Volar Locking Plate Fixation of Distal Radius Fractures

Overview

Distal radius fractures are the most common upper-extremity fractures and account for more than one in six fractures treated in emergency departments. Most dorsally displaced extraarticular fractures, especially in the elderly, can be treated nonoperatively. About 30% are more complex injuries that need surgery (AO).

Volar locked plating has become the most commonly used form of ORIF since its introduction around 2000. It is biomechanically superior to dorsal and dual-column plating, and gives better early function than dorsal plating, external fixation and percutaneous pinning (Campbell). The sources agree, however, that long-term superiority over other methods has not been shown: the AAOS guideline recommends no specific method of operative fixation (Rockwood).

Assessment

Radiographic Parameters (AO)

Signs of Instability (AO)

• Marked metaphyseal comminution

• Angulation > 10°

• Shortening > 5 mm

• Intraarticular step-off > 2 mm

• Carpal malalignment

CT

• Obtain CT when plain films do not show the congruity and displacement of the sigmoid notch, lunate facet and scaphoid fossa. Sagittal and coronal reconstructions and 3D CT show the position and size of the fragments and their extension into the metaphysis (AO).

Associated Injuries

• About 30%–40% of distal radius fractures have associated soft-tissue injuries. Most displaced fractures involve TFCC injury.

• Scapholunate injury is more common in intraarticular fractures that separate the scaphoid and lunate fossae. Look carefully for scapholunate widening.

• High-energy injuries may include a scaphoid waist fracture.

• Assess every wrist fracture for open wounds (usually palmar-ulnar), median and ulnar nerve injury, and compartment syndrome (AO).

Key Concepts

Three-Column Theory (Rikli and Regazzoni; AO)

Classification

• AO/OTA (2R3): A extraarticular, B partial articular, C complete articular, in increasing order of severity.

• Fernandez (mechanism-based): I – bending (metaphyseal); II – shearing of the articular surface; III – compression of the articular surface; IV – avulsion, radiocarpal fracture-dislocation; V – combined, high-energy. Complexity increases from type I to V, which gives prognostic information.

• Note that all current classification systems have poor intra- and interobserver reliability (AO).

Indications

Surgical Indications (AO)

• Open fractures

• Fractures with compartment syndrome

• Associated neurovascular and/or tendon injury

• Bilateral fractures

• Radiocarpal fracture-dislocations

• Palmar and dorsal shear fractures (volar and dorsal Barton)

• Volarly displaced fractures

• Dorsally displaced fractures in active patients that remain displaced after reduction: radial shortening > 3 mm, dorsal tilt > 10°, or intraarticular step-off > 2 mm

Evidence in the Elderly (AO; Rockwood)

• In patients over 65 with dorsally displaced fractures, randomized trials found no difference at 12 months between nonoperative treatment and volar locked plating; complications were higher with surgery (AO).

• Rockwood reports conflicting evidence: one randomized trial (n = 300) found no clear advantage at 12 or 24 months, whereas another (n = 122) found better patient-reported outcomes and physical function after plating at 3 months and 1 year.

Where Volar Plating Fits Best (Rockwood)

• Unstable extraarticular (Colles-type) fractures, volar shear patterns, and many complete articular fractures.

• With variable-angle locking, more complex intraarticular fractures, including lunate facet fractures, can be treated.

• Also used for corrective osteotomy of distal radius malunion.

• There must be enough distal bone for screws or pins. For very small distal fragments, consider volar rim plates, keeping in mind the high early rates of tendon irritation.

Timing and Preoperative Planning

• Timing depends on the soft-tissue injury, the planned definitive fixation and available resources (AO).

• Monitor high-energy injuries for compartment syndrome and perform fasciotomy immediately if it develops.

• Gustilo type II and III open fractures and fractures with neurovascular injury need emergency surgery. With severe soft-tissue problems, debridement and a joint-spanning external fixator are enough at the first stage.

• For most fractures awaiting surgery, closed reduction and cast or splint immobilization is recommended (AO).

• Equipment (Rockwood): Preferred volar locking plate, upper-arm tourniquet, 0.045-inch (1.14 mm) K-wires and a 16-gauge hypodermic needle.

Positioning and Setup

• Position the patient supine, with the shoulder abducted and the arm on a hand table. Place the tourniquet high on the arm, near the axilla, to leave room for manipulation (Rockwood).

• Position the C-arm parallel to the long axis of the arm so that both surgeon and assistant can reach the hand table (Rockwood). AO describes sitting the surgeon at the patient's head and the assistant on the other side of the hand table, with the fluoroscopy screen in full view of the team.

Surgical Technique

Approach (FCR / Modified Henry)

1. Make a longitudinal incision of about 8 cm over the FCR tendon, between the FCR and the radial artery. Extending it diagonally and radially across the wrist crease gives wider exposure without contracture (Campbell).

