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General

Henry Approach to the Radius (Volar Approach)

Comprehensive guide to the Henry (volar) approach to the radius - the most versatile forearm approach for distal radius fractures, radial shaft fractures, and forearm compartment syndrome - surgical anatomy, radial artery management, and exam preparation

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High Yield Overview

HENRY APPROACH - VOLAR RADIUS ACCESS

Most Versatile Forearm Approach | Extensile | Radial Artery at Risk

Clinical Imaging

Imaging Gallery

Critical Henry Approach Exam Points

Leash of Henry

The leash of Henry is a series of radial artery perforators that supply the pronator quadratus and distal radius. These vessels penetrate the pronator quadratus and must be carefully ligated when elevating the muscle from the radial border. Failure to ligate causes troublesome bleeding and poor visualization.

Superficial Radial Nerve

The superficial radial nerve emerges from under brachioradialis in the distal third of the forearm and runs superficially to supply sensory innervation to the dorsal first web space. Injury causes numbness and painful neuroma formation. Protect by retracting BR radially without excessive traction.

Pronator Quadratus

Pronator quadratus is the key to distal radius exposure. Elevate it sharply from the radial border (not ulnar - protects anterior interosseous nerve). Always repair the PQ at closure - it provides vascular supply to distal radius and improves healing. Some studies show better outcomes with PQ repair.

Internervous Plane

True internervous plane exists only in distal two-thirds between brachioradialis (radial nerve) and flexor carpi radialis (median nerve). Proximal extension is not internervous - pronator teres (median) must be released from radius. This is why the approach is safest distally.

At a Glance

The Henry (volar) approach is the most versatile forearm approach, providing extensile access from radial styloid to radial tuberosity for distal radius fractures (volar plating), radial shaft fractures, and forearm fasciotomy. The internervous plane (distally) lies between brachioradialis (radial nerve) and flexor carpi radialis (median nerve)—proximally this plane does not exist as pronator teres (median) must be released. The leash of Henry (radial artery perforators to pronator quadratus) must be ligated for distal exposure. Pronator quadratus is elevated from the radial border (protecting the AIN) and should be repaired at closure. At-risk structures include the superficial radial nerve (emerges under BR distally) and radial artery. Patient positioning is supine with arm supinated on hand table.

Mnemonic

HENRYHENRY - Approach Key Structures (Superficial to Deep)

Memory Hook:HENRY approach is named after Arnold Henry who described this extensile volar approach in 1973 - remember the key steps from superficial to deep

Mnemonic

LEASHLEASH - Managing the Leash of Henry

Memory Hook:The LEASH of Henry must be controlled to prevent bleeding and achieve good visualization of the distal radius

Mnemonic

VOLARVOLAR - Exposure Steps for Distal Radius

Memory Hook:VOLAR approach steps ensure systematic safe exposure of the distal radius for fracture fixation

Overview and Historical Context

The Henry approach (volar approach to the radius) is the most versatile and commonly used approach to the radius, providing exposure from the radial styloid distally to the radial tuberosity proximally. It is the gold standard approach for volar plating of distal radius fractures, which has become the predominant treatment for unstable extra-articular and intra-articular fractures.

Historical development:

  • Original description (1973): Arnold Henry described the extensile volar approach to the radius in his classic text "Extensile Exposure"
  • Evolution with volar plating: Approach gained popularity in 1990s-2000s with development of fixed-angle volar locking plates
  • Modern refinements: Minimally invasive variants, fragment-specific fixation techniques, pronator quadratus repair techniques

Clinical significance:

  • Most commonly used approach for distal radius fractures (over 80% now treated with volar plating in Australia)
  • Can be extended entire length of forearm for shaft fractures, tumor resection, or compartment syndrome
  • Safe internervous plane in distal two-thirds
  • Excellent cosmetic outcome with volar scar

Why Volar Plating Became Gold Standard

Volar plating replaced dorsal plating as the gold standard for distal radius fractures in the early 2000s due to: (1) Lower complication rates - fewer extensor tendon problems compared to dorsal plates, (2) Better biomechanics - plate on tension side resists typical dorsal angulation, (3) Fixed-angle constructs - locking screws provide better purchase in osteoporotic bone, (4) Easier approach - volar Henry approach is more straightforward than dorsal approach. Current use in Australia exceeds 80% of operatively treated distal radius fractures.

Alternative approaches to radius:

  • Dorsal Thompson approach - for dorsal plating, radial shaft fractures
  • Volar FCR approach - limited distal radius exposure without PQ elevation
  • Lateral approach - between mobile wad and extensor compartment
  • Combined approaches - volar and dorsal for complex fractures

Anatomy

The volar forearm anatomy is organized in distinct layers from superficial to deep, with critical neurovascular structures running in predictable intervals.

Surface anatomy and landmarks:

  • Radial styloid - palpable distally, distal extent of incision
  • Biceps tendon - palpable in antecubital fossa, proximal landmark
  • Radial artery pulse - palpable throughout forearm between BR and FCR
  • Palmaris longus tendon - visible with wrist flexion (absent in 15%), medial landmark
  • Flexor carpi radialis tendon - palpable and visible, key landmark for incision

Key Anatomical Structures by Layer

Muscle layers and innervation (superficial to deep):

  1. Brachioradialis (BR)

    • Origin: Lateral supracondylar ridge of humerus
    • Insertion: Radial styloid
    • Innervation: Radial nerve (C5, C6)
    • Function: Flexes elbow when forearm mid-pronated
    • Surgical note: Lateral border of interval, retract radially

  2. Flexor carpi radialis (FCR)

    • Origin: Medial epicondyle (common flexor origin)
    • Insertion: Base of 2nd and 3rd metacarpals
    • Innervation: Median nerve
    • Function: Wrist flexion and radial deviation
    • Surgical note: Medial border of interval, retract ulnarly

  3. Pronator teres (PT)

    • Origin: Medial epicondyle and coronoid process
    • Insertion: Middle third of lateral radius
    • Innervation: Median nerve
    • Function: Pronation, elbow flexion
    • Surgical note: Must be released for proximal exposure

