Volar approaches to the distal radius

Czech version

Authors: V. Kunc
Authors‘ workplace: I. ortopedická klinika 1. LF UK a FN Motol, Praha ; Ústav anatomie, 2. LF UK, Praha ; Klinika úrazové chirurgie FZS UJEP a Krajská zdravotní, a. s. – Masarykova nemocnice Ústí nad Labem, o. z.
Published in: Rozhl. Chir., 2025, roč. 104, č. 8, s. 326-331.
Category: Review
doi: https://doi.org/10.48095/ccrvch2025326

Overview

Introduction: The modified Henry approach is predominantly used in the treatment of distal radius fractures. Over the years, it has undergone numerous modifications, and its original interpretation varies significantly. This summary also discusses other volar approaches to the distal radius. The original description of the approach is attributed to Arnold Kirkpatrick Henry, who, in his three publications, mentions the interval between the radial artery and the flexor carpi radialis muscle. Currently, many controversies are being debated, including extended approaches, techniques and options for transecting the pronator quadratus muscle, indications and methods for carpal tunnel release, transection of the brachioradialis muscle, and others.

Variations: Anatomical structures visualized during the modified Henry approach are not highly variable. Occasionally, an accessory flexor carpi radialis brevis muscle and several variants of the pronator quadratus muscle may be present, which have only been described in case reports.

Conclusion: Among the many controversies debated regarding the modified Henry approach, the most clinically significant are the proper release of the brachioradialis muscle and the early detection of carpal tunnel symptoms followed by appropriate intervention. Other volar approaches are used less frequently and typically in specific indications.

Keywords:

distal radius – anatomical variability – Henry approach – surgical approaches

Sources

1. Chung KC, Spilson SV. The frequency and epidemiology of hand and forearm fractures in the United States. J Hand Surg Am 2001; 26(5): 908–915. doi: 10.1053/jhsu.2001.26322.

2. Henry AK, Wheeler WI. Exposures of long bones and other surgical methods. New York: William Wood and Company 1927.

3. Henry AK. Extensile exposure applied to limb surgery. 1st ed. Baltimore: Williams and Wilkins Company 1945.

4. Henry AK. Extensile exposure. 2nd ed. Edinburgh: Livingstone 1957 (dotisk 1973).

5. Bartoníček J, Naňka O, Tuček M. Přístupy k diafýze radia. Rozhl Chir 2015; 94(10): 415–424.

6. Ilyas AM. Surgical approaches to the distal radius. Hand (N Y) 2011; 6(1): 8–17. doi: 10.1007/s11552-010-9281-9.

7. Jupiter JB, Campbell DA, Nunez FA. Manual of fracture managment –⁠ wrist. Stuttgart: Georg Thieme Verlag 2019.

8. Hastings H 2nd, Leibovic SJ. Indications and techniques of open reduction. Internal fixation of distal radius fractures. Orthop Clin North Am 1993; 24(2): 309–326.

9. Pourgiezis N, Bain GI, Roth JH. Volar ulnar approach to the distal radius and carpus. Can J Plast Surg 1999; 7(6): 273–278.

10. Orbay JL, Badia A, Indriago IR et al. The extended flexor carpi radialis approach: a new perspective for the distal radius fracture. Tech Hand Up Extrem Surg 2001; 5(4): 204–211. doi: 10.1097/00130911-200112000-00004.

11. Gontre G, Heifner JJ, Jordan JA et al. First dorsal compartment release during volar approach for distal radius fracture fixation reduces symptoms in patients with pre-existing De Quervain disease. J Hand Surg Glob Online 2024; 6(4): 510–513. doi: 10.1016/j.jhsg.2024.03.009.

12. Koh S, Andersen CR, Buford WL et al. Anatomy of the distal brachioradialis and its potential relationship to distal radius fracture. J Hand Surg 2006; 31(1): 2–8. doi: 10.1016/j.jhsa.2005.08.012.

13. Viegas SF, Patterson RM, Hokanson JA et al. Wrist anatomy: incidence, distribution, and correlation of anatomic vartiations, tears, and arthrosis. J Hand Surg Am 1993; 18(3): 463–475. doi: 10.1016/0363-5023(93)90094-J.

14. Tirrel TF, Franko OI, Bhola S et al. Functional consequence of distal brachioradialis tendon release: a biomechanical study. J Hand Surg Am 2013; 38(5): 920–926. doi: 10.1016/j.jhsa.2013.01.029.

15. Rodriguez-Nedenführ M, Vázquez T, Parkin I et al. Incidence and morphology of the brachioradialis accessorius muscle. J Anat 2001; 199(Pt 3): 353–355. doi: 10.1046/j.1469-7580.2001.19930353.x.

