import { ComparisonTable, ContentSection, EvidenceCard, ExamCheatSheet, ExamPearl, ExamWarning, InfoCard, InfoCardGrid, MedicalImage, MnemonicCard, OnePagerSummary, SafetyAlert, Tab, Tabs, Timeline, TimelineItem, VivaScenario, VivaScenarioSection } from '@/components/mdx' {/* SECTION 1: ONE-PAGER SUMMARY */} ### Imaging Gallery {/* REMOVED: 1-bar-chart-demonstrating-the-age-distribution-of-th.png */} {/* SECTION 2: EXAM WARNING */} 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. 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 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. 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. {/* SECTION 3: MNEMONICS */} 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. {/* SECTION 4: OVERVIEW */} 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 **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 {/* SECTION 5: 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 **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:** 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) **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 {/* SECTION 6: INDICATIONS */} 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) {/* SECTION 7: 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 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. {/* SECTION 8: 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 **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 {/* SECTION 9: SURGICAL TECHNIQUE */} **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 **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 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. **Extended Classification Systems:** **Approach Variations:** 1. **Standard Henry** - longitudinal along FCR 2. **Modified Henry (FCR approach)** - incision directly over FCR sheath 3. **Extended Henry** - proximal extension with PT release 4. **Minimal incision Henry** - limited 3-4cm incision for simple fractures **Watershed Line Anatomy:** - Junction between concave (distal) and flat (proximal) volar radius - Corresponds to **pronator fossa** anatomically - Natural boundary for plate positioning - Flexor tendons glide smoothly proximal to this point **Watershed line identification is critical:** - Draw line along volar cortex on lateral X-ray - Plate edge should be proximal to this line - Any plate prominence beyond this = Soong Grade 2 - Document Soong grade in operative note and post-op assessment **Surgical Urgency Classification:** **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 **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) **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** **Detailed Neurological Assessment:** **Median nerve (most commonly affected in distal radius fractures):** - **Sensory**: Thenar eminence (palmar cutaneous branch), radial 3.5 digits palmar surface - **Motor**: Thumb opposition (opponens pollicis), thumb abduction (APB) - **Test**: Scratch hypothenar vs thenar - patient identifies which side - **Acute carpal tunnel syndrome**: 5-10% of distal radius fractures - urgent reduction required **Anterior interosseous nerve (branch of median):** - **Motor only**: FPL (thumb IP), FDP index/long (DIP), pronator quadratus - **Test**: "OK sign" - pinch thumb tip to index tip, observe for tip-to-tip contact - **Injury suggests**: Proximal median nerve involvement or compartment syndrome **Ulnar nerve:** - **Sensory**: Small finger, ulnar half ring finger - **Motor**: Finger abduction/adduction (interossei), first dorsal interosseous bulk - **Test**: Cross fingers, spread fingers against resistance **Radial nerve:** - **Sensory**: Dorsal first web space (superficial radial nerve) - **Motor**: Wrist extension, finger MCP extension - **Test**: Wrist and finger extension against gravity **Acute carpal tunnel syndrome** occurs in 5-10% of distal radius fractures and requires **urgent fracture reduction** to decompress the carpal tunnel. If symptoms persist after reduction, **carpal tunnel release at time of ORIF** is indicated. Do NOT delay surgery for nerve conduction studies - clinical diagnosis is sufficient for acute setting. **Assessment for Surgical Planning:** **Soft tissue assessment:** - Timing of injury (swelling peaks at 24-72 hours) - Skin quality and elasticity - Blistering (fracture blisters indicate significant soft tissue injury) - Previous incisions/scars (may affect approach choice) **Fracture pattern assessment (clinical clues):** - Dorsal angulation = typical Colles pattern (volar plating appropriate) - Volar angulation = Smith's pattern (volar plating still works) - Shortening = comminution, may need buttress/bridge plating - Radial deviation = radial styloid involvement - DRUJ tenderness = TFCC