comparison of volar henry and extended flexor carpi

Original ArticleHand Microsurg 2019;8:71-79

doi:10.5455/handmicrosurg.51509

ABSTRACT Objective: The aim of this study was to compare the clinical and radiological results of volar Henry (VH) and extended flexor carpi radialis (EFCR) approaches used for open reduction of distal radius fractures.Methods: We reviewed 85 patients with distal radius fractures treated with volar locking plates between 2014 and 2017. The EFCR approach was used in 30 (35.3%) patients, and the VH approach was used in 55 (64.7%) patients for open reduction. Clinical results were reviewed by the Quick Disability of the Arm, Shoulder and Hand; Patient-Related Wrist Evaluation; and Boston Carpal Tunnel Syndrome questionnaires. Bilateral wrist range of motion, grip, and pinch strengths were measured, and sensory evaluations were done with the Semmes-Weinstein monofilament test and static two-point discrimination tests. Radiological evaluations were done with final follow-up radiographs.Results: The mean age was 50.7, and the average follow-up time was 31.8 months. No differences were found between the two groups related to clinical and radiological outcome evaluations. In the VH group, six post-operative complex regional pain syndromes, one tendon rupture, three delayed carpal tunnel syndromes, and one osteomyelitis were observed. In the EFCR approach group, complex regional pain syndrome was observed in four patients.Conclusion: Similar clinical and radiological results were found with the EFCR approach and VH approach in the treatment of distal radius fractures. As the EFCR approach seems to be safe for routine open reduction of distal radius fractures, it should especially be kept in mind in cases with median nerve entrapment.

Key words: Approach, distal radius, extended flexor carpi radialis, fracture, volar Henry

Comparison of volar Henry and extended flexor carpi radialis approaches in the surgical treatment of distal radius fractures

Ulas Akgun, Umut Canbek

IntroductionDistal radius fractures are the most commonly

seen skeletal injuries within upper extremity and makes up about 1/6 of all fractures [1]. Although distal radi-

us fractured had been mostly treated either by using casts or percutaneous fixation methods historically; with the recent improvements in locking plates, open reduction and internal fixation is used more frequently

Department of Orthopaedics and Traumatology, Mugla Sitki Kocman University, Faculty of Medicine, Mugla, TurkeyUlas Akgun, MD, Department of Orthopaedics and Traumatology, Mugla Sitki Kocman University, Faculty of Medicine, Mugla, Turkey e-mail: [email protected] 02, 2019 / July 09, 2019

Author affiliations :Correspondence :

Received / Accepted :

© 2019 Turkish Society for Surgery of the Hand and Upper Exremity www.handmicrosurgeryjournal.com

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in treatment, especially in cases with unstable fractures [2]. Due to the risk of extensor tendon irritation with dorsal plates, volar anatomic locking plates are usually preferred for internal fixation of distal radius fractures [3, 4].

The well-known technique for the open reduction of distal radius fractures from palmar side is volar Hen-ry (VH) approach, which uses the interval between flexor carpi radialis (FCR) tendon and radial artery [5]. In 2010, a new method named extended flexor car-pi radialis (EFCR) approach was defined in the litera-ture [6]. With this approach, a single volar incision is used to release transverse carpal ligament (TCL) and allowing the exposure of distal radius, simultaneous-ly. The EFCR approach is thought to improve surgical field of view by facilitating the retraction of structures that run through carpal tunnel without creating addi-tional morbidity [7]. The rationale for developing this extended approach is to treat acute carpal tunnel syn-drome (CTS) cases which might be caused by distal ra-dius fractures and also to prevent subacute CTS which might develop in late post-operative period [8].

The studies about the reliability and long-term results of EFCR approach are limited in the literature. The main objective of this study was to retrospectively compare the clinical and radiological results of the VH and EFCR approaches used for open reduction in the surgical treatment of distal radius fractures.

