Anterolateral Approach to Radius (Henry)

The Henry anterolateral (volar) approach gives extensile exposure to the entire length of the radius from the proximal 1/3 to the distal metaphysis, using true internervous planes (brachioradialis versus pronator teres proximally, brachioradialis versus FCR distally). It is the standard exposure for radial shaft fractures, nonunion, malunion and forearm pathology. Critical structures are managed along the way: the radial artery (mobilized medially — it lies about 8mm from the FCR tendon at the wrist), the superficial radial nerve (emerging from under brachioradialis in the distal third, the most commonly injured sensory nerve) and the PIN (protected during proximal dissection by working on the anterior border of supinator in full supination, which rotates the nerve posteriorly away from the volar field). Plate osteosynthesis remains the gold standard for diaphyseal forearm fractures, with high union rates when anatomical principles, periosteal preservation and rigid fixation are respected. What it exposes. The whole radius — proximal 1/3, middle 1/3 and distal metaphysis — through one extensile incision. This makes Henry the most versatile radius approach; the Thompson (dorsal) approach is confined to the proximal and middle shaft and gives poor distal access. Primary indications.

• Radial shaft fractures with greater than 50 percent displacement or greater than 10 degrees angulation — the commonest indication. Open fractures (Gustilo I-IIIA) with a volar wound are suitable; if there is volar contamination, switch to the posterior Thompson approach for debridement and fixation.
• Both-bone forearm fractures: fix the radius through Henry and the ulna through a separate subcutaneous-border incision, keeping the two exposures in independent planes and NOT dissecting across the interosseous membrane, to limit synostosis (Dohn 2012). Anatomical reduction restores length, rotation and the radial bow — the key determinant of forearm rotation and grip (Nappo 2019).
• Radial nonunion or malunion with functional impairment — revision ORIF with bone grafting (iliac crest autograft or allograft).
• Forearm pathology: radioulnar synostosis take-down with interposition (Dohn 2012), radial osteotomy for angular deformity, tumour excision (osteoid osteoma, enchondroma, metastasis), osteomyelitis debridement with antibiotic cement spacer, and radial artery repair or reconstruction. Relative indications. Minimally displaced fractures with progressive displacement on serial X-rays, fractures in polytrauma (to allow early mobilization), and pathological fractures. Contraindications.
• Absolute: open fractures with volar contamination (high infection risk — use Thompson); acute compartment syndrome requiring fasciotomy (use a dorsal approach for four-compartment fasciotomy and delay ORIF).
• Relative: proximal fractures involving the radial neck (higher PIN risk — consider antegrade nailing or a posterior approach); isolated distal metaphyseal fractures (consider volar plating via the FCR approach for more direct distal exposure); active volar soft tissue infection (delay until controlled). Position and landmarks. Supine, arm abducted 90 degrees on an arm board, forearm supinated (palm up) for most of the dissection, upper-arm tourniquet at 250 to 280 mmHg for 90 to 120 minutes, and fluoroscopy available. The incision follows the mobile wad (the brachioradialis belly): beginning 2 to 3 cm distal to the antecubital fossa and running to within 4 to 5 cm of the radial styloid, curving radially toward the FCR tendon distally. Landmarks are the biceps tendon proximally, the brachioradialis belly in the middle (palpable with wrist extension), and the FCR tendon with the radial styloid distally. Outcomes. Closed diaphyseal radius fractures unite at high rates (typically over 95 percent) with rigid fixation and preserved biology; even severe open or high-energy fractures reach about 96 percent final union, often after a planned second-stage procedure (Nappo 2019). Nonunion is uncommon and is driven principally by segmental bone loss and deep infection rather than patient factors (Nappo 2019). Functional recovery is good when the radial bow is restored: mean forearm rotation 85 to 90 percent of the contralateral side, grip 90 to 95 percent at 12 months, and return to work at 12 to 16 weeks for manual labour or 6 to 8 weeks for sedentary work. The dominant threats are transient SRN dysesthesia, PIN palsy after proximal dissection, and radioulnar synostosis. Global principles. Forearm shaft fractures show a bimodal pattern worldwide — high-energy trauma in younger patients and low-energy osteoporotic falls in older patients. In adults, displaced diaphyseal radius and both-bone fractures are treated operatively because anatomical restoration of length, rotation and the radial bow is required for forearm rotation; 3.5 mm dynamic-compression or locking-compression plating with at least 5 to 6 cortices (three bicortical screws) on each side is the international AO gold standard. Forearm shaft implants are not bearing-surface devices, so there is no dedicated joint-registry survivorship metric — outcome benchmarking comes from trauma cohorts reporting union, synostosis and reoperation (for example Nappo 2019). A single pre-incision cephalosporin is standard for closed fractures (add gram-negative cover and extend for open fractures by Gustilo grade); routine pharmacological VTE prophylaxis is not indicated for isolated upper-limb fixation, and smoking cessation is counselled given its strong association with impaired healing.

Work down through the layers along the mobile wad, using the radial artery pulsation as the landmark for the internervous plane, mobilizing the artery medially and adapting the deep dissection to the proximal, middle and distal thirds of the radius.

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Structures at risk, by layer

Henry versus Thompson. Both are true internervous approaches. Henry wins on versatility (entire radius length, tension-side plating, separate-plane both-bone fixation); Thompson wins when there is volar contamination, for primary PIN exploration, or for proximal or radial-head pathology.