2. Open the FCR sheath and retract the tendon. Take care not to compress the median nerve (AO).

3. Mobilize the FPL bluntly and retract it ulnarly with the FCR. This exposes the space of Parona between the digital flexors and the transversely oriented pronator quadratus (Rockwood).

4. Elevate the pronator quadratus with an L-shaped incision: longitudinally along the radial border of the radius and transversely at the distal junction of the muscle with the volar extrinsic ligaments. The Rockwood authors coagulate the perforating vessels from the radial artery along the radial edge at the same time (Rockwood).

5. Respect the watershed line. The fibrous transition zone lies a few millimeters proximal to it. The watershed line marks the boundary with the volar extrinsic wrist ligaments, which must not be detached from the radius, because this can cause wrist instability (AO). The joint line can be located with a hypodermic needle placed in the joint (AO).

6. If the fracture is distal, the pronator quadratus does not need to be elevated fully proximally (AO).

7. If the brachioradialis holds a displaced radial styloid fragment, release it to remove the deforming force (Campbell; Rockwood).

8. Avoid sharp self-retaining retractors in the deep dissection, because of the risk to the median nerve and radial artery (Rockwood).

9. Note: This interval exposes the radial side of the distal radius better than the ulnar side. Ulnar-sided fragments can still be treated, but take particular care that they are reduced and captured by the fixation (Rockwood).

Reduction

1. Simple extraarticular fractures: Under traction, lever the fracture with a Freer elevator, and press on the dorsal cortex to reduce the dorsal fragments as the Freer is withdrawn (Campbell). A stack of towels or a bolster under the wrist helps hold volar translation and tilt.

2. Plate as a reduction tool (dorsally displaced fractures): Fix the volar locking plate to the distal fragment first, with locking screws placed in the subchondral bone under fluoroscopy. The angle between the plate and the shaft should equal the displacement angle of the distal fragment. Bringing the plate down onto the shaft then restores normal palmar tilt (AO). Because the volar surface of the distal radius is flat, a flat implant tends to correct fragment malposition automatically (AO).

3. Volar shear fractures: These are unstable, with palmar subluxation of the carpus, and need a volar buttress plate. Place the plate as far ulnarly as possible to support the important palmar-ulnar fragment; otherwise the carpus may redisplace (AO).

4. Dorsoulnar fragment: It is part of both the radiocarpal joint and the DRUJ and must be reduced anatomically. In fresh fractures, traction followed by manual compression of the palmar fragments and the plate may reduce it. If not, manipulate it percutaneously with a K-wire (AO).

5. Provisional fixation (Rockwood): Use a 16-gauge hypodermic needle as a guide and soft-tissue protector for 0.045-inch K-wires. It can be placed percutaneously at the tip of the radial styloid, and it protects the superficial radial nerve and radial artery from the spinning wire. Wires can be passed obliquely across the fracture to the ulnar cortex of the shaft, or transversely as subchondral support for articular fragments.

6. A toothed bone clamp on the radial shaft proximally helps retract soft tissues, align the proximal plate along the shaft and keep it in contact with bone (Rockwood).

Plate Fixation

1. Sigmoid notch view (true AP): The volar and dorsal lips of the sigmoid notch superimpose as a single subchondral line. Obtain this view and use it throughout to judge reduction and coronal plate position (Rockwood).

2. Plate position: Proximally aligned with the radial shaft. Distally, as distal as needed to capture subchondral bone and as ulnar as possible to capture the lunate facet, but not distal to the watershed line (Rockwood).

3. Insert the first screw through the oblong hole in the shaft, which allows small proximal–distal adjustments (Campbell; Rockwood).

4. Begin distal fixation on the ulnar side. Insert ulnar-corner screws under fluoroscopic control to avoid penetrating the radiocarpal joint, the DRUJ or the dorsal cortex (AO).

5. Drill and measure the distal holes and insert locking screws at least 2 mm shorter than measured, to avoid dorsal cortical perforation (Campbell).

6. Once the distal screws are in, release finger traction; the fracture is usually reduced and fixed at this stage (Campbell).

7. Check for joint penetration:

   • Obtain a tilted lateral view to judge the direction of the distal screws, confirm capture of the articular fragments and exclude joint penetration (Rockwood).

   • Skyline (dorsal tangential) view: Elbow flexed about 75°, forearm fully supinated, wrist maximally flexed. Adjust the elbow a few degrees until the radial styloid, the full width of the dorsal cortex, Lister's tubercle and the DRUJ are visible (Campbell).

8. Volar lunate facet fragments must be inspected carefully and confirmed to be fixed; otherwise fixation can be lost later (Rockwood).

9. Fill the remaining holes and confirm an extraarticular screw position.

10. Fractures extending into the diaphysis: Open reduction with a long, bridging T-plate is preferred, because diaphyseal healing takes longer than metaphyseal healing (AO).