injury, may need DRUJ stabilization **Pre-operative optimization:** - Glycaemic control (HbA1c less than 8% preferred for elective surgery) - Smoking cessation counselling (4+ weeks ideal, but not essential for trauma) - Anticoagulation management (warfarin, DOACs - may need bridging) - Medical clearance for significant comorbidities **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 **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 **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. **CT Imaging:** **MRI - Limited Role in Acute Setting:** - Not routinely required for fracture management - Consider for suspected TFCC injury with persistent DRUJ symptoms - Scapholunate ligament injury if clinical suspicion - Generally obtained post-operatively if ongoing symptoms **Wrist Arthroscopy (Intraoperative):** - Useful for articular reduction assessment - TFCC evaluation and repair - Scapholunate ligament assessment - Indicated for complex intra-articular fractures (AO C3) **Pre-operative Blood Tests:** **For elective/semi-urgent cases:** - FBC (baseline hemoglobin, WCC, platelets) - UEC (renal function for contrast/NSAID use) - Coagulation studies (if on anticoagulation) - Group and hold (not usually required for elective DR ORIF) **HbA1c** for diabetic patients (glycaemic control) **Elderly/comorbid patients:** - ECG if cardiac history - Chest X-ray if respiratory symptoms - Blood glucose level **Pathological fracture suspected:** - Myeloma screen (protein electrophoresis, Bence-Jones) - LFTs, calcium **Intraoperative Imaging:** **Fluoroscopy - Standard for volar plating:** - C-arm positioning from contralateral side - Views required: 1. **PA** - radial height, inclination, ulnar variance 2. **True lateral** - volar tilt, plate position (Soong grade), screw length 3. **Oblique** (45-degree pronated) - dorsal cortex screw penetration 4. **Skyline view** (tangential to articular surface) - intra-articular screws **Must confirm no dorsal screw penetration:** - Oblique view with wrist pronated 45 degrees - Palpate dorsal cortex with finger through small incision - Check screw tips do not protrude beyond dorsal cortex - Dorsal penetration = extensor tendon irritation/rupture (EPL most common) **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) **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 **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 **Pre-operative Decision Making:** **Age and activity level:** - Young, active patient = aggressive reduction, ORIF - Low-demand elderly = accept more deformity, consider non-operative - Hand dominance affects functional demands - Occupation critical (manual worker vs office worker) **Pattern analysis:** - **Extra-articular (AO A)** - volar plate usually sufficient - **Partial articular (AO B)** - may need specific fragment fixation - **Complete articular (AO C)** - restore articular surface, may need combined approaches - **Dorsal comminution** - affects stability of volar-only fixation **Timing considerations:** - Optimal surgery window: within 7 days (before swelling peaks) - If significant swelling: temporary splint, delay 5-7 days - Fracture blisters: wait for epithelialization (7-14 days) - Open fracture: urgent debridement, may stage fixation **Surgical Planning for Henry Approach:** **Implant selection:** - Standard volar locking plate (2.4mm or 2.7mm screws) - Low-profile plates for thin patients - Variable angle locking plates for complex fractures - Extended plates for proximal comminution **Plate positioning goals:** - Soong Grade 0 position (2-3mm proximal to volar rim) - Avoid dorsal screw penetration - Distal screws in subchondral bone (1-2mm from articular surface) - Proximal screws engage both cortices **Severe dorsal comminution** (greater than 50% dorsal cortex involvement) may result in **inadequate stability with volar plate alone**. Options include: 1. Dorsal plate in addition to volar (combined approach) 2. Spanning external fixator to neutralize load 3. Accept more limited ROM with longer immobilization 4. Bone graft/substitute to fill dorsal void **Pre-operative CT** helps assess dorsal wall integrity. **Intraoperative Decision Points:** ### 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:** 3. **Identify flexor carpi radialis tendon** - key landmark - FCR tendon is prominent and easily palpated - Retract skin edges with self-retaining retractors 4. **Open FCR tendon sheath** longitudinally - Incise sheath directly over tendon - Avoid injury to tendon itself 5. **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:** 6. **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:** 7. **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) 8. **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):** 