Patients and MethodsStudy PopulationEthics approval for the study was obtained from the

local ethics committee (2017/3). One hundred eighty-eight consecutive patients between January 2014 and November 2017, treated by internal fixation with volar locking anatomic plates for Arbeitsgemeinschaft Os-teosynthese/Orthopaedic Trauma Association (AO/OTA) type 2R3 distal radius fractures were included in the study [9]. Patients with bilateral distal radius frac-tures (n=8), with other fractures than distal radius that might affect ipsilateral or contralateral function in the

upper extremity (n=19), open fractures (n=3), time to surgery more than two weeks (n=9), and patients with follow-up periods less than 12 months were excluded. Thirty-five patients could not be reached, and finally, 85 patients consented to participate in the study. Informed consent was obtained from all participating patients.

In our clinic, two of six orthopedic surgeons rou-tinely perform the EFCR approach, whereas four pre-fer the VH approach for the open reduction of distal radius fractures. Patients were divided into two groups according to surgical approach used. Group 1 consist-ed of 30 (35.3%) patients who were treated with the EFCR approach, whereas Group 2 consisted of 55 (64.7%) patients treated with the VH approach.

Outcome AssessmentAll surgical outcomes were evaluated by a physi-

otherapist who was blinded to the surgical approach. Clinical and functional results were reviewed using the Quick Disability of the Arm, Shoulder and Hand Ques-tionnaire (QDASH) [10]; Patient-Related Wrist Eval-uation Questionnaire (PRWE) [11]; and Boston Car-pal Tunnel Syndrome Questionnaire (BCTSQ) [12], which were all proven as valid and reliable in the Turk-ish language. Bilateral wrist range of motion was meas-ured using a goniometer, and bilateral grip strength was measured using a hydraulic hand dynamometer (Base-line, Model No. 12-0240, Fabrication Enterprises, NY, USA). Bilateral palmar, key, and tip-pinch strengths were also measured using a hydraulic pinch gauge (Baseline, Model No. 12-0235, Fabrication Enterpris-es, NY, USA). All measurements of range of motion and strength were rated in percentages with compari-son to the non-injured side. The Purdue Pegboard Test (PPT) (Lafayette Instrument Company, Model No. 32020A, IN, USA), where the patients insert small pins into pinholes in a limited time period, was used to eval-uate fine motor skills of the patients [13].

Sensory evaluation of median nerve innervat-ed fingers (first, second, third, and radial half of the fourth finger) were done using the Semmes-Wein-

Comparison of two surgical approaches in distal radius fractures

Hand and Microsurgery | 72www.handmicrosurgeryjournal.com

fragments was recorded in preoperative radiographs. In the last follow-up radiographs, the radial inclina-tion, radial height, radial volar tilt, articular step-off, and ulnar variance values, as described by Medoff, were measured by two independent orthopedic sur-geons who did not know which approach was used in the treatment [16].

Surgical TechniqueThe patients were operated on under general anes-

thesia or axillary nerve block using a tourniquet. In the VH approach (Figure 1), the deep volar compartment was accessed by entering the plane between the flexor carpi radialis (FCR) tendon and radial artery. The frac-ture line was visualized following a reverse L-shaped incision on the radial attachment of the pronator quad-ratus muscle to the radius.

In the EFCR approach (Figure 2), as defined by Pensy et al., the incision was made just proximal to the wrist crease over the FCR tendon [6]. The FCR tendon sheath was released, and the superficial leaf of the trans-verse carpal ligament was cut. The FCR tendon was retracted radially, and the flexor pollicis longus (FPL) tendon was retracted to the ulnar side, exposing the deep leaf of the TCL, which was subsequently released

Figure 1. The volar Henry approach (A) The plane between flexor carpi radialis tendon (black arrow) and the radial artery (white arrow) is used. (B) The pronator quadratus muscle (*) is exposed. (C) After the elevation of pronator quadratus muscle from radial border, the fracture line (white arrowhead) is clearly visible.

