Comprehensive guide to the Henry anterolateral volar approach to the radius for ORIF of radial shaft fractures and forearm pathology
Reviewed by OrthoVellum Editorial Team
Orthopaedic clinicians and medical editors • Published by OrthoVellum Medical Education Team
BR vs PT/FCR Interval | Radial Artery Medial | SRN at 6-9cm from Styloid
The Henry approach is the STANDARD anterolateral (volar) approach to the entire length of the radius from the proximal 1/3 to the distal metaphysis (Henry 1945). It is the MOST VERSATILE radius approach, providing EXTENSILE exposure for radial shaft fractures, nonunion, malunion, and forearm pathology.
The Henry approach utilizes a TRUE internervous plane that VARIES by location along the radius:
Proximal 1/3 Radius (Elbow to Proximal Shaft):
Middle 1/3 Radius (Mid-Shaft):
Distal 1/3 Radius (Distal Shaft to Metaphysis):
1. RADIAL ARTERY (PRIMARY VASCULAR HAZARD):
2. SUPERFICIAL RADIAL NERVE (MOST INJURED NERVE):
3. POSTERIOR INTEROSSEOUS NERVE (PIN):
4. LATERAL ANTEBRACHIAL CUTANEOUS NERVE (LABC):
5. MEDIAN NERVE:
Most vulnerable vascular structure: The radial artery is the SINGLE MOST VULNERABLE structure during Henry approach (0.5-1% iatrogenic injury rate - Leversedge 2008). The artery lies BETWEEN brachioradialis (lateral) and FCR (medial) in the middle/distal radius - NOT in the internervous plane itself.
Surgical strategy: (1) Identify radial artery pulsation as LANDMARK for internervous plane. (2) Incise fascia LATERAL to artery (between BR and artery). (3) Mobilize artery MEDIALLY with FPL and median nerve using BLUNT dissection. (4) Avoid LATERAL retraction of artery (increases tension and injury risk). (5) Control artery with vessel loops if high-risk dissection.
If injured: Immediate vascular surgery consultation for primary repair or reverse interposition graft.
Most common complication: The superficial radial nerve (SRN) is the MOST COMMONLY INJURED nerve structure during Henry approach (5-10% sensory dysesthesia, 2% permanent - Ring 2004). The SRN emerges from under brachioradialis 6-9cm proximal to radial styloid and crosses the surgical field to reach the dorsum of the hand.
Prevention: (1) Identify SRN exiting from under distal brachioradialis tendon. (2) Protect with GENTLE MEDIAL retraction (avoid stretching). (3) Avoid electrocautery near SRN. (4) Minimize retraction time.
Clinical manifestation: Painful neuroma, dysesthesia over dorsal thumb/index finger web space (SRN distribution). Most resolve spontaneously by 3-6 months. Persistent neuroma may require neuroma excision or nerve transfer.
Setup:
Skin Incision:
Incision Landmarks:
1. Subcutaneous Layer:
2. Fascia Incision:
ZONE 1: PROXIMAL 1/3 RADIUS (Elbow to Proximal Shaft)
Interval: Between brachioradialis (lateral, radial nerve) and pronator teres (medial, median nerve)
Steps:
PIN Protection:
ZONE 2: MIDDLE 1/3 RADIUS (Mid-Shaft)
Interval: Between brachioradialis (lateral, radial nerve) and FCR (medial, median nerve)
Steps:
Radial Artery Protection:
ZONE 3: DISTAL 1/3 RADIUS (Distal Shaft to Metaphysis)
Interval: Between FCR (medial, median nerve) and brachioradialis tendon (lateral, radial nerve)
Steps:
SRN Protection:
Radius Periosteum:
Fracture Reduction:
Plate Fixation:
Deep Layers:
Superficial Layers:
Postoperative:
PRIMARY INDICATIONS:
1. Radial Shaft Fractures (MOST COMMON INDICATION):
2. Radial Nonunion/Malunion:
3. Forearm Pathology:
RELATIVE INDICATIONS:
ABSOLUTE CONTRAINDICATIONS:
RELATIVE CONTRAINDICATIONS:
Union Rates:
Functional Outcomes:
Complications:
| factor | henry | thompson | preferred |
|---|---|---|---|
| Internervous Plane | TRUE internervous: BR (radial n.) vs PT/FCR (median n.) - NO nerve transection required | TRUE internervous: ECRB (radial n.) vs EDC (PIN) - NO nerve transection required | Equal (both true internervous planes) |
| Radius Exposure Length | ENTIRE LENGTH: Proximal 1/3 to distal metaphysis (MOST VERSATILE) | PROXIMAL/MIDDLE shaft only: Radial head to distal 1/3 (limited distal exposure) | Henry (more versatile - Chapman 1989) |
| Vascular Structures at Risk | RADIAL ARTERY (0.5-1% injury) - lies between BR and FCR, requires medial mobilization (Leversedge 2008) | NONE - posterior approach AVOIDS all major vessels (SAFEST from vascular standpoint) | Thompson (no vascular risk) |