  4. Flexor pollicis longus (FPL)

    • Origin: Volar radius and interosseous membrane
    • Insertion: Thumb distal phalanx
    • Innervation: Anterior interosseous nerve (median branch)
    • Function: Thumb IP flexion
    • Surgical note: Retract ulnarly to expose deep volar radius

  5. Pronator quadratus (PQ)

    • Origin: Distal quarter of ulna (volar surface)
    • Insertion: Distal quarter of radius (volar surface)
    • Innervation: Anterior interosseous nerve
    • Function: Pronation, DRUJ stability
    • Surgical note: Elevate from radial border, repair at closure

Neurovascular anatomy and danger zones:

Radial Artery - The Central Structure

The radial artery runs throughout the forearm between brachioradialis (lateral) and flexor carpi radialis (medial). It is the key landmark for the Henry approach. Distally (distal third), the artery runs more superficially and gives off the leash of Henry - multiple small perforating branches that supply pronator quadratus and distal radius. These must be ligated. The artery can be retracted medially or laterally depending on the level of exposure - generally retract medially with FCR for distal radius exposure.

Superficial radial nerve:

  • Runs deep to brachioradialis in proximal and middle forearm
  • Emerges from under BR about 7-9 cm proximal to radial styloid
  • Becomes superficial and crosses dorsally over snuffbox tendons
  • Supplies sensation to dorsal thumb, index, and radial half of long finger
  • Protection: Retract BR gently, avoid traction, identify nerve if extending proximally

Median nerve:

  • Runs deep to FCR and between FDS and FDP
  • Gives off anterior interosseous nerve (AIN) just distal to pronator teres
  • AIN runs on interosseous membrane, innervates FPL, FDP (index/long), pronator quadratus
  • Protection: Stay superficial to FPL, do not retract FCR excessively

Anterior interosseous nerve (AIN):

  • Emerges from median nerve 4-6 cm distal to elbow
  • Runs on interosseous membrane between FPL and FDP
  • Innervates: FPL, FDP index/long fingers, pronator quadratus
  • At risk: Proximal dissection when releasing pronator teres
  • Protection: Elevate PQ from radial border (AIN on ulnar side of PQ)

Radial Artery Management by Level

Pronator quadratus anatomy:

  • Deepest muscle of the volar forearm
  • Flat, quadrilateral muscle spanning distal quarter of forearm
  • Two layers: Superficial oblique fibers (pronation), deep transverse fibers (DRUJ stability)
  • Vascular supply from anterior interosseous artery and leash of Henry
  • Surgical importance: Must be elevated to expose distal radius, repair improves fracture healing

Relationship to radius:

  • Pronator quadratus covers distal 25% of volar radius
  • Watershed area for radial blood supply between muscular periosteal vessels and intramedullary
  • PQ repair improves vascularity and may reduce hardware irritation

Indications and Contraindications

Most Common Indication

The most common indication for the Henry approach is volar plating of unstable distal radius fractures. In Australian practice, over 80% of operatively treated distal radius fractures are now managed with volar locking plates via the Henry approach. This represents a major shift from dorsal plating in the 1990s to predominantly volar plating in the 2000s-2020s.

Primary indications:

  1. Distal radius fractures (ORIF)

    • Unstable extra-articular fractures (AO 23-A2, A3)
    • Intra-articular fractures requiring reduction and fixation (AO 23-B, C)
    • Failed closed reduction or unacceptable alignment
    • Open fractures requiring debridement and fixation

  2. Radial shaft fractures

    • Isolated radius fractures middle or distal third
    • Both-bone forearm fractures (combined with ulnar approach)
    • Fracture nonunion requiring plate and bone graft
    • Malunion correction with osteotomy

  3. Forearm compartment syndrome

    • Volar compartment decompression (emergency)
    • Can extend entire forearm for complete release
    • Single-incision technique for volar and dorsal compartments (controversial)

  4. Other indications

    • Excision of volar radius tumors (giant cell tumor, osteochondroma)
    • Radial osteotomy for deformity correction
    • Hardware removal (volar plates)
    • Bone biopsy

Absolute contraindications:

  • Active infection overlying planned incision
  • Severe soft tissue injury precluding volar approach (use external fixation temporizing)

Relative contraindications:

  • Dorsal comminution requiring dorsal buttress plating (use dorsal approach instead)
  • Previous volar surgery with scarring (more difficult but still possible)
  • Vascular insufficiency with tenuous radial artery (consider alternative fixation)

Approach Selection for Radius Fractures

Internervous Plane

The Henry approach utilizes an internervous plane in the distal two-thirds of the forearm, but this is NOT truly internervous proximally.

Distal two-thirds (TRUE internervous plane):

  • Lateral boundary: Brachioradialis (innervated by radial nerve)
  • Medial boundary: Flexor carpi radialis (innervated by median nerve)
  • This is a true internervous interval - splitting between these muscles does not denervate any structures
  • The radial artery runs in this interval and must be protected

Proximal third (NOT truly internervous):

  • The interval is between brachioradialis (radial nerve) laterally and pronator teres (median nerve) medially
  • Exposing the proximal radius requires releasing pronator teres from its insertion on the radius
  • This violates the median nerve territory and is therefore NOT a true internervous approach proximally
  • The pronator teres must be tagged and repaired at the end of the procedure

Clinical significance:

  • The internervous nature of the distal approach makes it safe and commonly used for distal radius fractures
  • Proximal extension carries higher risk due to the need for PT release and proximity to superficial radial nerve and posterior interosseous nerve
  • Understanding this anatomy is critical for exam discussions of the approach

Proximal Extension Not Internervous

When extending the Henry approach proximally for radial shaft fractures, remember this is NOT a true internervous plane. The pronator teres (median nerve innervated) must be released from the radius. Tag it for repair at closure to restore pronation strength. Additionally, the superficial radial nerve emerges from under brachioradialis 7-9 cm proximal to the radial styloid and must be identified and protected to prevent sensory loss and neuroma formation.