A

B

C

stein Monofilament Test (SWMFT) (Baseline Tactile Semmes-Weinstein Monofilaments, Model No. 12-1662, Fabrication Enterprises, NY, USA) and static two-point discrimination (S2PD) (Baseline Aesthesi-ometer, Model No. 12-1481, Fabrication Enterprises, NY, USA) measurement [14]. The SWMFT was re-viewed in five categories (1=0.07 g, 2=0.4 g, 3=2 g, 4=4 g and 5=100 g), and the mean value of each measured finger was recorded [15]. In the S2PD test, the lowest measurement value in millimeters where two points on the evaluated fingers are felt as different points was doc-umented, and mean values were calculated. Postopera-tive complications, such as complex regional pain syn-drome (CRPS), tendon rupture, CTS, and infection, were documented.

In radiological evaluation, the number of fracture

Akgun U and Canbek U

73 | Hand and Microsurgery Year 2019 | Volume 8 | Issue 2 | 71-79


from its radial attachment. A retractor was positioned over the FPL tendon, preserving the structures that run through the carpal tunnel. Finally, the fracture line was accessed by lifting the pronator quadratus, similar to

the VH approach.Following reduction, a 2.4-mm volar locked distal

radius plate (Acu-lock2, Acumed, Hillsboro, OR, USA, or Hipokrat, Izmir, Turkey) was used for fixation. Fore-arm braces were used in all patients until suture remov-al, and patients were encouraged to perform active fin-ger exercises following surgery. Sutures were removed two weeks after surgery, and passive wrist range of mo-tion exercises were initiated. Active strengthening exer-cises were started four weeks following surgery.

C

B

A D

EFigure 2. The extended flexor carpi radialis approach (A) The incision starts just proximal to the wrist crease over the flexor carpi radialis tendon (black arrow), and distal tendon sheath is released with a scal-pel. (B) After retracting flexor carpi radialis tendon (black arrow) radi-ally and flexor pollicis longus tendon (white arrow) ulnarly, transvers carpal ligament (T) is exposed. (C) The deep leaf of transvers carpal ligament is released from its radial side. (D) The pronator quadratus muscle (*) is exposed. (E) After the elevation of pronator quadratus muscle from radial border, the fracture line (white arrowhead) is clear-ly visible.


Statistical AnalysisDescriptive statistics are shown as mean ± stand-

ard deviation (SD) in continuous variables and as (n) and (%) in nominal variables. The normal spread of in-tergroup variables was assessed using the Shapiro–Wilk Test. A student’s t-test was used in the assessment of quantitative variables with a normal spread, whereas the Mann–Whitney U test was used to compare vari-ables without a normal spread. Pearson’s Chi-Squared test was used to compare qualitative variables. The sig-nificance level was set at p < 0.05, and IBM SPSS Sta-tistics, Version 22 (IBM Corp, Armonk, NY, USA) was used to calculate all statistics.

ResultsThe patients included 48 (56.5%) males and 37

(43.5%) females with a mean age of 50.7 ± 13.8 (range 19 to 79) years. The mean time from injury to operation was 2.7 ± 2.2 (range 1 to 13) days, and the mean fol-low-up time was 31.8 ± 12.1 (range 13 to 58) months. No significant difference was found in terms of demo-graphics, follow-up periods, the period from injury to surgery, and number of fracture fragments between the groups (Table 1). Clinical and radiological outcomes were found to be similar between two groups in the fi-nal follow-up examination (Table 2).

In the VH approach group, postoperative CRPS

was observed in six (10.9%) patients, one (1.8%) pa-tient was operated on for an FPL tendon rupture, sur-gical TCL release was required in three (5.5%) patients due to CTS, and osteomyelitis of the distal radius met-aphysis was seen in one (1.8%) patient. In the EFCR approach group, CRPS was observed in four (13.3%) patients. No tendon ruptures, CTS, or infection were seen in the EFCR group. No significant difference was found between the groups in terms of complication rates (Table 3).

