Comprehensive operative technique guide for open reduction and internal fixation of distal radius fractures using a volar locking plate — indications, modified Henry approach, step-by-step reduction and fixation, DRUJ assessment, complications and rehabilitation
High-yield overview
Open reduction and volar locking plate fixation for unstable distal radius fractures | advanced
Surgical Imaging
Critical Danger Structures and Exam Traps
Watershed Line and Flexor Tendon Rupture
The trap: Placing the volar plate distal to the watershed line or leaving a prominent distal edge causes attritional wear of the flexor pollicis longus tendon against the plate edge, leading to delayed rupture weeks to months after surgery.
The fix: Position the plate proximal to or flush with the watershed line. If the fracture pattern forces distal placement, ensure the pronator quadratus is repaired as a robust interposition flap between plate and tendons. Use low-profile plates with rounded edges.
Dorsal Screw Penetration and Extensor Rupture
Location: The dorsal cortex of the distal radius is thin. Locking screws that are too long penetrate dorsally and abrade the extensor tendons (especially extensor pollicis longus) in the third compartment.
Risk: Extensor pollicis longus rupture occurs in up to 5 percent of cases with prominent dorsal screws. Prevention requires measuring screw length 2 mm short of the dorsal cortex on calibrated fluoroscopy and confirming with 10-degree lateral and oblique views.
Median Nerve and Palmar Cutaneous Branch
Location: The median nerve lies ulnar to the flexor carpi radialis; the palmar cutaneous branch arises 5 cm proximal to the wrist crease and travels between the flexor carpi radialis and the flexor digitorum superficialis.
Risk: Excessive ulnar retraction or blind dissection in the proximal interval injures the palmar cutaneous branch, causing painful neuroma. The median nerve itself is at risk if the interval is developed too ulnarly or if a carpal tunnel release is performed through the same incision without adequate visualisation.
Radial Artery and Superficial Radial Nerve
Location: The radial artery lies immediately radial to the flexor carpi radialis tendon in the distal forearm. The superficial branch of the radial nerve emerges from beneath the brachioradialis 8-10 cm proximal to the radial styloid.
Risk: Failure to identify and protect the radial artery during radial retraction leads to bleeding or thrombosis. The superficial radial nerve sensory branches are vulnerable to traction injury or laceration during proximal exposure or percutaneous pin placement.
Intra-articular Screw Placement
Location: Locking screws placed too distally or at incorrect angles can enter the radiocarpal joint or the distal radioulnar joint.
Risk: Intra-articular screw penetration causes rapid chondral wear and arthritis. Prevention demands direct visualisation of the articular surface through a small capsular window or use of arthroscopy, plus multiple fluoroscopic projections including the 10-degree lateral view to profile the joint surface.
DRUJ Instability Missed Intraoperatively
Location: The triangular fibrocartilage complex and ulnar styloid are the primary stabilisers of the distal radioulnar joint. Fracture patterns involving the sigmoid notch or ulnar styloid base frequently destabilise the joint.
Risk: Failure to assess DRUJ stability after radius fixation leads to chronic instability, pain and reduced forearm rotation. Every case requires a shuck test under anaesthesia with direct comparison to the contralateral side before wound closure.
Mnemonic
V.O.L.A.RVOLAR — Modified Henry Approach Landmarks
Mnemonic
P.L.A.T.EPLATE — Fixation Principles
Mnemonic
R.A.D.I.U.SRADIUS — Reduction Sequence
Surgical Indications
Acceptable Parameters for Non-Operative Treatment
In a healthy, active adult the following radiographic parameters after closed reduction allow cast treatment with acceptable risk of malunion and post-traumatic arthritis:
Radial inclination greater than 15 degrees
Volar tilt between 0 and 15 degrees
Radial height within 2 mm of the contralateral wrist
Intra-articular step or gap less than 2 mm
No DRUJ instability on clinical examination
Any deviation beyond these thresholds, especially in young or high-demand patients, favours operative fixation to restore anatomy and minimise long-term complications.