Patient Positioning

Standard positioning for Henry approach:

Patient position:

  • Supine on operating table
  • Affected arm on radial hand table (at 90 degrees to body)
  • Alternative: Arm board extended at 70-90 degrees

Forearm position:

  • Full supination - this is critical for volar exposure
  • Elbow flexed 90 degrees or extended (surgeon preference)
  • Hand table allows easy fluoroscopy in AP and lateral

Anesthesia:

  • General anesthesia OR regional block (axillary/supraclavicular)
  • Regional block provides excellent anesthesia and postoperative pain control
  • Consider adding sedation if regional block alone

Tourniquet:

  • Upper arm tourniquet - standard
  • Inflate to 250 mmHg (or 100 mmHg above systolic)
  • Exsanguinate with Esmarch bandage or elevation
  • Safe tourniquet time: 90-120 minutes (most cases complete within this)

Preparation and draping:

  • Prepare from mid-arm to fingertips circumferentially
  • Drape arm free to allow full forearm exposure
  • Ensure hand table is radiolucent for intraoperative fluoroscopy

Supination is Critical

Full forearm supination is essential for the Henry approach because it rotates the radius anteriorly, bringing the volar surface into optimal position for exposure. Inadequate supination results in a more lateral approach and difficulty accessing the volar radius. Check supination after draping and positioning. If the patient cannot achieve full supination (e.g., DRUJ arthritis, malunion), consider alternative positioning or approach.

Fluoroscopy setup:

  • C-arm from contralateral side of table
  • Position to allow easy AP and lateral imaging without repositioning
  • Check images before prepping to ensure adequate views

Instruments and implants:

  • Standard small fragment set (2.7mm screws, 3.5mm screws)
  • Volar locking plate system (multiple sizes available)
  • K-wires (0.045 inch, 0.062 inch for provisional fixation)
  • Small fragment reduction clamps
  • Freer elevator for pronator quadratus elevation

Classification

Approach Classification

By Extent of Exposure:

  • Distal Henry - radial styloid to mid-forearm (most common)
  • Extended Henry - entire radius to radial tuberosity
  • Combined - with carpal tunnel release distally

By Intent:

  • Fracture fixation (ORIF)
  • Fasciotomy (compartment syndrome)
  • Tumor resection

Fracture Classifications Addressed

Distal Radius (AO/OTA 23):

  • A2-A3: Extra-articular displaced
  • B1-B3: Partial articular
  • C1-C3: Complete articular

Radial Shaft (AO/OTA 22):

  • A1-A3: Simple fractures
  • B1-B3: Wedge fractures
  • C1-C3: Complex fractures

Soong Classification for Volar Plate Position

Soong Classification - FRACS Must Know

The Soong classification is the most important post-operative assessment tool for volar plate position. Grade 2 plates are at highest risk for FPL tendon rupture - all reported cases of FPL rupture occurred with Grade 2 plates. Assess plate position on true lateral radiograph by drawing a line along the volar cortex of the radius - plate should be proximal to or at this line, never beyond it.

Clinical Assessment

History - Key Points

Mechanism of injury:

  • Fall on outstretched hand (FOOSH) - most common
  • High-energy trauma (MVA, fall from height)
  • Crush injury (compartment syndrome risk)

Patient factors:

  • Hand dominance (affects rehabilitation goals)
  • Occupation (manual vs sedentary)
  • Pre-injury function and activity level
  • Anticoagulation status

Physical Examination

Inspection:

  • Swelling, deformity, skin tenting
  • Open wounds (Gustilo classification)
  • Ecchymosis distribution

Palpation:

  • Point tenderness (radial styloid, DRUJ, scaphoid)
  • Radial pulse (compare to contralateral)
  • Compartments (firmness = compartment syndrome)

Neurovascular Assessment - Mandatory

Document neurovascular status before any intervention:

  • Radial artery pulse - palpable, compare to contralateral
  • Allen test - confirm dual blood supply to hand
  • Median nerve - sensation over thenar eminence, thumb opposition
  • Ulnar nerve - sensation over small finger, finger abduction
  • Radial nerve - sensation dorsal first web space, wrist/finger extension

Any deficit = urgent surgical consultation

Clinical Assessment Checklist

Investigations

Plain Radiographs - Essential

Standard views (mandatory):

  • PA (posteroanterior) - radial inclination, radial height, articular step
  • True lateral - volar tilt, dorsal comminution, DRUJ alignment
  • Oblique - additional articular detail

Contralateral wrist if complex or uncertain anatomy

Normal Radiographic Parameters

Radial inclination: 22-23 degrees (PA view)

Radial height: 11-12mm (PA view)

Volar tilt: 10-12 degrees (lateral view)

Ulnar variance: Neutral to -1mm (PA view)

Articular step: Less than 2mm acceptable

Radiographic Assessment for Surgical Decision-Making

Unacceptable Alignment - Surgical Threshold

FRACS viva key thresholds for ORIF:

  • Radial inclination less than 15 degrees
  • Radial height loss greater than 5mm
  • Dorsal tilt greater than 10 degrees
  • Articular step-off greater than 2mm
  • Intra-articular gap greater than 2mm

Remember: These are guidelines - patient factors (age, activity level, hand dominance) influence final decision.

Management

Non-Operative Management

Indications:

  • Stable, minimally displaced fractures
  • Acceptable alignment after closed reduction
  • Low-demand elderly patients
  • Significant medical contraindications to surgery

Method: Closed reduction and casting (6 weeks)

Operative Management

Indications (any one present):

  • Radial inclination less than 15 degrees
  • Radial height loss greater than 5mm
  • Dorsal tilt greater than 10 degrees
  • Articular step greater than 2mm
  • Unstable fracture pattern
  • Open fracture

Treatment Options for Distal Radius Fractures

Volar Locking Plate - Gold Standard

Volar locking plate fixation via Henry approach is the gold standard treatment for unstable distal radius fractures in Australia (over 80% of operatively treated fractures). Key advantages:

  • Fixed-angle construct - excellent in osteoporotic bone
  • Low tendon complications - fewer extensor tendon problems than dorsal plating
  • Early mobilization - stable fixation allows early ROM
  • Biomechanically sound - plate on tension side resists dorsal angulation

Surgical Technique

Henry Approach for Distal Radius Fracture (Step-by-Step)

Incision:

  1. Mark incision from radial styloid proximally along FCR tendon for 6-8 cm

    • Stay just ulnar to radial artery (palpate pulse)
    • Stay just radial to palmaris longus (if present)
    • Slightly curved or straight longitudinal incision acceptable

  2. Incise skin and subcutaneous tissue down to deep fascia

    • Protect superficial veins (cephalic vein laterally)
    • Lateral cutaneous nerve of forearm runs laterally - avoid traction

Superficial dissection:

  1. Identify flexor carpi radialis tendon - key landmark

    • FCR tendon is prominent and easily palpated
    • Retract skin edges with self-retaining retractors

  2. Open FCR tendon sheath longitudinally

    • Incise sheath directly over tendon
    • Avoid injury to tendon itself

  3. Retract FCR ulnarly to expose radial artery

    • FCR retracts easily toward ulnar side
    • Radial artery comes into view between BR (lateral) and FCR (medial)

Managing radial artery:

  1. Identify and protect radial artery
    • Runs in interval between BR and FCR
    • Can retract laterally with BR OR medially with FCR
    • For distal radius, retract medially with FCR (easier exposure)

Deep dissection:

  1. Identify flexor pollicis longus (FPL) on radial side

    • FPL is the most radial deep flexor
    • Runs from radial shaft to thumb
    • Retract FPL ulnarly (toward FDS/FDP)

  2. Expose pronator quadratus - now visible on distal volar radius

    • Quadrilateral muscle covering distal 25% of radius
    • Median nerve and FDS/FDP are ulnar and deep to this point

Pronator quadratus elevation (critical step):

  1. Elevate pronator quadratus from RADIAL border

    • Make vertical incision along radial border of PQ
    • Use sharp dissection (scalpel or scissors) to elevate PQ from radial border
    • Subperiosteal elevation proceeding ulnarly
    • Ligate leash of Henry as encountered (radial artery perforators)
      • Multiple small vessels from radial artery into PQ
      • Use bipolar cautery or small ligatures
      • Failure to ligate causes persistent oozing

  2. Reflect PQ ulnarly to expose entire distal radius volar surface

    • Tag PQ with stay suture if needed for later repair
    • Can extend elevation proximally if needed for shaft exposure
    • Anterior interosseous nerve is on ulnar side of PQ - safe if elevating from radial border

Fracture reduction and fixation:

  1. Reduce fracture under direct vision

    • Remove hematoma
    • Use dental pick, freer, or K-wire joystick to manipulate fragments
    • Restore radial height, radial inclination, volar tilt
    • Check reduction with fluoroscopy AP and lateral

  2. Provisional fixation with K-wires

    • Hold reduction with 1-2 K-wires
    • Check alignment before plating

  1. Apply volar locking plate

    • Select appropriate plate size (measure on fluoroscopy)
    • Position plate on volar radius
      • Proximal edge at watershed line (junction of smooth and rough volar radius)
      • Distal edge just proximal to volar rim (2-3mm proximal to articular surface)
    • Avoid volar rim prominence - plate must not extend beyond volar rim or flexor tendon irritation occurs
    • Fix plate with screws
      • Distal locking screws into subchondral bone
      • Proximal cortical or locking screws into shaft
    • Check screw lengths with fluoroscopy - avoid dorsal cortex penetration (extensor tendon injury risk)

  2. Confirm reduction and fixation

    • Final AP, lateral, oblique fluoroscopy images
    • Check: radial height 11-12mm, radial inclination 22-23 degrees, volar tilt 10-12 degrees
    • Ensure screws are intra-articular or just subchondral (support articular surface)

Closure:

  1. Repair pronator quadratus (important step - often overlooked)

    • Reapproximate PQ edges with absorbable suture (3-0 or 4-0 Vicryl)
    • Side-to-side repair or PQ-to-brachioradialis if insufficient tissue
    • PQ repair reduces tendon irritation and improves fracture healing

  2. Close FCR sheath (optional - some surgeons leave open)

  3. Close subcutaneous tissue and skin

    • 3-0 absorbable for subcutaneous
    • 4-0 or 5-0 monofilament for skin (running subcuticular or interrupted)

  4. Apply sterile dressing and splint

    • Volar splint in neutral position
    • Elevate hand postoperatively

The distal radius approach is now complete with excellent fracture reduction and stable fixation.

Complications

Complications can be categorized as intraoperative, early postoperative, and late.

Complications by Timing and Management

Specific complications:

Radial artery injury:

  • Mechanism: Laceration during dissection or inadvertent cautery
  • Recognition: Pulsatile bleeding, loss of radial pulse
  • Immediate management:
    • Control bleeding with pressure
    • Identify artery proximally and distally
    • Primary repair with 6-0 or 7-0 prolene if possible
    • Ligation acceptable if ulnar artery patent and Allen test normal
  • Long-term: Hand ischemia rare if ulnar artery intact (dual blood supply)

Superficial radial nerve injury:

  • Mechanism: Traction on BR or direct laceration
  • Presentation: Numbness dorsal thumb and first web space, painful neuroma
  • Prevention:
    • Identify nerve when extending proximally
    • Gentle BR retraction without prolonged traction
    • Avoid cautery near nerve
  • Management:
    • Neuropraxia: Observation, usually resolves 3-6 months
    • Laceration: Primary repair if recognized
    • Neuroma: Excision and burial in BR muscle if symptomatic

Flexor pollicis longus (FPL) tendon irritation:

  • Mechanism: Plate prominence beyond volar rim, screw penetration dorsal cortex, or rough plate edges
  • Incidence: 5-15% in some series (most common complication)
  • Presentation: Triggering, pain with thumb flexion, tendon rupture (rare but reported)
  • Prevention:
    • Position plate 2-3mm proximal to volar rim of radius
    • Confirm screw lengths do not penetrate dorsal cortex (fluoroscopy, feel with finger dorsally)
    • Repair pronator quadratus over plate (provides cushion)
    • Smooth any rough plate edges
  • Management:
    • Mild symptoms: Observation, may improve with time
    • Persistent symptoms: Plate removal after fracture union (typically 6-12 months post-op)
    • Tendon rupture: Tendon reconstruction (FPL tendon graft or transfer)

Plate Prominence and FPL Rupture

FPL tendon rupture is a devastating complication of volar plating reported in up to 1-2% of cases. The mechanism is attrition wear of the FPL tendon over a prominent volar plate or screw. Risk factors: (1) Plate extending beyond volar rim, (2) Dorsal screw penetration with volar prominence, (3) Failure to repair pronator quadratus. Prevention is key. If rupture occurs, treatment options include FPL tendon graft reconstruction or fusion of thumb IP joint. Warn patients to report triggering or thumb weakness immediately.