9. **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 10. **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:** 11. **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 12. **Provisional fixation** with K-wires - Hold reduction with 1-2 K-wires - Check alignment before plating {/* REMOVED: 1-bar-chart-demonstrating-the-age-distribution-of-th.png */} 13. **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) 14. **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:** 15. **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 16. **Close FCR sheath** (optional - some surgeons leave open) 17. **Close subcutaneous tissue and skin** - 3-0 absorbable for subcutaneous - 4-0 or 5-0 monofilament for skin (running subcuticular or interrupted) 18. **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. ### Proximal Extension of Henry Approach (Middle and Proximal Radius) **When needed:** - Radial shaft fractures middle or proximal third - Radial osteotomy - Tumor resection - Compartment syndrome requiring full forearm decompression **Key difference from distal approach:** - **NOT a true internervous plane** in proximal third - Requires **pronator teres release** from radius (median nerve innervated) - Higher risk to radial artery and superficial radial nerve **Incision:** 1. **Extended incision** from radial styloid to antecubital fossa - Curve medially in antecubital fossa to avoid crossing elbow flexion crease perpendicularly - Can zigzag or lazy-S in antecubital fossa 2. **Incise skin and subcutaneous tissue** - Protect cephalic vein if possible - Lateral cutaneous nerve of forearm medial to incision - protect **Proximal dissection:** 3. **Identify interval between brachioradialis (lateral) and pronator teres (medial)** - BR is lateral, PT is medial - Both muscles are prominent in proximal forearm 4. **Develop interval between BR and PT** - Retract BR laterally - Radial artery runs in this interval - **Identify superficial radial nerve** - runs deep to BR, emerges distally - Protect nerve - avoid traction on BR - Nerve can be retracted with BR or protected separately 5. **Identify radial recurrent artery** (if extending to elbow) - Branch of radial artery running proximally - May need to ligate for exposure **Pronator teres release (required for proximal radius exposure):** 6. **Release pronator teres from radius** - PT inserts on middle third lateral radius - Incise PT insertion sharply - Elevate PT medially and anteriorly - Tag PT for later repair 7. **Protect median nerve and anterior interosseous nerve** - Median nerve runs deep to PT - AIN branches from median nerve just distal to PT - Avoid retraction on median nerve **Exposure of proximal radius:** 8. **Elevate supinator from proximal radius** (if needed for very proximal exposure) - Supinator wraps around proximal radius - **Posterior interosseous nerve runs through supinator** - at high risk - Keep forearm **fully supinated** to move PIN away from surgical field - Subperiosteal dissection protects PIN 9. **Expose radius shaft** - Radius shaft now visible - Plate can be applied to volar or lateral surface **Closure:** 10. **Repair pronator teres** to radius - Reattach PT to radius with drill holes or suture anchors - Restores pronation strength 11. **Standard layered closure** Proximal extension is more complex and has higher nerve injury risk but provides excellent exposure when needed. ### Henry Approach for Forearm Compartment Syndrome (Volar Decompression) **Indication:** - Acute forearm compartment syndrome - Volar compartment pressures over 30 mmHg or delta pressure less than 30 mmHg **Urgency:** - **EMERGENCY procedure** - irreversible muscle necrosis begins at 6-8 hours - Do not delay for imaging or optimisation **Incision for volar compartment release:** 1. **Extended volar incision** from palm to antecubital fossa - Entire volar forearm must be decompressed - Can add carpal tunnel release distally if needed - Zigzag in antecubital fossa 2. **Extend incision into hand** if needed - Carpal tunnel release - Thenar and hypothenar compartment release if hand compartment syndrome **Compartment release:** 3. **Release deep fascia along entire length** - Open fascia over flexor compartments - Both superficial flexors (FDS, FCR, FCU, PT) and deep flexors (FDP, FPL) 4. **Identify and decompress pronator quadratus** - PQ forms separate compartment distally - Incise PQ fascia 5. **Assess muscle viability** - Color: Pink viable, dark red/black nonviable - Contractility: Muscle should contract with stimulation - Consistency: Firm and elastic is viable, mushy is necrotic - Capillary bleeding: Viable muscle bleeds when cut - **Debride nonviable muscle** if present 6. **Dorsal compartment release** (if