Absolute Indications for Surgery
Intra-articular displacement with step or gap greater than 2 mm
Radial shortening greater than 5 mm or dorsal tilt greater than 20 degrees after attempted closed reduction
Open fractures or fractures with associated carpal tunnel syndrome requiring decompression
Associated DRUJ instability that cannot be reduced and held in a cast
Polytrauma or bilateral injuries where early mobilisation is essential
Relative Indications
Dorsal comminution with high risk of late collapse in cast
Volar shear (Smith) or Barton fracture patterns that are inherently unstable
Associated ulnar styloid fracture at the base with DRUJ instability
Patient factors: young age, high functional demand, inability to tolerate prolonged immobilisation
Contraindications
Absolute:
Active infection at the surgical site
Severe medical comorbidities precluding anaesthesia
Non-ambulatory patients with low functional demand where malunion is acceptable
Relative:
Osteoporosis severe enough to preclude stable fixation (consider augmentation or alternative fixation)
Delayed presentation with established malunion (consider corrective osteotomy instead)
Evidence for Operative versus Non-Operative Treatment
Radiographic Thresholds Predicting Loss of Reduction
Multiple prospective studies have defined the parameters beyond which cast treatment fails:
Radial shortening greater than 2 mm or dorsal tilt greater than 10 degrees after reduction predicts greater than 50 percent chance of significant displacement at union.
Intra-articular incongruity greater than 2 mm is associated with symptomatic arthritis in greater than 40 percent of patients at 5-7 years.
Functional Outcomes with Volar Locking Plates
Modern volar locking plates allow early mobilisation and achieve high rates of anatomic reduction even in osteoporotic bone. Comparative series demonstrate superior radiographic outcomes and faster return to function compared with external fixation or percutaneous pinning, particularly for intra-articular fractures.
Landmark Studies
Evidence
Unstable distal radial fractures treated with external fixation, a radial column plate, or a volar plate
Level I
Wei DH, Raizman NM, Bottino CJ, et al • J Bone Joint Surg Am
Clinical implication: Volar locking plates provide superior early radiographic and functional recovery; final outcomes converge by 1 year.
Long-term outcomes of volar plate fixation for distal radius fractures
Level II
Rozental TD, Blazar PE, Franko OI, et al • J Hand Surg Am
Clinical implication: Anatomic reduction with volar locking plates yields durable function; radiographic arthritis does not always correlate with symptoms.
Evidence
Complications of volar locking plate fixation
Level III
Arora R, Lutz M, Hennerbichler A, et al • J Hand Surg Am
Clinical implication: Meticulous plate positioning proximal to the watershed line and accurate screw length measurement are mandatory to prevent tendon complications.
Evidence
DRUJ instability after distal radius fracture fixation
Level I
Lindau T, Adlercreutz C, Aspenberg P • J Hand Surg Br
Clinical implication: DRUJ stability must be assessed and addressed in every distal radius fracture case; ulnar styloid base fractures warrant fixation or TFCC repair when instability is demonstrated.
Relevant Surgical Anatomy
Bony Anatomy of the Distal Radius
The distal radius articular surface has a volar tilt of approximately 11 degrees and radial inclination of 22-24 degrees. The sigmoid notch articulates with the ulnar head and is critical for DRUJ stability. The radial styloid provides attachment for the brachioradialis and the radial collateral ligament complex.
Volar Soft-Tissue Anatomy — Modified Henry Interval
The modified Henry approach exploits the interval between the flexor carpi radialis tendon (ulnar) and the radial artery (radial). The radial artery is mobilised radially with its venae comitantes. The palmar cutaneous branch of the median nerve travels between the flexor carpi radialis and flexor digitorum superficialis and must be protected during proximal dissection.
Pronator Quadratus and the Watershed Line
The pronator quadratus covers the volar distal radius. It is elevated from radial to ulnar as a flap, preserving its ulnar attachment for later repair over the plate. The watershed line is the most volar extent of the distal radius articular surface; plates placed distal to this line directly contact the flexor tendons and risk attritional rupture.
Dorsal Structures at Risk
The extensor pollicis longus tendon lies in the third dorsal compartment immediately dorsal to the distal radius. Screws that penetrate the dorsal cortex abrade this tendon. The extensor compartments are separated by septa; the EPL is particularly vulnerable because of its oblique course over the dorsal radius.
The Volar (Modified Henry) Approach — Step-by-Step Exposure
Incision and Superficial Dissection
A longitudinal incision is made 1 cm radial to the flexor carpi radialis tendon, extending from 5 cm proximal to the wrist crease distally to the level of the radial styloid. The fascia is opened along the radial border of the flexor carpi radialis. The radial artery is identified immediately radial to the tendon and gently retracted radially with a vessel loop.