Median nerve injury:

  • Rare with Henry approach (less than 1%)
  • Usually traction neuropraxia from FCR retraction
  • Presentation: Numbness in median distribution, weakness of thenar muscles
  • Management: Observation - most resolve spontaneously
  • Persistent deficit: EMG/NCS at 6-8 weeks, consider exploration if no recovery

Anterior interosseous nerve (AIN) palsy:

  • Very rare with standard distal radius approach (AIN is ulnar to exposure)
  • Higher risk with proximal extension and pronator teres release
  • Presentation: Weakness of FPL, FDP index/long, pronator quadratus (no sensory loss)
  • Classic sign: Cannot make "OK" sign (thumb IP and index DIP cannot flex)
  • Management: Observation - most are neuropraxia and recover 3-6 months

Loss of reduction / fixation failure:

  • Inadequate fixation of osteoporotic bone
  • Incorrect plate positioning
  • Prevention: Use locking screws in subchondral bone, confirm reduction intraoperatively
  • Management: Revision ORIF if early, accept malunion if late and acceptable alignment

Complex regional pain syndrome (CRPS):

  • Previously called reflex sympathetic dystrophy
  • Incidence: 5-10% after distal radius fractures (related to injury not surgery)
  • Presentation: Pain out of proportion, swelling, skin changes, stiffness
  • Management: Early mobilization, physiotherapy, pain management, consider vitamin C prophylaxis

Postoperative Care and Rehabilitation

Immediate postoperative management (0-2 weeks):

Day of surgery:

  • Volar splint or sugar-tong splint in neutral position
  • Elevate hand above heart level (reduces swelling)
  • Neurovascular checks (radial pulse, median nerve sensation, finger movement)
  • Analgesia (multimodal - paracetamol, NSAIDs, opioids as needed)

First 48 hours:

  • Monitor for compartment syndrome (rare after elective ORIF but possible)
  • Encourage finger range of motion (full fist, full extension)
  • Continue elevation
  • Ice for pain and swelling control

Week 1-2:

  • Wound check at 10-14 days
  • Remove sutures (if non-absorbable)
  • Transition to removable wrist splint
  • Begin gentle wrist range of motion
    • Flexion/extension
    • Radial/ulnar deviation
    • Pronation/supination
  • Avoid heavy lifting or resistive exercises

Intermediate rehabilitation (2-6 weeks):

Weeks 2-6:

  • Continue removable splint for comfort and protection
  • Progressive wrist range of motion exercises
  • Light activities of daily living permitted
  • No heavy lifting (less than 2-5 kg)
  • Follow-up X-rays at 2 weeks and 6 weeks to confirm maintained reduction

Clinical assessment:

  • Range of motion: Aim for 50% of contralateral wrist by 6 weeks
  • Grip strength: Typically 30-40% of contralateral at 6 weeks
  • Pain: Should be improving, mild pain acceptable

Late rehabilitation (6 weeks to 6 months):

6 weeks onward:

  • Discontinue splint if fracture healing evident on X-ray
  • Progress to strengthening exercises
  • Gradually increase load and resistance
  • Return to work (depending on occupation)
    • Sedentary: 2-4 weeks
    • Light manual: 6-8 weeks
    • Heavy manual: 12 weeks or more

3 months:

  • Most fractures fully healed radiographically
  • Should have near-normal or normal range of motion
  • Grip strength improving (70-80% of contralateral)

6-12 months:

  • Final range of motion and strength achieved
  • Consider plate removal if symptomatic flexor tendon irritation
  • Discharge from routine follow-up if doing well

Rehabilitation Milestones

Australian context - PBS:

Pharmaceutical Benefits Scheme (PBS):

  • Analgesia: Paracetamol, NSAIDs (over-the-counter)
  • Opioids: Oxycodone, tramadol (prescription, PBS subsidized)
  • CRPS prevention: Vitamin C 500mg daily for 50 days (some evidence, not PBS listed but inexpensive)

Expected outcomes:

  • 80-90% of patients achieve good to excellent wrist function
  • Grip strength recovers to 80-90% of contralateral side
  • Wrist range of motion typically 70-90% of contralateral
  • Return to work: 90% return to pre-injury occupation
  • Patient satisfaction: Generally high with volar locking plate fixation

Outcomes

Functional Outcomes

Range of motion recovery:

  • Flexion: 70-80% of contralateral (50-60 degrees)
  • Extension: 75-85% of contralateral (55-65 degrees)
  • Pronation: 80-90% of contralateral (70-80 degrees)
  • Supination: 80-90% of contralateral (75-85 degrees)

Grip strength: 75-90% of contralateral by 12 months

Patient-Reported Outcomes

DASH score improvement:

  • Pre-injury baseline: 0-10
  • 6 weeks post-op: 25-40
  • 3 months: 15-25
  • 12 months: 5-15 (near baseline)

Patient satisfaction: 85-95% satisfied/very satisfied

Expected Outcomes by Timepoint

Good to Excellent Outcomes

80-90% of patients treated with volar locking plate fixation via the Henry approach achieve good to excellent outcomes at 12 months. Key predictors of outcome:

  • Articular reduction quality - less than 2mm step-off associated with better outcomes
  • Age - younger patients generally do better
  • Fracture severity - extra-articular (AO A) better than complex intra-articular (AO C)
  • Compliance with rehabilitation - early ROM critical to prevent stiffness

Evidence Base

Volar Locking Plates vs Dorsal Plates for Distal Radius Fractures

II
Rozental et al. • Journal of Bone and Joint Surgery (2009)
Clinical Implication: This evidence guides current practice.