indicated) - Can do through same volar incision (controversial) OR separate dorsal incision (safer) - Dorsal compartment contains mobile wad (BR, ECRL, ECRB) and finger/thumb extensors - Traditional teaching: separate dorsal incision to avoid creating large skin bridge **Wound management:** 7. **Do NOT close skin** - Leave wound open - Apply sterile dressing (betadine-soaked gauze or negative pressure wound therapy) 8. **Splint forearm** in neutral position 9. **Plan return to OR in 24-48 hours** - Second look for additional debridement if needed - Delayed primary closure or skin grafting The compartment syndrome release is complete - muscle viability has been preserved. {/* SECTION 10: COMPLICATIONS */} **Complications can be categorized as intraoperative, early postoperative, and late.** **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) **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 {/* SECTION 11: POSTOPERATIVE CARE */} **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 **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 {/* SECTION 12: EVIDENCE BASE */} **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 **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 **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 **Comparative Outcomes Data:** **Factors Affecting Outcomes:** **Articular congruity is the strongest predictor of outcome:** - Less than 2mm step-off: Excellent outcomes, low arthritis risk - 2-3mm step-off: Good outcomes, some increased arthritis risk - Greater than 3mm step-off: Fair outcomes, significantly increased arthritis **Post-traumatic arthritis:** 10-20% radiographic changes at 5 years (most mild, asymptomatic) **Restoration of normal anatomy correlates with function:** - Radial inclination restoration associated with improved grip - Volar tilt restoration associated with improved ROM - Ulnar variance restoration important for DRUJ function - Malunion (even mild) increases post-traumatic arthritis risk **Modifiable and non-modifiable factors:** - Age: Younger patients recover faster and more completely - Smoking: Delays healing, increases complication risk (counsel cessation) - Diabetes: Slower healing, higher infection risk - Osteoporosis: Higher risk of fixation failure, important to address - Compliance: Hand therapy critical - patients who engage do better **Long-Term Outcomes:** **5-year outcomes:** - 85-90% maintain functional improvement - 10-15% develop radiographic post-traumatic arthritis (most mild) - 5-10% have persistent symptoms requiring intervention - Hardware removal performed in 10-15% for symptoms **10-year outcomes (limited data):** - Post-traumatic arthritis rates increase to 20-30% radiographically - Most remain clinically asymptomatic or mildly symptomatic - Wrist fusion or arthroplasty rarely needed (less than 2-3%) **Australian Outcomes Data:** **Registry and audit data:** - Consistent with international literature - 80-90% good/excellent outcomes - Return to work: 90% return to pre-injury occupation - Sedentary: 2-4 weeks - Light manual: 6-8 weeks - Heavy manual: 12+ weeks **Medicare data:** - Distal radius ORIF is one of the most common orthopaedic procedures - Low revision rate confirms efficacy of volar plating approach {/* SECTION 13: VIVA SCENARIOS */} {/* SECTION 14: MCQ PRACTICE POINTS */} **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. **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. **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. **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. **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. **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. **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. **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). **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. **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. **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. **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). **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. **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. **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. {/* SECTION 15: 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. {/* SECTION 16: EXAM CHEAT SHEET */} {/* SECTION 17: REFERENCES */} 1. Henry AK. Extensile Exposure. 2nd ed. Edinburgh: Churchill Livingstone; 1973. 2. Rozental TD, Blazar PE. Functional outcome and complications after volar plating for dorsally displaced, unstable fractures of the distal radius. J Hand Surg Am. 2006;31(3):359-65. doi:10.1016/j.jhsa.2005.12.014 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

Henry Approach to the Radius (Volar Approach)

Henry Approach to the Radius (Volar Approach)