| Nerve Injury Risk | SRN dysesthesia 10% (2% permanent), PIN 2% (proximal dissection only) - Ring 2004 | PIN injury 2% (Arcade of Frohse violation) - Witt 2014 | Equal (both approximately 2% permanent nerve injury) |
| Plate Biomechanics | VOLAR plating in TENSION side (resists bending forces optimally) - superior biomechanics | DORSAL plating in COMPRESSION side (suboptimal bending resistance) | Henry (tension side plating - biomechanical advantage) |
| Synostosis Risk (Both-Bone Fx) | 2% (single volar incision for both radius and ulna AVOIDS interosseous membrane violation - Vince 1990) | 9% (dual incision approach violates interosseous membrane - increases hematoma/synostosis) | Henry (4.5-fold lower synostosis risk) |
| Distal Radius Access | EXCELLENT - extends to distal metaphysis (within 4-5cm of styloid) | POOR - limited distal access (difficult beyond distal 1/3) | Henry (distal radius pathology) |
| Indications | RADIAL SHAFT FRACTURES (standard approach), nonunion/malunion, synostosis, distal shaft pathology | PIN exploration, proximal radius pathology, OPEN FRACTURES with volar contamination (Henry contraindicated) | Depends on pathology location and wound status |
1. RADIAL ARTERY INJURY (0.5-1%):
Mechanism:
Prevention:
Management:
Outcome:
2. POSTERIOR INTEROSSEOUS NERVE (PIN) INJURY (2-5% in Proximal Dissection):
Mechanism:
Prevention:
Recognition:
Management:
Outcome:
1. SUPERFICIAL RADIAL NERVE (SRN) DYSESTHESIA (5-10%):
Mechanism:
Clinical Manifestation:
Prevention:
Management:
Outcome:
2. NONUNION (2-3%):
Risk Factors:
Diagnosis:
Management:
Outcome:
3. RADIOULNAR SYNOSTOSIS (2-9%):
Risk Factors:
Clinical Manifestation:
Prevention:
Management:
Outcome:
4. INFECTION (2-3%):
Risk Factors:
Clinical Manifestation:
Management:
Outcome:
"A 35-year-old male sustains a closed mid-shaft radius fracture after a fall from a bike. The fracture is displaced 60% with 15° dorsal angulation. Initial closed reduction in ED fails to maintain alignment (redisplaced to 50% on post-reduction X-rays). How would you manage this fracture? Describe your surgical approach and key steps."
"You performed a Henry approach for a distal 1/3 radius fracture. Postoperatively, the patient complains of painful dysesthesia over the dorsum of the thumb and index finger web space. What is the likely diagnosis? How do you prevent this complication? How would you manage it?"
"**Proximal 1/3 Radius Fracture** requires MODIFIED Henry approach with **supinator muscle splitting** to access proximal radial shaft. The **posterior interosseous nerve (PIN)** is at HIGHEST RISK during proximal dissection (2-5% injury rate - Spinner 1968). **PROXIMAL HENRY APPROACH MODIFICATIONS:** **1. Internervous Plane (DIFFERENT from mid/distal radius):** - **Proximal 1/3**: Between brachioradialis (lateral, radial nerve) and pronator teres (medial, median nerve) - vs Mid/distal radius: BR vs FCR **2. Supinator Muscle Splitting (CRITICAL FOR PIN PROTECTION):** - Supinator covers proximal radius from lateral epicondyle to radial shaft - PIN lies on DEEP SURFACE of supinator (2-5cm distal to radial head - Spinner 1968) - **Technique**: Split supinator in LINE OF ITS FIBERS (parallel to radius) using BLUNT dissection - Avoid deep dissection on dorsal radius (PIN on deep supinator surface) **3. FOREARM POSITIONING (MOST IMPORTANT SAFETY STEP):** - Place forearm in **FULL SUPINATION** during proximal dissection - **Rationale**: Supination migrates PIN ANTERIORLY (away from posterior radius) by mean 4mm vs neutral - INCREASES safety clearance (Stern 1984) - Pronation migrates PIN POSTERIORLY toward surgical field - DANGEROUS position **4. PIN ANATOMY:** - Origin: Radial nerve bifurcates at lateral epicondyle into SRN (superficial) and PIN (deep) - Course: PIN enters supinator at **Arcade of Frohse** (2-3cm distal to radiocapitellar joint) - Exit: PIN exits supinator at distal border (4-5cm distal to radial head) - becomes deep branch innervating finger/thumb extensors **5. SUBPERIOSTEAL ELEVATION:** - After splitting supinator, elevate muscle from radius periosteum using elevator - Exposes proximal radial shaft - Avoid dorsal dissection (PIN lies dorsally on supinator deep surface) **OUTCOME:** - PIN injury risk: 2-5% with proximal dissection (vs 0% with mid/distal dissection) - 90% spontaneous recovery by 6 months (Ring 2004) - Full supination reduces injury risk by 40% (Stern 1984)"
High-Yield Exam Summary