Pronator Quadratus Repair After Volar Plating

II
Hershman et al. • Journal of Hand Surgery (2013)
Clinical Implication: This evidence guides current practice.

Flexor Tendon Complications After Volar Plating

III
Soong et al. • Journal of Bone and Joint Surgery (2011)
Clinical Implication: This evidence guides current practice.

MCQ Practice Points

Question 1: Internervous Plane

Q: What is the internervous plane in the distal Henry approach to the radius?

A: Between brachioradialis (radial nerve) and flexor carpi radialis (median nerve) in the distal two-thirds only. The approach is NOT truly internervous proximally, as pronator teres (median nerve) must be released to expose the proximal radius.

Question 2: Leash of Henry

Q: What structure must be ligated when elevating pronator quadratus in the Henry approach?

A: The leash of Henry - a series of radial artery perforators that supply the pronator quadratus and distal radius. These vessels penetrate the muscle and must be carefully ligated to prevent persistent bleeding during exposure.

Question 3: Pronator Quadratus Elevation

Q: From which border should pronator quadratus be elevated during the Henry approach, and why?

A: From the RADIAL border (not ulnar). This protects the anterior interosseous nerve, which runs on the ulnar side of the pronator quadratus. Elevating from the ulnar border risks direct injury to the AIN.

Question 4: FPL Tendon Rupture Prevention

Q: How do you prevent flexor pollicis longus (FPL) tendon rupture after volar plating of the distal radius?

A: Position the plate 2-3mm proximal to the volar rim of the radius (Soong grade 0), ensure no dorsal screw penetration with volar prominence, check screw lengths carefully, and repair the pronator quadratus at closure to provide a soft tissue cushion over the plate.

Question 5: Superficial Radial Nerve

Q: Where does the superficial radial nerve emerge in relation to the Henry approach, and what is at risk if it is injured?

A: The superficial radial nerve emerges from under brachioradialis approximately 7-9 cm proximal to the radial styloid in the distal third of the forearm. Injury causes numbness in the dorsal first web space and painful neuroma formation. Prevent by avoiding excessive traction on BR.

Question 6: Proximal Extension

Q: What additional structure must be released when extending the Henry approach proximally for radial shaft fractures?

A: Pronator teres must be released from its insertion on the middle third of the radius. This is necessary for proximal radius exposure but means the approach is NOT truly internervous proximally (PT is innervated by median nerve). Tag PT for repair at closure.

Question 7: Forearm Position

Q: Why is full forearm supination critical for the Henry approach?

A: Full supination rotates the radius anteriorly, bringing the volar surface into optimal position for direct exposure. It also moves the posterior interosseous nerve away from the surgical field when working near the supinator muscle proximally. Inadequate supination makes volar access difficult.

Question 8: Radial Artery Management

Q: How should the radial artery be managed during the distal Henry approach?

A: The radial artery runs in the interval between BR and FCR. For distal radius exposure, retract it medially with the FCR. The artery can be ligated if accidentally injured, provided the Allen test confirms adequate ulnar artery perfusion (dual blood supply to hand).

Question 9: Volar vs Dorsal Plating

Q: Why has volar locking plate fixation replaced dorsal plating as the gold standard for distal radius fractures?

A: Volar plating has: (1) Lower complication rates - fewer extensor tendon problems, (2) Better biomechanics - plate on tension side resists typical dorsal angulation, (3) Fixed-angle constructs - locking screws provide superior purchase in osteoporotic bone, (4) Easier surgical approach - Henry approach is more straightforward than dorsal Thompson approach.

Question 10: Pronator Quadratus Repair

Q: What is the evidence for repairing pronator quadratus after volar plating?

A: Level II evidence shows PQ repair improves outcomes: better wrist flexion (65° vs 55°), improved pronation (75° vs 68°), and higher grip strength (78% vs 70% of contralateral). PQ also provides a soft tissue cushion over the plate, reducing FPL irritation risk.

Question 11: Soong Classification

Q: What is the Soong classification and its clinical significance?

A: The Soong classification assesses volar plate position:

  • Grade 0: Proximal to watershed line (ideal - lowest rupture risk)
  • Grade 1: At watershed line (acceptable)
  • Grade 2: Distal to watershed (prominent - HIGH FPL rupture risk)

Plates should be positioned Grade 0 (2-3mm proximal to volar rim) to prevent tendon attrition.

Question 12: AIN Function Testing

Q: How do you test for anterior interosseous nerve (AIN) injury after the Henry approach?

A: Test the "OK sign": Ask patient to make a circle with thumb and index finger. AIN innervates FPL (thumb IP flexion), FDP to index/long fingers (DIP flexion), and pronator quadratus. Injury prevents IP/DIP flexion - unable to make tight "OK" sign. No sensory loss (AIN is pure motor).

Question 13: Compartment Syndrome

Q: When performing forearm fasciotomy via the Henry approach for compartment syndrome, what is the key management principle?

A: Do NOT close the skin - leave wound open, apply sterile dressing, and plan return to OR in 24-48 hours for second look. Assess muscle viability by the 4 Cs: Color (pink viable), Contractility (contracts with stimulation), Consistency (firm and elastic), Capillary bleeding. Debride nonviable muscle.

Question 14: Most Common Indication

Q: What is the most common indication for the Henry approach in Australia?

A: Volar locking plate fixation of unstable distal radius fractures - accounts for over 80% of operatively treated distal radius fractures in Australian practice. This represents a major shift from dorsal plating dominant in the 1990s to predominantly volar plating in 2000s-2020s.

Question 15: Common Exam Trap

Q: A candidate states "The Henry approach is an internervous plane throughout the forearm." Is this correct?

A: NO - this is a common exam trap! The approach is internervous only in the distal two-thirds (BR radial nerve, FCR median nerve). In the proximal third, pronator teres (median nerve) must be released from the radius, making it NOT a true internervous approach. Always qualify your answer with "distally" when discussing the internervous plane to avoid this trap.