16. Turkof E, Puig S, Choi MS et al. Superficial branch of the radial nerve emerging between two slips of a split brachioradialis muscle tendon: a variation of possible clinical relevance. Acta Anat (Basel) 1994; 150(3): 232–234. doi: 10.1159/000147624.

17. Tubbs SR, Shoja MM, Loukas M. Bergman’s comprehensive encyclopedia of human anatomic variation. Hoboken: Wiley-Blackwell 2016 : 300–304.

18. Zhang X, Huang X, Shao X et al. A comparison of minimally invasive approach vs conventional approach for volar plating of distal radial fractures. Acta Orthop Traumatol Turc 2017; 51(2): 110–117. doi: 10.1016/j.aott.2017.02.013.

19. Lebailly F, Zemirline A, Facca S et al. Distal radius fixation through a mini-invasive approach of 15 mm. PART 1: a series of 144 cases. Eur J Orthop Surg Traumatol 2014; 24(6): 877–890. doi: 10.1007/s00590-013-1363-2.

20. Mirarchi AJ, Nazir OF. Minimally invasive surgery: Is there a role in distal radius fractrue managment? Curr Rev Musculoskelet Med 2021; 14(1): 95–100. doi: 10.1007/s12178-020-09689-x.

21. Sen MK, Strauss N, Harvey EJ. Minimally invasive plate osteosynthesis of distal radius fractures using a pronator sparing approach. Tech Hand Up Extrem Surg 2008; 12(1): 2–6. doi: 10.1097/BTH.0b013e3180cac281.

22. Lo HY, Cheng HY. Clinical study of the pronator quadratus muscle: anatomical features and feasibility of pronator-sparing surgery. BMC Musculoskelet Disord 2014; 15 : 136. doi: 10.1186/1471-2474-15-136.

23. Huang X, Jia Q, Li H et al. Evaluation of sparing the pronator quadratus for volar plating of distal radius fractures: a retrospective clinical study. BMC Musculoskelet Disord 2022; 23(1): 625: doi: 10.1186/s12891-022-05576-3.

24. Huang X, Wu B, Hamiti Y. Evaluation of the treatment of distal radial volar fracture by different methods sparing the pronator quadratus. J Orthop Surg Res 2023; 18(1): 722. doi: 10.1186/s13018-023-04184-8.

25. Maniglio M, Truong V, Zumstein M et al. Should we repair the pronator quadratus in a distal radius fracture with an ulnar styloid base fracture? A biomechanical study. J Wrist Surg 2021; 10(5): 407–412. doi: 10.1055/s-0041-1730341.

26. Armagenil M, Bezirgan U, Başarır K et al. The pronator quadratus muscle after plating of distal radius fractures: is the muscle still working? Eur J Orthop Surg Traumatol 2014; 24(3): 335–339. doi: 10.1007/s00590-013-1193-2.

27. Ahsan ZS, Yao J. The importance of pronator quadratus repair in the treatment of distal radius fractures with volar plating. Hand (N Y) 2012; 7(3): 276–280. doi: 10.1007/s11552-012-9420-6.

28. Lu CK, Lie WC, Chang CC et al. A systematic review and meta-analysis of the pronator quadratus repair following volar plating of distal radius fractures. J Orthop Surg Res 2020; 15(1): 419. doi: 10.1186/s13018-020-01942-w.

29. Shi F, Ren L. Is pronator quadratus repair necessary to improve outcomes after volar plate fixation of distal radius fractures? A systematic review and meta-analysis. Orthop Traumatol Surg Res 2020; 106(8): 1627–1635. doi: 10.1016/j.otsr.2020.06.003.

30. Tahririan MA, Javdan M, Motififard M. Results of pronator quadratus repair in distal radius fractures to prevent tendon ruptures. Indian J Orthop 2014; 48(4): 399–403. doi: 10.4103/0019-5413.136275.

31. Brown EN, Lifchez SD. Flexor pollicis longus tendon rupture after volar plating of a distal radius fracture: pronator quadratus plate coverage may not adequately product tendons. Eplasty 2011; 11: e43.

32. Stewart BP, Lee JY, Wellington IJ et al. Location of distal pronator quadratus repair in distal radius fractures: a cadaveric biomechanical study. Clin Biomech (Bristol) 2023; 105 : 105975. doi: 10.1016/j.clinbiomech.2023.105975.

33. Dy CJ, Brogan DM, Colorado BS. Absence of the pronator quadratus muscle precluding distal nerve transfer. J Hand Surg Am 2019; 44(6): 523.e1–523.e5. doi: 10.1016/j.jhsa.2018.08.002.

34. Sivakumar BS, Symes M, Nandepalan H. Pronator quadratus accessorius. ANZ J Surg 2024; 94(7–8): 1424–1425. doi: 10.1111/ans.19126.