Deep Exposure
The interval is developed bluntly down to the pronator quadratus. Small perforating vessels are ligated. The pronator quadratus is incised along its radial border and elevated subperiosteally from radial to ulnar as a continuous flap. The brachioradialis insertion on the radial styloid may be partially released to facilitate reduction of the radial column.
Fracture Exposure and Joint Inspection
The fracture hematoma is evacuated. For intra-articular fractures a small capsular window is created at the radial styloid to allow direct visualisation of the articular surface. Depressed fragments are elevated and provisionally stabilised with K-wires.
Clinical Pearl
Technical Tip: 'I always identify the radial artery first and protect it with a vessel loop before developing the deep interval. The pronator quadratus flap is my friend — I raise it carefully from radial to ulnar and repair it over the plate at the end. If the plate must sit at or distal to the watershed line, I make sure the flap is robust and completely covers the hardware.'
Dangers at this step
Excessive ulnar retraction injuring the median nerve or palmar cutaneous branch
Failure to mobilise and protect the radial artery leading to bleeding or thrombosis
Inadequate pronator quadratus flap compromising later tendon protection
Missing an associated carpal injury or DRUJ instability during exposure
Positioning and Preparation
Patient position: Supine on a radiolucent table with the arm abducted on a hand table. A tourniquet is applied to the upper arm but is rarely inflated for WALANT or regional techniques; if used, 250 mmHg for a maximum of 90 minutes.
Anaesthesia: Regional block (axillary or supraclavicular) with sedation or general anaesthesia. WALANT is an option for extra-articular fractures in cooperative patients.
Setup: Image intensifier positioned for easy PA, lateral and oblique views. The contralateral wrist is prepped and draped for comparison of radiographic parameters and DRUJ stability testing.
Consent: Discuss risks including flexor or extensor tendon rupture, median nerve injury, CRPS, intra-articular screw placement, malunion, stiffness, and the possible need for hardware removal.
Operative Technique — Step-by-Step
Step 1: Exposure and Initial Fracture Assessment
Perform the modified Henry approach as described. Expose the fracture, evacuate hematoma, and assess the pattern. Identify the radial styloid fragment, the volar ulnar fragment (critical for sigmoid notch and DRUJ stability), and any central articular depression.
Step 2: Provisional Reduction
Restore radial height, inclination and volar tilt using manual traction, pointed reduction clamps, and K-wires as joysticks. For intra-articular fractures, elevate depressed fragments through the fracture window and support them with subchondral K-wires or bone graft substitute if needed. Confirm reduction with fluoroscopy against the contralateral wrist.
Step 3: Plate Application and Temporary Fixation
Select an appropriate pre-contoured volar locking plate. Position the plate on the volar surface proximal to the watershed line. Secure provisionally with a non-locking screw in the proximal oval hole to allow fine adjustment. Confirm plate position on lateral fluoroscopy — the distal row should sit at or proximal to the watershed line.
Step 4: Distal Locking Screw Placement
Place the distal locking screws first under direct vision and fluoroscopic guidance. The most ulnar screw in the distal row supports the volar ulnar fragment and protects the sigmoid notch. Use variable-angle locking screws if needed to achieve subchondral purchase without joint penetration. Measure screw length 2 mm short of the dorsal cortex.
Step 5: Proximal Fixation and Final Reduction
Secure the proximal shaft with locking or non-locking screws. Fine-tune reduction if necessary by loosening the proximal screw and adjusting. Confirm overall alignment: radial height, inclination, volar tilt, and ulnar variance all within acceptable parameters compared with the contralateral side.
Step 6: DRUJ Stability Assessment
Perform the shuck test under anaesthesia with the forearm in neutral, pronation and supination. Compare directly with the contralateral DRUJ. If instability is present, consider ulnar styloid fixation, TFCC repair, or temporary K-wire stabilisation of the DRUJ.
Step 7: Final Imaging and Wound Closure
Obtain complete fluoroscopic series: PA, true lateral, 10-degree lateral, and two oblique views. Inspect the articular surface directly if intra-articular. Repair the pronator quadratus flap over the plate. Close skin with absorbable sutures. Apply a volar splint.
Clinical Pearl
Technical Tip: 'After the plate is on but before final screw tightening, I take the 10-degree lateral view to profile the joint surface and confirm no screw has entered the radiocarpal joint. I also always compare radial height and volar tilt to the contralateral wrist on the image intensifier before leaving the operating room.'