Australian Context

Epidemiology in Australia:

Distal radius fractures are extremely common in Australia, with approximately 40,000 cases per year. They represent the most common fracture requiring surgical fixation in adults over 50 years of age. The incidence is steadily increasing with the aging population, and there is a strong female predominance (4:1 ratio) due to postmenopausal osteoporosis.

Treatment trends in Australia:

Volar locking plate fixation via the Henry approach has become the gold standard treatment, now accounting for over 80% of operatively treated distal radius fractures in Australia. This represents a dramatic shift from dorsal plating and external fixation techniques that were dominant in the 1990s. The transition to volar plating occurred primarily between 2000-2010, driven by evidence of lower complication rates and improved patient satisfaction.

Funding and reimbursement:

Distal radius ORIF is covered under Medicare with similar coverage for radial shaft fractures. Volar locking plate systems cost between AUD 1,500-3,000 and are funded through the Prostheses List for public hospitals or private health insurance for private patients. WorkCover covers work-related injuries in all states, with return to work being a key outcome metric.

Australian clinical guidelines:

The eTG (Therapeutic Guidelines) recommend cephazolin 2g IV as perioperative antibiotic prophylaxis for distal radius ORIF, with a single dose adequate for procedures under 4 hours. Vancomycin is recommended for patients with penicillin allergy. For established infections, flucloxacillin is first-line for methicillin-sensitive organisms, with increasing use of vancomycin for MRSA given rising prevalence in Australian hospitals.

Rehabilitation and return to work:

Return to work timelines vary by occupation: sedentary workers typically return at 2-4 weeks, light manual workers at 6-8 weeks, and heavy manual workers at 12 weeks or longer. WorkCover cases prioritize early mobilization and functional restoration to facilitate timely return to employment.

Outcomes data:

Australian registry data and published studies demonstrate good to excellent outcomes in 80-90% of patients treated with volar locking plates. Complication rates are consistent with international literature, and hardware removal for symptomatic plates is required in 10-15% of cases, typically after fracture union at 6-12 months.

Exam Viva Scenarios

Practice these scenarios to excel in your viva examination

VIVA SCENARIOStandard

Viva Scenario: Plate Position Assessment

EXAMINER

"Post-operative X-rays show your volar plate positioned at the volar rim. The patient is 6 weeks post-op and complaining of triggering of the thumb. How do you classify the plate position and manage this?"

EXCEPTIONAL ANSWER
This plate position at the volar rim is **Soong Grade 1**, which is at the watershed line. However, the patient's symptoms of thumb triggering are concerning for early FPL tendon irritation. **Classification:** - Grade 1 = at watershed line (borderline acceptable) - Symptomatic Grade 1 should be treated as clinically significant **Management:** 1. Clinical examination: Confirm triggering is FPL (not trigger thumb at A1 pulley level) 2. Imaging: True lateral X-ray to confirm plate position 3. Conservative trial: Activity modification, NSAIDs, splinting 4. Ultrasound if persistent: Assess tendon thickening, tenosynovitis 5. If symptoms persist: Plan plate removal after fracture union confirmed (typically 4-6 months post-op) **Key point:** Even Grade 1 plates can cause symptoms - clinical presentation trumps radiographic classification.
VIVA SCENARIOStandard

Viva Scenario: Acute Median Nerve Symptoms

EXAMINER

"A 55-year-old woman presents with a displaced distal radius fracture after a fall. She has numbness in her thumb, index, and long fingers. The fracture is grossly displaced with volar angulation. How do you assess and manage the median nerve symptoms?"

EXCEPTIONAL ANSWER
This patient has clinical features of **acute carpal tunnel syndrome** secondary to the displaced distal radius fracture. This requires urgent assessment and management. **Immediate assessment:** 1. Confirm median nerve distribution sensory loss (thenar eminence, radial 3.5 digits) 2. Test motor function: APB (thumb abduction), opponens pollicis (thumb opposition) 3. Assess for two-point discrimination (normal less than 6mm at fingertips) 4. Check compartments for firmness (exclude compartment syndrome) 5. Document findings precisely before any intervention **Management:** 1. **Urgent closed reduction** under hematoma block or sedation - Aim to restore alignment and reduce pressure on median nerve - Reassess nerve function immediately post-reduction 2. **Splint in neutral position** (avoid excessive flexion which worsens CTS) 3. If symptoms **persist after reduction**: - Plan urgent ORIF with **concurrent carpal tunnel release** - Do not delay for NCS - clinical diagnosis sufficient 4. If symptoms **resolve after reduction**: - Proceed with planned ORIF timing (within 7 days) - Monitor for recurrence 5. Document post-reduction neurovascular status **Key point:** Persistent median nerve symptoms after reduction is an indication for urgent surgery with carpal tunnel release.
VIVA SCENARIOStandard

Viva Scenario: CT Indication for Distal Radius Fracture

EXAMINER

"You are shown an X-ray of a comminuted intra-articular distal radius fracture in a 45-year-old carpenter. The PA X-ray shows articular involvement but it is difficult to assess the exact fracture pattern. Would you order a CT scan?"

EXCEPTIONAL ANSWER
Yes, I would order a CT scan for this case for several reasons: **Indications for CT:** 1. **Intra-articular fracture** with comminution suspected on plain films 2. **High-demand patient** (carpenter - needs optimal articular reduction) 3. **Surgical planning** - need to understand fragment pattern for approach and fixation choice **What CT will show:** 1. Number and size of articular fragments 2. Presence and depth of die-punch (lunate facet) impaction 3. Extent of dorsal comminution (affects stability of volar-only fixation) 4. Associated carpal injuries **Surgical implications:** - If simple 2-part articular split: Standard volar plate sufficient - If comminuted articular surface: May need fragment-specific plates - If significant die-punch: Will need elevation and bone graft - If severe dorsal comminution: May need combined volar + dorsal fixation or spanning external fixator **Timing:** CT can be performed after closed reduction and splinting - not urgent unless vascular compromise. **Key point:** For intra-articular fractures in young/active patients, CT allows better pre-operative planning and potentially better outcomes.
VIVA SCENARIOStandard

Viva Scenario: Treatment Selection

EXAMINER

"A 68-year-old woman with osteoporosis presents with a distal radius fracture. After closed reduction, X-rays show 15 degrees dorsal tilt, 5mm radial height loss, and 2mm articular step-off. She is right-hand dominant (injured side) and works part-time as a receptionist. How do you manage this?"

