Modern Study Review (AI-Generated)
High-Yield Summary
Open Reduction and Internal Fixation (ORIF) of distal radius fractures via a volar approach is the current gold standard for displaced, unstable, or intra-articular fractures, especially in active patients over 50 years old. The volar locking plate provides stable fixation, allowing early mobilization and improved functional outcomes. Mastery of the volar anatomy and careful soft tissue handling are critical to avoid neurovascular injury and optimize recovery.
Key Diagnostic Findings
Anatomy
- Distal radius articulates with the carpus and ulna; volar surface contains critical structures including the flexor carpi radialis (FCR) tendon, radial artery, flexor pollicis longus (FPL), and pronator quadratus (PQ).
- Ulnar styloid fracture often accompanies distal radius fractures and may affect distal radioulnar joint (DRUJ) stability.
Clinical Presentation
- Mechanism: Fall on an outstretched hand (FOOSH) or high-energy trauma (e.g., horse fall).
- Signs: Volar displacement/deformity, swelling, pain, limited wrist motion, possible median nerve symptoms.
- Associated injuries: Ulnar styloid fracture, DRUJ instability.
Imaging
- Standard wrist radiographs: PA, lateral, and oblique views to assess fracture pattern, displacement, and articular involvement.
- CT scan: Recommended for complex intra-articular fractures to evaluate fragment comminution and joint congruity.
Classification Systems
| Classification | Description | Clinical Relevance |
|---|---|---|
| AO/OTA | Type A (extra-articular), B (partial articular), C (complete articular) | Guides treatment and prognosis |
| Fernandez | Mechanism-based (Type I-V) | Helps understand fracture etiology |
| Lidström | Displacement and comminution patterns | Historical, less commonly used |
| Neer | Focus on distal radius fractures with volar/dorsal displacement | Useful for surgical planning |
Current Gold Standard Treatment
Non-operative Indications and Treatment
- Minimally displaced, stable fractures without articular step-off or DRUJ instability.
- Treatment: Closed reduction, immobilization in a cast or splint for 4-6 weeks, followed by early mobilization.
Operative Indications and Treatment
- Displaced intra-articular fractures with >2 mm step-off or gap.
- Volarly displaced fractures with instability.
- Comminuted fractures with metaphyseal collapse.
- Associated DRUJ instability or ulnar styloid fractures compromising stability.
Operative Technique (Volar ORIF):
- Patient supine, arm on hand table.
- Volar approach via incision just ulnar to FCR tendon, avoiding radial artery injury.
- Mobilize FCR tendon ulnarly; incise pronator quadratus along radial border and elevate subperiosteally.
- Reduce fracture fragments anatomically; use volar locking plate contoured with slight spring to buttress distal fragments.
- Fixation with cortical screws proximally and locking/cancellous screws distally.
- Confirm reduction and hardware placement with fluoroscopy.
Modern Complications & Outcomes
Complications
| Complication | Description | Prevention/Management |
|---|---|---|
| Tendon irritation or rupture (FPL) | Due to plate prominence or screw penetration | Proper plate positioning, screw length check |
| Median nerve neuropathy | From retraction or hematoma | Gentle soft tissue handling, decompression if needed |
| Complex Regional Pain Syndrome (CRPS) | Painful stiffness post-op | Early mobilization, pain control |
| Infection | Superficial or deep | Sterile technique, antibiotics |
| Loss of reduction or malunion | Inadequate fixation or early motion | Stable fixation, patient compliance |
| DRUJ instability | Associated ulnar styloid fractures | Address ulnar styloid if unstable |
Outcomes
- Volar locking plate ORIF allows early wrist motion, leading to improved range of motion and grip strength compared to casting.
- Functional outcomes correlate with anatomic reduction, especially articular congruity.
- Most patients regain near-normal wrist function by 3-6 months post-op.
- Long-term arthritis risk increases with residual articular incongruity.
Classic Clinical Notes
ORIF Distal Radius (Volar)
- Patient: 64-year-old woman who fell off horse – completely volarly displaced, intra-articular fracture of the distal radius, with ulnar styloid fracture.
- Surgeon: O’Brien
- Positioning: Supine, Boyse table
Description:
- Regular prep and drape, with the arm out on the table.
- The tough part is to ensure that you get enough proximal exposure to put the plate on.
- Make the incision straight just ulnar to FCR. He does not continue the incision across the transverse crease of the wrist.
- Cauterize the little veins that come into view in the subcutaneous tissue.
- Find the tendon sheath of FCR and incise along the radial aspect of it. If you go too radial you’ll incise the radial artery.
- Mobilize the tendon ulnarly. Incise the undersurface of the tendon sheath.
- All of the muscles – FPL and FDP are then mobilized ulnarly until you reach pronator quadratus.
- This is incised along its radial border and peeled subperiosteally ulnarly. This should get you into the fracture hematoma and fracture.
- Subperiosteal dissection distally gets you into the capsular attachments. Proximal dissection is required to get the plate on.
- Bend a bit of spring into the plate, then use it to buttress the distal fragment back on.
- Secure the shaft, then put a cancellous screw into the distal fragment.
Last Updated on January 25, 2026 by orthonet
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