Plate positioned distal to watershed line risking flexor pollicis longus rupture
Intra-articular screw placement leading to rapid arthritis
Failure to recognise and stabilise DRUJ instability
Inadequate pronator quadratus repair leaving hardware exposed to flexor tendons
Implant Selection and Fixation Principles
Plate Design
Modern volar locking plates are pre-contoured to the volar radius anatomy. Low-profile plates with rounded distal edges minimise tendon irritation. Variable-angle locking technology allows screw trajectories to be adjusted to match fragment anatomy while maintaining locking fixation in osteoporotic bone.
Screw Configuration
The distal row typically contains 5-7 locking screws that support the articular surface. The most radial screw supports the radial styloid; the most ulnar screw supports the volar ulnar fragment and protects the sigmoid notch. Proximal shaft fixation uses 3-4 screws in the diaphysis. All distal screws should achieve subchondral purchase without dorsal penetration.
Bone Graft or Substitute
Cancellous autograft or synthetic bone substitute is used to support elevated articular fragments in depressed intra-articular fractures. The graft is placed through the fracture window before final plate application.
Complications and Their Prevention
Flexor Tendon Rupture
Most commonly flexor pollicis longus. Caused by plate position distal to the watershed line or prominent screw heads. Prevention: plate placement proximal to watershed line, robust pronator quadratus repair, use of low-profile plates. Incidence in modern series is less than 1 percent with proper technique.
Extensor Tendon Rupture
Most commonly extensor pollicis longus. Caused by dorsal screw penetration. Prevention: accurate screw length measurement (2 mm short of dorsal cortex), multiple fluoroscopic views including 10-degree lateral, direct inspection when possible. Incidence approximately 1-2 percent.
Median Nerve Neuropathy or CRPS
Median nerve irritation from retraction, hematoma, or carpal tunnel swelling. CRPS risk is increased with prolonged immobilisation or inadequate pain control. Prevention: gentle handling, perioperative multimodal analgesia, early mobilisation, vitamin C prophylaxis in high-risk patients.
Intra-articular Screw Placement
Incidence 1-3 percent in series without routine joint inspection. Prevention: direct visualisation or arthroscopic confirmation for intra-articular fractures, multiple fluoroscopic projections, use of variable-angle screws to avoid joint penetration.
Malunion
Residual dorsal tilt, radial shortening or intra-articular incongruity. Prevention: anatomic reduction confirmed against contralateral wrist, stable fixation allowing early motion, careful postoperative radiographic monitoring.
Infection and Wound Complications
Incidence less than 1 percent in clean elective cases. Prevention: meticulous sterile technique, antibiotic prophylaxis, careful soft-tissue handling, robust pronator quadratus coverage.
Post-operative Protocol
Immediate Phase (Day 0-14)
Volar splint for 10-14 days for wound protection
Immediate finger, elbow and shoulder mobilisation
Elevation and ice for swelling control
Suture removal at 10-14 days
Early Motion Phase (2-6 weeks)
Transition to removable wrist splint
Begin gentle active wrist flexion/extension and forearm rotation under therapy guidance
Progressive strengthening once radiographic healing is evident
Late Phase (6-12 weeks)
Full active and passive range of motion exercises
Progressive resistance strengthening
Return to light work at 6-8 weeks; heavy manual work at 3-4 months
Expected Outcomes
Greater than 85 percent of patients achieve good to excellent functional results with modern volar locking plate fixation. Grip strength recovers to 80-90 percent of contralateral by 6 months. Range of motion typically reaches 80 percent of normal. Post-traumatic arthritis develops in 20-30 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
Clinical Decision Scenarios
Practise clinical reasoning and management decisions out loud
Viva scenarioAdvanced
Clinical prompt
“A 42-year-old right-hand-dominant carpenter sustains a displaced intra-articular distal radius fracture after a fall from height. Post-reduction radiographs show 4 mm of radial shortening, 15 degrees of dorsal tilt, and a 3 mm intra-articular step-off at the sigmoid notch. How do you manage this patient?”
Practical approach
This fracture exceeds acceptable parameters for non-operative treatment in a young, high-demand manual worker. Radial shortening greater than 2 mm, dorsal tilt greater than 10 degrees, and intra-articular step-off greater than 2 mm are all indications for surgery. The sigmoid notch involvement raises concern for DRUJ instability.
**Pre-operative plan**: CT scan to fully characterise the articular fragments and sigmoid notch involvement. Plan for open reduction and volar locking plate fixation via the modified Henry approach. Counsel the patient on the need for anatomic reduction, the risk of flexor or extensor tendon complications, and the possibility of DRUJ instability requiring additional procedures.