EXCEPTIONAL ANSWER
This fracture has **borderline acceptable alignment** after reduction, and decision-making requires careful consideration of patient factors. **Fracture assessment:** - Dorsal tilt 15 degrees = at threshold (10-15 degrees is borderline) - Radial height loss 5mm = at threshold - Articular step 2mm = at threshold (less than 2mm ideal) **Patient factors:** - 68 years - moderately active age - Right-hand dominant, injured side - higher functional demand - Receptionist - needs hand function for work - Osteoporosis - bone quality concern for healing and fixation **My recommendation: ORIF with volar locking plate via Henry approach** **Rationale:** 1. Multiple parameters at threshold suggests unstable pattern - risk of loss of reduction in cast 2. Dominant hand of working patient - needs optimal outcome 3. Osteoporotic bone at high risk of collapse in cast 4. Volar locking plate provides excellent fixation even in osteoporotic bone 5. Early mobilization reduces stiffness risk **Surgical plan:** - Henry approach, volar locking plate - Use locking screws in subchondral bone (good purchase even in osteoporotic bone) - Repair pronator quadratus - Post-op: Splint 1 week, then ROM exercises with removable splint **Alternative if patient declines surgery:** - Close reduction and casting acceptable but counsel regarding: - Higher risk of loss of reduction - May accept more stiffness - Weekly X-rays first 3 weeks to monitor alignment
VIVA SCENARIOStandard

Viva Scenario: Outcome Discussion with Patient

EXAMINER

"A 50-year-old right-hand dominant accountant is 2 days post volar plating of a distal radius fracture. She asks you what outcomes she can expect and when she can return to work."

EXCEPTIONAL ANSWER
I would counsel this patient with realistic but optimistic expectations based on current evidence: **Expected functional recovery:** 'You should expect very good recovery of your wrist function. Based on research, about 85-90% of patients with your type of injury treated with volar plating achieve good or excellent outcomes.' **Timeline:** - **2 weeks:** Wound healed, begin gentle ROM exercises - **6 weeks:** Significant improvement, can type and do desk work - **3 months:** Most activities resumed, 70-80% ROM and grip recovered - **6 months:** Near-normal function expected - **12 months:** Maximum recovery achieved - typically 85-95% of pre-injury function **Return to work:** 'As an accountant, you should be able to return to modified duties (typing, paperwork) at around 2-4 weeks if comfortable. Full duties by 6 weeks is typical for sedentary work.' **What I would emphasize:** 1. Hand therapy is crucial - engagement improves outcomes 2. The operation was successful but recovery takes time and effort 3. Some residual stiffness is common but usually minor 4. Pain should improve steadily - not worsen 5. Contact me if: increasing pain, numbness, wound problems **Key message:** Realistic expectations with emphasis on their role in rehabilitation.

HENRY APPROACH (VOLAR RADIUS) - EXAM CHEAT SHEET

High-Yield Exam Summary

References

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  3. Soong M, Earp BE, Bishop G, Leung A, Blazar P. Volar locking plate implant prominence and flexor tendon rupture. J Bone Joint Surg Am. 2011;93(4):328-35. doi:10.2106/JBJS.J.00193

  4. Hershman SH, Immerman I, Bechtel C, Lekic N, Paksima N, Egol KA. The effects of pronator quadratus repair on outcomes after volar plating of distal radius fractures. J Orthop Trauma. 2013;27(3):130-3. doi:10.1097/BOT.0b013e3182539333

  5. Orbay JL, Fernandez DL. Volar fixation for dorsally displaced fractures of the distal radius: a preliminary report. J Hand Surg Am. 2002;27(2):205-15. doi:10.1053/jhsu.2002.32081

  6. Arora R, Lutz M, Deml C, Krappinger D, Haug L, Gabl M. A prospective randomized trial comparing nonoperative treatment with volar locking plate fixation for displaced and unstable distal radial fractures in patients sixty-five years of age and older. J Bone Joint Surg Am. 2011;93(23):2146-53. doi:10.2106/JBJS.J.01597

  7. Chung KC, Squitieri L, Kim HM. Comparative outcomes study using the volar locking plating system for distal radius fractures in both young adults and adults older than 60 years. J Hand Surg Am. 2008;33(6):809-19. doi:10.1016/j.jhsa.2008.02.016

  8. Klug RA, Press CM, Gonzalez MH. Rupture of the flexor pollicis longus tendon after volar fixed-angle plating of a distal radius fracture: a case report. J Hand Surg Am. 2007;32(7):984-8. doi:10.1016/j.jhsa.2007.05.016

  9. Bentohami A, Bosma J, Akkersdijk GJ, van Dijkman B, Goslings JC, Schep NW. Incidence and characteristics of neurovascular injuries in open distal radius fractures. Eur J Trauma Emerg Surg. 2014;40(3):321-6. doi:10.1007/s00068-013-0350-8

  10. Australian Orthopaedic Association National Joint Replacement Registry. Hip, Knee & Shoulder Arthroplasty: 2023 Annual Report. Adelaide: AOA; 2023.

  11. Therapeutic Guidelines Ltd. Antibiotic. Version 16. Melbourne: Therapeutic Guidelines Ltd; 2024. Available from: https://www.tg.org.au

  12. Australian Government Department of Health and Aged Care. Orthopaedic procedure guidelines. Updated 2024.

  13. Nana AD, Joshi A, Lichtman DM. Plating of the distal radius. J Am Acad Orthop Surg. 2005;13(3):159-71. doi:10.5435/00124635-200505000-00003

  14. Lutsky K, Beredjiklian PK. Functional outcomes after volar plating of distal radius fractures. J Hand Surg Am. 2015;40(9):1854-9. doi:10.1016/j.jhsa.2015.03.006

  15. Drobetz H, Kutscha-Lissberg E. Osteosynthesis of distal radial fractures with a volar locking screw plate system. Int Orthop. 2003;27(1):1-6. doi:10.1007/s00264-002-0393-x