Extensile options. Extend proximally along the radial border of FCR and brachioradialis to reach the proximal shaft and control the radial artery; extend distally along the FCR to the distal radius metaphysis. For both-bone fractures, keep the radius (Henry) and ulnar (subcutaneous border) incisions in independent planes and never dissect across the interosseous membrane (Dohn 2012). Closure. Repair pronator quadratus to the radial border (distal dissection); reapproximate supinator loosely (optional, as muscle heals spontaneously); meticulous haemostasis avoiding cautery near the SRN or radial artery; close the deep fascia, subcutaneous layer and subcuticular skin. A sugar-tong splint prevents forearm rotation for 7 to 10 days, followed by early range of motion at 2 weeks and radiographs at 2, 6 and 12 weeks. Complications and management. - Radial artery injury (0.5 to 1 percent). Mechanism: sharp dissection too close to the artery, aggressive lateral retraction, or laceration during periosteal elevation. Prevention: use the pulsation as the landmark, mobilize medially with blunt dissection, and keep retractors on bone. Management: immediate direct pressure, then vascular clamps proximal and distal; primary repair with 6-0 or 7-0 Prolene for a defect less than 1 cm, or a reverse interposition vein graft (saphenous or cephalic) for a defect greater than 1 cm; ligation is the last resort and only after confirming a complete, dominant ulnar supply. Mandatory vascular surgery consultation. - Posterior interosseous nerve injury (2 to 5 percent in proximal dissection). Mechanism: deep dissection through supinator in pronation, excessive retraction around the radial neck, or deep retractor placement (the usual mechanism — Luthringer 2021). Prevention: full supination (Luthringer 2021), subperiosteal release from the anterior radial insertion, no dorsal dissection and no retractors deep to the radial neck. Recognition: postoperative finger and thumb extension weakness (EPL, EDC, EIP) with wrist extension preserved (ECRL and ECRB are innervated proximal to the PIN). Management: observation for 3 to 6 months with dynamic splinting (most traction neurapraxias recover — about 90 percent by 6 months); nerve exploration with neurolysis or grafting if no recovery by 6 months; tendon transfers (PT to ECRB, FCR or FDS to EDC, PL to EPL) if no recovery by 12 months. Permanent deficit is rare (less than 1 percent). - Superficial radial nerve dysesthesia (5 to 10 percent). Mechanism: excessive retraction, traction, electrocautery, or dissection too far distally. Manifestation: painful dysesthesia over the dorsal thumb and index web space, sometimes a painful neuroma. Prevention: identify the SRN exiting under BR (6 to 9 cm proximal to the styloid), gentle medial retraction, avoid electrocautery near it, and release retractors periodically. Management: for transient dysesthesia (most cases), observe for 3 to 6 months (about 80 percent resolve) with desensitisation therapy and neuropathic agents (gabapentin, amitriptyline); for a persistent neuroma (about 2 percent, beyond 6 months), neuroma excision with relocation of the nerve end into deeper tissue (and grafting if there is a true defect). - Nonunion (2 to 3 percent). Risk factors: inadequate fixation (fewer than six cortices per side), excessive periosteal stripping, smoking (about a tenfold increase), traditional NSAIDs, and infection. Management: revision ORIF with debridement to bleeding bone, iliac crest autograft (gold standard), a larger 3.5 mm locking plate with 8 to 10 cortices, adjuncts such as BMP or low-intensity pulsed ultrasound, and mandatory smoking cessation. - Radioulnar synostosis. Risk factors (Dohn 2012; Nappo 2019): both-bone fractures, proximal-third fractures, high-energy or open mechanisms, associated head injury, surgical delay and comminution, and single-incision exposure of both bones or graft placed across the interosseous space. Manifestation: progressive loss of forearm rotation with a radiographic bone bridge (usually proximal 1/3). Prevention: separate incisions in independent planes, preserve the interosseous membrane, evacuate interosseous haematoma, and consider HO prophylaxis (indomethacin or focal radiotherapy) in the highest-risk patients. Management: observe if asymptomatic; if symptomatic, wait 12 to 18 months for maturation, then excise the bridge and interpose fat or silastic, with postoperative indomethacin (25 mg three times daily for 12 weeks) and aggressive ROM. Outcome: 70 to 80 percent gain improved rotation (mean about 40 degrees); recurrence is 15 to 20 percent (higher if excised before maturation). - Infection (2 to 3 percent; 10 to 15 percent for Gustilo II-III open fractures). Superficial infection (about 2 percent): erythema and drainage without deep involvement, managed with oral antibiotics (flucloxacillin or cephalexin for 10 to 14 days) and wound care. Deep infection (0.5 to 1 percent): persistent pain, raised inflammatory markers and purulent drainage — managed with irrigation and debridement, culture-guided IV antibiotics (typically 6 weeks), retaining stable hardware until union (debridement plus suppressive antibiotics), and removing hardware only if loose or after union, with staged revision. Deep infection is a leading nonunion driver (Nappo 2019).

• Both-bone forearm ORIF — radius via Henry, ulna via a separate subcutaneous-border incision; the principal operation done through this exposure.
• Radial shaft ORIF for displaced fractures (greater than 50 percent displacement or greater than 10 degrees angulation).
• Radial nonunion or malunion — revision ORIF with bone grafting.
• Radioulnar synostosis take-down with interposition (Dohn 2012).
• Radial osteotomy for angular deformity correction.
• Tumour excision (osteoid osteoma, enchondroma, bone metastases) and osteomyelitis debridement with antibiotic cement spacer.
• Radial artery repair or reconstruction for vascular injury.