**Operative goals**: Restore radial height, inclination and volar tilt to within 2 mm and 5 degrees of the contralateral wrist. Achieve anatomic reduction of the articular surface with less than 1 mm step or gap. Stabilise the volar ulnar fragment to protect the sigmoid notch. Assess and address DRUJ stability intraoperatively.
**Key technical points**: Position the plate proximal to the watershed line. Use subchondral locking screws measured 2 mm short of the dorsal cortex. Confirm reduction and screw position with multiple fluoroscopic views plus direct joint inspection. Perform the shuck test before closure and stabilise the DRUJ if unstable.
**Post-operative**: Early mobilisation under hand therapy supervision. Monitor for tendon irritation and CRPS. Expect return to light duties at 8 weeks and full manual work at 4 months.
Viva scenarioAdvanced
Clinical prompt
“You have just applied a volar locking plate to a comminuted distal radius fracture. On the 10-degree lateral fluoroscopic view you notice that one of the ulnar-most distal locking screws appears to be entering the distal radioulnar joint. What do you do?”
Practical approach
An intra-articular screw in the sigmoid notch is unacceptable and must be corrected immediately. The screw is likely too long, too ulnar, or at an incorrect angle.
**Immediate action**: Loosen or remove the offending screw. Reassess the reduction of the volar ulnar fragment — this fragment is often the key to sigmoid notch stability. If the fragment is displaced, it may need to be reduced and secured with a separate small fragment screw or K-wire before reapplying the locking screw in a safer trajectory.
**Technique adjustment**: Use variable-angle locking screws if available to redirect the screw away from the joint. Confirm the new position with multiple views including a true lateral and an oblique view profiling the sigmoid notch. If doubt remains, perform a small arthrotomy or arthroscopy to directly visualise the joint surface.
**Prevention for future cases**: Always inspect the sigmoid notch reduction before placing the most ulnar distal screw. Use the 10-degree lateral view routinely and have a low threshold for direct joint inspection in comminuted fractures involving the ulnar column.
Viva scenarioStandard
Clinical prompt
“A 68-year-old woman with osteoporosis undergoes volar locking plate fixation of a distal radius fracture. At the 3-month review she complains of pain on the volar radial aspect of the wrist and difficulty flexing the thumb IP joint. What is the likely diagnosis and how do you manage it?”
Practical approach
The presentation is classic for attritional rupture of the flexor pollicis longus tendon secondary to plate irritation. The most common cause is plate position distal to the watershed line or a prominent distal edge left exposed because of inadequate pronator quadratus repair.
**Diagnosis confirmation**: Clinical examination shows inability to flex the thumb IP joint against resistance with the wrist extended (to put the tendon under tension). Ultrasound or MRI can confirm the rupture and localise the site of attrition.
**Management**: Surgical exploration and tendon reconstruction. Options include primary repair if the tendon ends are healthy (rare at 3 months), tendon transfer (EIP to FPL), or interposition grafting. The plate edge must be smoothed or the plate removed if union is solid. The pronator quadratus must be repaired or augmented to cover any remaining hardware.
**Prevention**: In future cases, ensure the plate sits proximal to the watershed line. If the fracture pattern forces distal placement, achieve a robust, watertight pronator quadratus repair over the plate. Consider lower-profile plates with rounded edges in osteoporotic patients.
Exam day cheat sheet
Distal Radius ORIF with Volar Locking Plate — Exam Day Summary
References
Evidence
Volar locking plate versus external fixation for distal radius fractures: a randomised controlled trial
Level I
Wei DH, Raizman NM, Bottino CJ, et al • J Bone Joint Surg Am
Evidence
Five-year outcomes of volar plate fixation of distal radius fractures
Level II
Rozental TD, Blazar PE, Franko OI, et al • J Hand Surg Am
Evidence
Complications following volar locking plate fixation of distal radius fractures
Level III
Arora R, Lutz M, Hennerbichler A, et al • J Hand Surg Am
Evidence
Distal radioulnar joint instability after distal radius fracture fixation
Level II
Lindau T, Adlercreutz C, Aspenberg P • J Hand Surg Br
Evidence
Systematic review of complications after volar plating of distal radius fractures
Level I
Wichlas F, Haas NP, Disch A, et al • J Orthop Trauma