Pronator Quadratus

1. Repair of the pronator quadratus is optional. Repair is often difficult because of swelling and tissue quality, and it has not been shown to affect outcome (Campbell; Rockwood). AO recommends attempting to resuture the horizontal limb of the L to cover the implant and reduce soft-tissue irritation.

Ulnar Styloid and DRUJ

1. Most DRUJ injuries need no additional surgery if the distal radius is fixed anatomically and stably, particularly when the sigmoid notch fragments are reduced and ulnar translation of the radial shaft is corrected. Both restore the stabilizing effect of the distal interosseous membrane (AO).

2. DRUJ test (AO): Compress the ulnar head into the sigmoid notch while passively rotating the forearm through full supination and pronation. A palpable "clunk" indicates instability.

3. Test DRUJ stability after radial fixation and, if possible, compare with the other wrist. If the DRUJ remains unstable with an ulnar styloid fracture, consider ORIF of the styloid (Rockwood).

4. Campbell's options for an unstable DRUJ with a displaced styloid: one or two percutaneous K-wires. If instability persists, excise the fragment and reattach the peripheral TFCC to the base of the styloid with nonabsorbable suture through drill holes or a bone anchor.

5. Close in layers and apply a volar resting splint.

Postoperative Care

• Leave the MCP joints free and encourage immediate finger motion (Rockwood).

• Forearm rotation exercises are essential. The fingers, wrist, elbow and shoulder should be used in light daily activities. A sling is used only for a few days to control swelling. Reassure patients that using the hand will not damage the fixation (AO).

• About 2 weeks: Remove sutures and change to a removable splint. Begin gentle wrist motion once fracture stability is assured (Campbell; Rockwood). Campbell uses a removable thermoplastic splint for 6 weeks.

• Unstable DRUJ, or doubtful fixation because of comminution or poor bone: Immobilization in a cast for 6 weeks is acceptable without compromising final motion and function (Rockwood).

• Most patients do a home program; elderly patients may need supervised therapy twice a week (Campbell).

• An accelerated protocol (immediate motion, strengthening from 2 weeks) led to an earlier return to function than standard rehabilitation in a randomized trial (Campbell).

Complications

• Reported complication rates for volar locked plating range up to 48%, although most series are small (Rockwood). Campbell cites historical rates of up to 15%.

• Tendon problems are the most common:

  • Flexor irritation or rupture from a plate placed too distally (beyond the watershed line) or not covered by the pronator quadratus.

  • Extensor tenosynovitis or rupture from dorsally prominent screws.

  • EPL rupture can also follow cast treatment (AO).

• Loss of reduction of the volar lunate facet if this fragment is not captured (Rockwood).

• Intraarticular screw penetration, usually with distal implant placement, inadequate exposure or inadequate imaging, and often with malreduction (AO).

• Acute carpal tunnel syndrome after injury, poor casting or fragment malposition. Complex regional pain syndrome, often from swelling in a tight cast or extreme wrist positioning (AO).

• Compartment syndrome in high-energy injuries; injury to cutaneous nerve branches; wrist stiffness; malunion (common in osteoporotic fractures but often well tolerated) (AO).

• Risk factors for reduced or delayed function: older age, lower bone density, more severe fractures and high-energy trauma. Volar comminution is the strongest predictor of later displacement (Campbell).

Outcomes and Evidence

• Volar plate vs percutaneous pinning: Better function at 3 and 6 months (AO) or 6, 9 and 12 weeks (Rockwood, Rozental et al.), with no significant difference at 1 year. Plating allows faster rehabilitation and return to function.

• Volar plate vs bridging external fixation: Earlier motion was statistically but not clinically better with plating; function and complication rates were similar at 1 year (Rockwood, Egol et al.).

• Volar plate vs fragment-specific fixation: No difference in outcome, but more complications with fragment-specific fixation (Rockwood).

• Rockwood authors' preference: Volar locked plating, except when other methods control the fragments better or the fracture is too comminuted. Dorsal shear injuries and fractures with major articular comminution are approached dorsally; highly comminuted unstable fractures are treated with a dorsal spanning plate.

References

1. Cosgrove CT. Fractures of the shoulder, arm, and forearm. In: Azar FM, Sawyer JR, Throckmorton TW, eds. Campbell's Operative Orthopaedics. 15th ed. Philadelphia: Elsevier; 2026. Chapter 62, Technique 62.17.

2. Kastelec M. Distal radius and wrist. In: Buckley RE, Moran CG, Apivatthakakul T, eds. AO Principles of Fracture Management. 3rd ed. Stuttgart: Thieme; 2017. Chapter 6.3.3. (Turkish edition: AO Kırık Tedavisinin Prensipleri.)

3. Distal radius and ulna fractures. In: Tornetta P III, Ricci WM, Ostrum RF, McKee MD, Ollivere BJ, de Ridder VA, eds. Rockwood and Green's Fractures in Adults. 10th ed. Philadelphia: Wolters Kluwer; 2024. Chapter 43. (Turkish edition: Erişkin Kırıkları.)