Dorsal Approach to Distal Radius

What it exposes. The dorsal approach gives direct access to the dorsal distal radius — the dorsal cortex, the dorsal articular rim, and the dorsal capsule — and is the exposure of choice whenever the pathology is dorsal. It is built around Lister's tubercle, the palpable dorsal prominence between the 2nd and 3rd extensor compartments, which is the single landmark that makes the whole approach navigable. Why dorsal (and not volar). Volar locking-plate fixation has become the workhorse for most distal radius fractures because it controls volar tilt with a fixed-angle construct and sits under a thick soft-tissue envelope. But a volar plate cannot buttress a dorsal cortex, and several patterns genuinely demand a dorsal exposure: a dorsal Barton shear fracture (the carpus follows the dorsal rim and redislocates without a dorsal buttress), severe dorsal comminution (AO/OTA 23-A3 or 23-C3) where the dorsal wall will collapse, and dorsal die-punch impaction. The dorsal route is also the natural corridor for scaphoid proximal-pole ORIF, chronic scapholunate ligament reconstruction, and the 3-4 wrist arthroscopy portal. Indications - Dorsal Barton fracture — shear fracture of the dorsal rim with radiocarpal subluxation (the carpus follows the dorsal fragment dorsally). This is an absolute indication for ORIF: closed reduction cannot hold it, and a dorsal buttress plate is required. It represents 5-10% of distal radius fractures and follows a high-energy fall on a flexed wrist.

• Dorsally displaced, comminuted Colles fractures — when there is significant dorsal comminution, metaphyseal impaction, or articular step-off requiring direct dorsal visualisation. AO/OTA 23-A3 (complete metaphyseal comminution) and 23-C3 (complete articular with metaphyseal comminution) patterns often need a dorsal plate because a volar plate cannot buttress the dorsal cortex.
• Scaphoid nonunion ORIF (dorsal approach) — proximal-pole and waist nonunions with DISI deformity are approached dorsally for screw fixation and grafting; the dorsal approach gives direct access to the proximal pole and a dorsal-to-volar screw trajectory that respects the dorsal vascular supply (the dorsal carpal branch of the radial artery enters at the waist).
• Chronic scapholunate ligament reconstruction — static SL dissociation (gap greater than 3mm on AP, DISI on lateral) needs access to the dorsal SL ligament (the strongest component) for tenodesis or bone-ligament-bone reconstruction.
• Wrist arthroscopy portal placement — the 3-4 portal (between the 3rd and 4th compartments, 1cm distal to Lister's tubercle in line with the radial border of the 3rd metacarpal) is the primary arthroscopy portal. Relative indications include reduction of a volar lunate dislocation when closed reduction fails (acute carpal tunnel syndrome complicates 30-40% of lunate dislocations, so a concomitant volar release is common), revision of failed volar plating with dorsal collapse, and high-energy radiocarpal fracture-dislocation. ORIF thresholds (any approach). Operative fixation is generally supported for dorsal angulation greater than 10 degrees, radial shortening greater than 3mm, intra-articular step-off greater than 2mm, or loss of reduction after an acceptable closed reduction. Contraindications - Absolute: active infection (cellulitis, abscess, osteomyelitis) over the dorsal wrist, and inadequate soft-tissue coverage (severe open injuries are spanned by an external fixator and plated staged once the soft tissues heal).
• Relative: low-demand elderly patients with minimally displaced extra-articular fractures — multiple trials in patients over 65 (including the widely cited Arora volar-plate-versus-cast study) show that despite better radiographic alignment with fixation, patient-reported outcomes (DASH/PRWE) are similar to non-operative care by one year, supporting shared decision-making. Severe comorbidity also tempers the decision: uncontrolled diabetes (HbA1c greater than 8%) and active smoking (greater than 10 cigarettes/day, which roughly triples nonunion risk) raise wound and infection rates; a prior CRPS history carries a 10-15% recurrence risk; and a very thin dorsal envelope (BMI less than 18) or rheumatoid arthritis raises extensor-tendon irritation from dorsal hardware (15-20% versus 2-5%), favouring a volar plate. Position & landmarks. Supine, arm on a radiolucent hand table, upper-arm tourniquet at about 250mmHg. The shoulder is abducted 90 degrees and the elbow flexed 90 degrees with the forearm in neutral rotation. Palpate and mark Lister's tubercle (between 2nd and 3rd compartments), the radial styloid, the course of the superficial radial nerve branches on the dorsoradial side, and the planned longitudinal incision directly over the tubercle. Bilateral wrist radiographs of the uninjured side are a useful template for radial height and inclination.

Work straight down over Lister's tubercle, protect the superficial radial nerve on the radial side, open the 3rd compartment and transpose the EPL, then capsulotomise to the dorsal radius. The 3rd-4th compartment interval is the heart of the approach.

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Structures at risk, by layer

Dorsal versus volar plating. Most distal radius fractures are better served by a volar plate, but the choice is driven by the fracture pattern. The dorsal route earns its place when the dorsal cortex needs a buttress or when the target is dorsal/carpal.

Extensile options. The dorsal approach is extensile along the radius: extend proximally along the shaft for diaphyseal control, and distally toward the carpus for scapholunate and scaphoid work. The 3-4 arthroscopy portal is the same interval, made 1cm distal to Lister's tubercle in line with the radial border of the 3rd metacarpal. Closure. Dorsal capsule with 2-0 Vicryl; the EPL remains transposed radially and is not replaced; the retinaculum is repaired loosely over the 4th compartment leaving room for the transposed EPL; subcutaneous 3-0 Vicryl and skin with 4-0 nylon or 4-0 Monocryl; a volar resting splint holds the wrist in 20 degrees of extension. Complications. The dominant problems are tendon-related. EPL rupture (0.2-5%, ischaemia/friction) is reconstructed with an EIP-to-EPL transfer rather than primary repair. Extensor tenosynovitis (~7.5% versus ~4.5% volar; Azzi 2017) is limited by a low-profile plate above the watershed line and countersinking, and symptomatic cases settle with plate removal after union. FPL rupture from volar screw penetration may need an FDS transfer. SRN injury causes dorsal thumb/web numbness or a neuroma. Wound issues are commoner in diabetics and smokers because the dorsal envelope is thin. CRPS is mitigated with early motion and vitamin C 500mg daily for 50 days. Residual shortening or dorsal tilt causing a symptomatic malunion may need a corrective osteotomy, and an articular step-off greater than 2mm predicts post-traumatic arthritis (Knirk & Jupiter 1986).

• Dorsal ORIF of scaphoid proximal-pole nonunion — direct access to the proximal pole with a dorsal-to-volar screw trajectory that respects the dorsal vascular supply.
• Scapholunate ligament reconstruction / dorsal capsulodesis — access to the dorsal SL ligament (the strongest component) for tenodesis or capsulodesis.
• Wrist arthrodesis — dorsal exposure of the radiocarpal and intercarpal joints for fusion.
• Dorsal buttress plating of dorsal Barton and severely comminuted Colles fractures.
• The 3-4 wrist arthroscopy portal and arthroscopy-assisted articular reduction.