-arm tourniquet is applied but rarely inflated for WALANT or regional techniques; if used, 250 mmHg for a maximum of 90 minutes. Anaesthesia is a regional block (axillary or supraclavicular) with sedation or a general anaesthetic; WALANT is an option for extra-articular fractures in cooperative patients. Position the image intensifier for easy PA, lateral and oblique views, and prep and drape the contralateral wrist for comparison of radiographic parameters and DRUJ stability testing.

The goal is to expose the fracture through the volar modified Henry approach — protecting the radial artery, the median nerve and its palmar cutaneous branch, and the flexor and extensor tendons — restore radial height, inclination and volar tilt, stabilise the articular surface and the volar ulnar (sigmoid notch) fragment with a locking plate sitting proximal to the watershed line, confirm DRUJ stability, and repair the pronator quadratus over the hardware. The exposure is laid out in full as the first steps below (and in depth on the volar approach to the distal radius page).

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Rehabilitation | Phase | Timing | Immobilisation | Therapy | |-------|--------|----------------|---------| | 1 | 0 to 2 weeks | Volar splint for wound protection | Immediate finger, elbow and shoulder mobilisation; elevation and ice | | 2 | 2 to 6 weeks | Removable wrist splint | Gentle active wrist flexion/extension and forearm rotation | | 3 | 6 to 12 weeks | Splint for heavy tasks only | Full active and passive range of motion; progressive resistance | Patients return to light work at 6 to 8 weeks and heavy manual work at 3 to 4 months. Greater than 85 percent achieve good to excellent functional results; grip strength recovers to 80 to 90 percent of the contralateral side by 6 months and range of motion typically reaches about 80 percent of normal. Post-traumatic arthritis develops in 20 to 30 percent radiographically but is symptomatic in less than 10 percent at 5 years when anatomic reduction is achieved. Rehabilitation pearls - Early motion prevents stiffness and reduces CRPS risk.

• Vitamin C 500 mg daily for 50 days may reduce CRPS incidence in high-risk patients.
• Formal hand therapy is essential for intra-articular fractures and elderly patients.
• Radiographic monitoring at 2, 6 and 12 weeks to detect late collapse. Complications

Relevant anatomy and reference values. The distal radius is one of the most frequently fractured bones. Its articular surface carries a volar tilt of approximately 11 degrees and a radial inclination of 22 to 24 degrees; the sigmoid notch articulates with the ulnar head and is critical for DRUJ stability, and the radial styloid gives attachment to the brachioradialis and the radial collateral ligament complex. These reference values define what anatomic reduction must restore. The modified Henry approach exploits the internervous interval between the flexor carpi radialis (median nerve) ulnarly and the radial artery radially; the pronator quadratus covers the volar distal radius and is elevated as a flap, and the watershed line marks the most volar extent of the articular surface beyond which a plate directly threatens the flexor tendons. Implant design and fixation principles. Modern volar locking plates are pre-contoured to the volar radius anatomy, with low-profile rounded distal edges to minimise tendon irritation and variable-angle locking technology that lets screw trajectories match fragment anatomy while maintaining locking fixation in osteoporotic bone. The distal row typically carries 5 to 7 locking screws supporting the articular surface — the most radial supports the styloid and the most ulnar supports the volar ulnar fragment and the sigmoid notch — with 3 to 4 proximal diaphyseal screws; every distal screw should achieve subchondral purchase without dorsal penetration. Cancellous autograft or synthetic substitute supports elevated articular fragments in depressed intra-articular fractures, placed through the fracture window before final plate application. Key evidence. Randomised and prospective data show volar locking plates provide superior early radiographic parameters and grip strength compared with external fixation, with final range of motion and patient-reported outcomes converging by one year, and durable function at minimum five-year follow-up with radiographic arthritis that is often asymptomatic. The complication literature is consistent that the dominant modifiable risk factors are plate position distal to the watershed line and dorsal screw penetration, and that DRUJ instability — present in roughly a quarter of cases after radius fixation and strongly linked to ulnar styloid base fractures — must be sought and addressed to preserve forearm rotation and grip strength.