DiscussionNowadays, volar anatomical locked plates are fre-

quently used for the fixation of distal radius fractures, and the VH approach was the preferred approach in most of the cases [2,5]. The usability, reliability, and efficacy of the VH approach for open reduction of dis-tal radius fractures are documented in various studies [17-19]. However, surgical release of TCL in the case of median nerve entrapment secondary to a distal radi-us fracture is not possible with the VH approach [20]. The direct midline volar approach, which is used both for TCL release and radius fracture surgery, is report-ed to cause severe median nerve complications [21]. A cadaver study performed by Pensy et al. in 2010 intro-duced the EFCR approach, which can be used both for TCL release and open reduction of distal radius frac-

Table 1. Patient data according to approach techniques.

Variable EFCR Approach (n=30) Volar Henry Approach (n=55) p Value Test

Age (years) 50.1 ± 13.6 (range 19 to 79) 51.1 ± 14.1 (range 21 to 78) 0.767 t

Sex 0.628 χ2

Male 18 (60%) 30 (54.5%)

Female 12 (40%) 25 (45.5%)

Follow-up time (months) 30.7 ± 12.3 (range 13 to 57) 34 ± 12.1 (range 13 to 58) 0.17 U

Time from injury to surgery (days) 1.6 ± 2.2 (range 0 to 9) 1.8 ± 2.3 (range 0 to 12) 0.433 U

Fragment count 0.879 χ2

2 13 (43.3%) 27 (49.1%)

3 14 (46.7%) 23 (41.8%)

4 3 (10%) 5 (9.1%)

t: Student’s t test, U: Mann-Whitney U test, χ2: Chi-square test



Table 2. Functional and radiological outcomes of two approach techniques.


QDASH score 12.6 ± 16.7 11.9 ± 15.5 0.857 t

PRWE score 14.3 ± 19.4 14.7 ± 18.1 0.802 t

BCTSQ

Symptom severity score 1.3 ± 0.6 1.3 ± 0.5 0.959 t

Functional status score 1.3 ± 0.7 1.3 ± 0.6 0.988 t

Wrist range of motion

Flexion/extension range (%*) 90.9 ± 12 93.2 ± 27.7 0.21 U

Radial/ulnar deviation range (%*) 90.1 ± 15.7 92.7 ± 27.4 0.455 U

Hand grip strength (%*) 88.3 ± 20.9 84 ± 19 0.499 U

Palmar pinch strength (%*) 90.4 ± 15.8 86.5 ± 19.4 0.183 U

Key pinch strength (%*) 92.9 ± 18.1 91.1 ± 18.7 0.371 U

Tip pinch strength (%*) 89 ± 11.4 88.9 ± 20.4 0.809 U

SWMFT category 0.564 χ2

1 20 (66.6%) 31 (56.3%)

2 8 (26.7%) 21 (38.2%)

3 2 (6.7%) 3 (5.5%)

Mean S2PD (mm) 3.5 ± 0.8 3.6 ± 0.7 0.153 t

Radiological evaluation

Radial inclination (degrees) 20.6 ± 1.7 20.5 ± 1.5 0.795 U

Radial height (mm) 10.3 ± 1.1 10.4 ± 0.7 0.864 U

Radial volar tilt (degrees) 7.1 ± 2.9 7 ± 2.5 0.716 U

Ulnar variance (mm) 1.4 ± 2.2 1.3 ± 1.8 0.917 U

Articular step-off (mm) 0.6 ± 1.1 0.4 ± 0.8 0.495 U

* Percentages compared to contralateral wrist, SWMFT: Semmes-Weinstein Monofilament Test, S2PD: Static two-point discrimination

Table 3. Complications of two approach techniques.


