Please confirm topic selection

Are you sure you want to trigger topic in your Anconeus AI algorithm?

Please confirm action

You are done for today with this topic.

Would you like to start learning session with this topic items scheduled for future?

Distal Radius Fractures
Updated: Oct 9 2017

Distal Radius Extra-articular Fracture ORIF with Volar Appr

Preoperative Patient Care
Operative Techniques

Preoperative Plan


Identify fracture characteristics

  • distal radius fracture pattern
  • bone quality
  • DRUJ disruption
  • amount of comminution
  • presence of intra-articular extension(s)


Execute surgical walkthrough

  • describe key steps of the procedure to the attending verbally prior to the start of the case
  • describe potential complications and steps to avoid them

Room Preparation


Surgical instrumentation

  • ensure precontoured volar locking plate system of choice is present in the room


Room setup and equipment

  • setup OR with standard operating table and radiolucent hand table
  • turn table 90° so that operative extremity points away from anesthesia machines
  • c-arm perpendicular to hand table with monitor in surgeon's direct line of site


Patient positioning

  • supine with shoulder at edge of bed centered at level of patient’s shoulder
  • hand centered on hand table, supinate arm
  • arm tourniquet placed on arm with webril underneath (optional)

Volar Approach


Mark incision

  • make incision along palpable flexor carpi radialis (FCR) tendon sheath
  • make ulnar or radial curve so you don't cross perpendicular to flexion crease


Incise skin flaps and subcutaneous fat

  • identify PCBMN


Dissect through FCR sheath

  • section fibers of volar FCR tendon sheath in line with tendon
  • retract FCR tendon ulnarly and incise through the dorsal aspect of the FCR sheath
  • can retract FCR radially if carpal tunnel access is necessary

Deep Dissection


Locate the FCR sheath under the FPL and retract ulnarly

  • after the FPL is bluntly retracted, the pronator quadratus (PQ) is seen
  • be careful of palmar cutaneous branch of median nerve
  • arises 5cm proximal to wrist joint, ulnar to FCR


Visualize the proximal extent of pronator quadratus and take down sharply with knife

  • incise radial and distal borders of quadratus and take down in L-shaped fashion
  • use bipolar to cauterize branching vessels from radial artery


Brachioradialis can be released if needed (optional)

  • removes deforming force
  • dorsal radial sensory nerve branch is deep to brachioradialis

Fracture Preparation and Reduction


Clear fracture site

  • remove interposing periosteum and hematoma from fracture site
  • use freer elevator to open fracture site

Provisional Fixation with K Wires and Plate


Reduce fracture

  • apply traction and manipulation of the hand to obtain a reduction
  • further reduction can be performed with direct fragment manipulation
  • place rolled blue towels under dorsal wrist to aid in volar translation or radial/ulnar deviation


Place Kwires for provisional fixation

  • if fragment(s) unstable use 1.6mm K-wires
  • from radial styloid proximally across fracture line

Definitive Plate and Screw Fixation


Distal fixation first

  • after fracture reduction check size, length, and rotation of plate on distal radius
  • use K-wires into plate to temporarily fix distally
  • hold plate down to bone distally
  • K-wires in distal row of plate will show angle/location of distal screws
  • want screws as distal as possible for subchondral bone support
  • hold proximal aspect of plate off bone with screw or elevator
  • drill and insert distal row screws
  • fluoro AP and radial inclination view (distal radius angled 20° off of hand table)
  • remove K-wires from distal plate
  • bring plate down to bone proximally and hold with 3 non-locking screws


Proximal fixation first

  • place cortical screw in proximal oval hole of plate using 3.5mm screw
  • plate can be readjusted later on due to oval hole
  • insert distal ulnar cortical screw after drilling through guide for preliminary fixation or locking screw if confident with plate location
  • check screw lengths after inserting all distal row locking screws
  • obtain fluoroscopic views to make sure no screw penetration into joint
  • checking a radial inclination view is critical (lateral xray with distal radius lifted 20° off hand table)
  • drill and insert screws into plate shaft proximal to fracture
  • if bony defect, can add auto/allograft bone as needed

Confirm Alignment and Implant Position


Take final fluoroscopic images

  • can compare to pre-op or intraop radiographs of contralateral wrist

Wound Closure


Irrigation, hemostasis, and drain

  • irrigate wounds thoroughly and deflate tourniquet (if utilized)
  • coagulate any bleeders carefully
  • evaluate for damage to radial artery
  • quadratus can be laid over plate
  • repair of quadratus does not improve outcome



  • close subcutaneous layer with 3-0 absorbable suture
  • 3-0 nylon vertical/horizontal mattress for skin
  • alternatively, can use running 4-0 or 5-0 Monocryl for subcuticular stitch


Dressing and splint

  • incision dressing (gauze, webril) followed by volar slab splint for immobilization
  • allow wrist to rest in neutral position while splint sets
  • post-operative vitamin C 500mg x 50 days to reduce incidence of RSD/CRPS (2010 AAOS Clinical Practice Guidelines)
Postoperative Patient Care
Private Note

Attach Treatment Poll
Treatment poll is required to gain more useful feedback from members.
Please enter Question Text
Please enter at least 2 unique options
Please enter at least 2 unique options
Please enter at least 2 unique options