Volar Approach to the Distal Radius (Henry / FCR Approach)

What it exposes. The volar approach gives direct access to the volar surface of the distal radius from the metaphysis to the radiocarpal joint, through the FCR interval (FCR tendon medially, radial artery laterally), deep to which lies pronator quadratus over the bone. It is the workhorse exposure for volar locked plating of distal radius fractures, and also serves malunion osteotomy, volar plate removal, and (extended distally into the palm) carpal tunnel release. Why volar (and the paradigm shift). Distal radius fractures are among the most common fractures in adults worldwide, with a bimodal distribution — high-energy injuries in young adults and low-energy fragility fractures in older adults, particularly post-menopausal women; they represent roughly one in six fractures presenting to emergency departments. Before the 2000s, dorsal plating was standard but carried high extensor-tendon rupture rates (10-15%) and prominent hardware. Volar locked plating (Orbay, Jupiter) shifted practice worldwide because (1) fixed-angle locked screws resist the dorsal collapse typical of Colles fractures, (2) the volar surface has pronator quadratus muscle cover acting as a biological barrier between plate and flexor tendons, and (3) stable fixation allows early mobilisation. The shift is reflected across major guidance (AAOS, BOA/BSSH, AO Foundation). Importantly, high-level evidence tempers this: in low-demand older patients the functional advantage of plating over non-operative care is modest and time-limited (Arora 2011), so approach and fixation choice should be patient-specific, not reflexive. Position and landmarks. Supine on the OR table, operative arm abducted onto a radiolucent hand table, shoulder abducted 80-90 degrees, elbow flexed 90 degrees and forearm supinated (volar surface up). An upper-arm pneumatic tourniquet inflated to about 250mmHg (exsanguinate with Esmarch first) gives a bloodless field; release before closure for haemostasis. Palpate and mark the radial styloid, the FCR tendon at the wrist crease (ask the patient to flex the wrist against resistance), the radial artery pulse lateral to FCR, and the distal wrist crease (approximating the radiocarpal joint). Plan a longitudinal incision along the FCR tendon, starting about 1cm proximal to the wrist crease (avoid the crease itself — hypertrophic scarring), 8-10cm long. Indications. Absolute triggers for ORIF: displaced intra-articular fracture with articular step-off greater than 2mm after reduction; unstable extra-articular fracture (dorsal tilt greater than 20 degrees, radial shortening greater than 5mm, ulnar variance more than 3mm positive, dorsal comminution); open fractures (Gustilo I-II); and bilateral fractures where the patient needs both hands for crutches/walker. Relative: failed closed reduction lost in cast at 7-10 days; high functional demand (athletes, manual labourers); young active patients. Patterns particularly suited to the volar approach: Colles (dorsally displaced — the plate buttresses against dorsal collapse), Smith's (volarly displaced — the plate directly buttresses the volar fragment), die-punch (lunate facet impaction), volar Barton (volar rim with radiocarpal subluxation), and chauffeur's (radial styloid). Non-fracture uses: symptomatic malunion correction, volar plate removal, and combined carpal tunnel release (acute CTS complicates roughly 5-10% of distal radius fractures). Contraindications. Absolute: active volar soft-tissue infection or osteomyelitis (stage the treatment). Relative: dorsal Barton fracture (may need a dorsal buttress plate), severe volar cortical comminution with no stable platform for the plate (consider bridging external fixation), severe volar soft-tissue injury or crush (wound-heaving concern), and the patient unable to comply with postoperative precautions.

Work down through the layers along the FCR tendon, protecting the palmar cutaneous nerve and radial artery, then raise pronator quadratus as an L-shaped flap to reach the volar distal radius, reduce the fracture, and apply the plate just proximal to the watershed line with every screw checked on lateral and skyline fluoroscopy.

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Structures at risk, by layer

Extensile options. The incision can be extended distally into the palm along the thenar crease to perform a concurrent carpal tunnel release when acute median nerve compression accompanies the fracture. Proximal extension is limited by the hand table, but the approach comfortably exposes from the distal radial metaphysis to the radiocarpal joint. For severe volar comminution with no stable cortical buttress, the volar exposure can be supplemented by a bridging external fixator rather than extended further. Closure. Pronator quadratus is re-approximated to the radial periosteum (side-to-side or via transosseous drill holes) where it reaches tension-free — accept partial coverage if severe comminution prevents a tension-free repair. The FCR sheath is usually not repaired. Close the deep fascia loosely over pronator with 3-0 Vicryl, the subcutaneous layer with 3-0 Vicryl (meticulous haemostasis), and skin with 4-0 Monocryl subcuticular plus adhesive. Apply a forearm-based volar splint with the wrist neutral, fingers free to the PIP joints, and elevate the hand postoperatively. Complications.

• Volar locked plating ORIF of distal radius fractures — the principal operation: Colles, Smith's, die-punch, volar Barton and chauffeur's patterns.
• Corrective osteotomy for distal radius malunion — the approach gives access for osteotomy, reduction and re-plating of a symptomatic malunion.
• Volar plate removal — symptomatic hardware (flexor tendon irritation, prominent plate) is explanted through the same approach.
• Carpal tunnel release — extended distally into the palm for acute median nerve compression accompanying the fracture.
• Supplement to external fixation for severe comminution without a stable volar cortical buttress.