Carpal tunnel syndrome 0 (0%) 3 (5.5%) 0.193 χ2

Complex regional pain syndrome 4 (13.3%) 6 (10.9%) 0.74 χ2

Osteomyelitis 0 (0%) 1 (1.8%) 0.458 χ2

Tendon rupture 0 (0%) 1 (1.8%) 0.458 χ2

χ2: Pearson chi-squared test

tures without risk of median nerve injury [6].To the best of our knowledge, there are only two

studies in the literature that compare VH and EFCR ap-proach results and complications. In a non-randomized prospective study that included 15 distal radius frac-

tures treated with the EFCR approach and 12 fractures treated using the VH approach by Tannan et al., similar clinical results were reported with both approaches [8]. Gwathney et al. used the EFCR approach in 68 distal radius fractures and reported no post-operative injury



of palmar cutaneous or recurrent motor branch of me-dian nerve in any of the patients [22]. In our study, we did not find a significant difference between the two ap-proaches in terms of grip and pinch strength. The simi-larity of thenar muscle strength in the EFCR approach and VH approach groups, as opposed to the direct volar approach, can be due to TCL release performed away from the median nerve motor branch [8,17].

In the study, no significant difference was found in patient-based QDASH, PRWS, and BCTSQ scores, or in sensory examinations or fine motor skills tests. Both groups reported similar postoperative complication rates. The main concern about the EFCR approach is the possibility of iatrogenic nerve damage due to the closer proximity of the approach to the median nerve in comparison to the VH approach, yet none of the pa-tients reported developing such complications in our study. Gwathney et al. reported early-term moderate sensory dysfunction in the median nerve innervated fingers in six patients treated with the EFCR approach, with complete remission three months after surgery in all patients [22]. Weber et al. defined the EFCR ap-proach in TCL release in 1997 and reported that TCL can be safely released from the radial side using a lon-gitudinal incision over the FCR ligament just proximal to the palmar crease of the wrist [23]. Moreover, the authors also showed, using magnetic resonance im-aging in the postoperative period, that the division of the TCL was distant from the median nerve and inter-preted that the perineural adhesion risk is lessened, as the structures over the median nerve are not disturbed [23]. According to our study results, we think that the EFCR approach does not create an additional morbidi-ty risk in comparison to the VH approach.

Although there are no statistically significant dif-ferences reported, 5.5% of patients required addition-al surgery due to CTS in the VH approach group, yet none of the patients treated with the EFCR approach reported symptomatic CTS. CTS is the most common entrapment neuropathy seen in the upper extremities,

reported to be seen in 3–6% of adults [24]. According to our study results, we think that the VH approach does not increase median nerve entrapment risk more than normal populations. On the other hand, the EFCR approach might prevent delayed CTS development, as no symptomatic cases were seen in the EFCR group.

Although TCL release is always indicated in pa-tients with progressive median nerve symptoms sec-ondary to distal radius fractures, the management of cases with non-progressive median nerve entrapment are controversial [24]. Some authors argue that a si-multaneous open or arthroscopic TCL release is es-sential in addition to surgery on distal radius fractures [25,26], whereas some think that the median nerve symptoms would be improved following fracture re-duction, deeming a routine additional intervention unnecessary [27]. Although there are no detailed data about the preoperative median nerve examinations of the patients in our study, the fact that the EFCR ap-proach allows us to perform a TCL release without re-quiring any additional incisions or instruments in the event of acute CTS seems to be an advantage over the VH approach.

The limitations of the study are its retrospective nature, the difference in number of patients in both groups, the fact that the patients were not randomized, and the fact that the surgeries were performed by dif-ferent surgeons. The lack of data about the preoperative median nerve examinations of the patients and the ina-bility to compare pre- and postoperative clinical results are additional limitations of this study.

In conclusion, we found similar clinical and radio-logical results with the EFCR approach and the VH ap-proach in the treatment of distal radius fractures. As the EFCR approach can be routinely used for the open re-duction of distal radius fractures according to surgeon preference, it should especially be kept in mind in cases with median nerve entrapment.

Conflict of interest statementThe authors have no conflicts of interest to declare.



FundingFinancial support for the purchase of the meas-

urement tools used in this study was provided by the Scientific Research Projects commission (Project No: 17/237) of our university.

Ethical ApprovalAll of the procedures performed in this study in-

volving human participants were done in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsin-ki Declaration and its later amendments or comparable ethical standards.

Informed ConsentInformed consent was obtained from all individual

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comparison of volar henry and extended flexor carpi

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