35. Munn A, Steckle V, Dong H et al. Aberrant tendinous variation of the pronator quadratus muscle: a case report. Eur J Anat 2024; 28(6): 753–757. doi: 10.52083/LZTU1726.

36. Medici A, Meccariello L, Rollo G et al. Does routine carpal tunnel release during fixation of distal radius fractures improve outcomes? Injury 2017; 48(Suppl 3): S30–S33. doi: 10.1016/S0020-1383(17)30654-X.

37. Gelberman RH, Garfin SR, Hergenroeder PT et al. Compartment syndromes of the forearm: diagnosis and treatment. Clin Orthop Relat Res 1981; 161 : 252–261.

38. Rothman A, Samineni AV, Sing DC et al. Carpal tunnel release performer during distal radius fracture surgery. J Wrist Surg 2022; 12(3): 211–217. doi: 10.1055/s-0042-1756501.

39. Gaspar MP, Sessions BA, Dudoussat BS. Single-incision carpal tunnel release and distal radius open reduction and internal fixation: a cadaveric study. J Wrist Surg 2016; 5(3): 241–246. doi: 10.1055/s-0036-1581053.

40. Pope D, Tang P. Carpal tunnel syndrome and distral radius fracture. Hand Clin 2018; 34(1): 27–32. doi: 10.1016/j.hcl.2017.09.003.

41. Bhashyam AR, Kao DS. Surgical technique for concurrent endoscopic carpal tunnel release and distal radius fracture fixation using the flexor carpi radialis approach: a case series. J Hand Surg Glob Online 2022; 4(3): 166–171. doi: 10.1016/j.jhsg.2021.11.007.

42. Mica MA, Bindra R, Moran SL. Anatomic considerations when performing the modified Henry approach for exposure of distal radius fractures. J Orthop 2016; 14(1): 104–107. doi: 10.1016/j.jor.2016.10.015.

43. Liu J, Pho RW, Pereira BP et al. Distribution of primary motor nerve branches and terminal nerve entry points to the forearm muscles. Anat Rec 1997; 248(3): 456–463. doi: 10.1002/(SICI)1097-0185(199707)248 : 3<456::AID-AR19>3.0.CO;2-O.

44. Yammine K, Erić M. Linburg-Comstock variation and syndrome. A meta-analysis. Surg Radiol Anat 2018; 40(3): 289–296. doi: 10.1007/s00276-017-1957-1.

45. Ashgar A, Jha RK, Patra A et al. The prevalence and distribution of the variants of Gantzer´s muscle: a meta-analysis of cadaveric studies. Anat Cell Biol 2022; 55(1): 3–13. doi: 10.5115/acb.21.141.

46. Sofos SS, Riaz M. Absence of flexor carpi radialis during an elective carpometacarpal arthroplasty of the thumb: a rare anatomical variation. Case Rep Med 2016; 2016 : 7853487. doi: 10.1155/2016/7853487.

47. Mantovani G, Lino W Jr, Fukushima WY et al. Anomalous presentation of flexor carpi radialis brevis: a report of six cases. J Hand Surg Eur 2010; 35(3): 234–235. doi: 10.1177/1753193409106179.

48. Laugharne E, Power D. Surgical exposure of the distal radius in a patient with a flexor carpi radialis brevis muscle anomaly. J Surg Case Rep 2010; 2010(1): 1. doi: 10.1093/jscr/2010.1.1.

49. Werntz RL, Hadeed AJ, Cappelleti GL et al. Flexor carpi radialis brevis resection for treatment of a distal radius fracture: a case report. J Wrist Surg 2021; 10(6): 536–538. doi: 10.1055/s-0041-1726407.

50. Gu Y, Zhao L, Ren Y et al. Clinical study of volar median appraoch combined with lateral radial auxiliary approach in treatment of C-type distal radius fractures: our clinical and radiological results. Med Sci Monit 2023; 29: e938806. doi: 10.12659/MSM.938806.

51. Gianakos A, Patal P, Athens CM et al. Single incision, dual window approach for comminuted distal radius fracture. J Wrist Surg 2021; 11(1): 84–88. doi: 10.1055/s-0041-1725961.

52. Prommersberger KJ, Van Schoonhoven J, Lanz UB. A radiovascular approach to dorsal malunions of the distal radius. Tech Hand Upper Extremity Surg 2000; 4(4): 236–243. doi: 10.1097/00130911-200012000-00003.

MUDr. Vojtěch Kunc, Ph.D.

Ústav anatomie

2. LF UK

V Úvalu 84

150 06 Praha 5

vjpkunc@gmail.com

ORCID autora

V. Kunc 0000-0002-3165-4977