technique the extended flexor carpi radialis...

T E C H N I Q U E

The Extended Flexor Carpi Radialis Approach:A New Perspective for the DistalRadius FractureJORGE L. ORBAY, M.D.ALEJANDRO BADIA, M.D.IGOR R. INDRIAGO, M.D.Miami Hand Center,Miami, FL, U.S.A.

ANTHONY INFANTE, D.O.Florida Orthopaedic Institute,Tampa, FL, U.S.A.

ROGER K. KHOURI, M.D.EDUARDO GONZALEZ, M.D.Miami Hand Center,Miami, FL, U.S.A.

DIEGO L. FERNANDEZ, M.D.Lindenhof Hospital,Berne, Switzerland

� HISTORICAL PERSPECTIVE

Volar fixation of dorsally unstable distal radius fracturesis a new method of treatment that provides the benefits ofstable internal fixation without the complications of thedorsal approach. A new, fixed-angle fixation device, thedistal volar radius (DVR) plate, (Fig. 1) has been intro-duced for this purpose. Experience gained by applyingthis technique to clinically complex cases led us to therealization that more exposure, especially in a dorsal di-rection, was necessary than that provided by the tradi-tional volar approaches. The need to reduce fractureswith significant articular displacement (Fig. 2) and theneed to release dorsal callus in inveterate fractures ornascent malunions led us to use an extended form of theflexor carpi radialis (FCR) approach.

Volar displaced distal radius fractures are commonlymanaged with volar buttress plates through the FCR ap-proach.1 This approach goes deep to the forearm fasciathrough the FCR tendon sheath and is continuous with

the distal part of the Henry approach. The traditionalFCR approach provides access to the volar aspect of thedistal radius, the volar wrist capsule, and the scaphoid. Incomparison with dorsal approaches, which present a highincidence of extensor tendon problems,2–6 the FCR ap-proach is relatively free of complications.

We extend the FCR approach by releasing the radialseptum, by mobilizing the proximal radial fragment, andby using the fracture plane for exposure or what is knownas intrafocal technique. Therefore, understanding theanatomy of the radial septum is important. On its proxi-mal aspect, it is a simple fascial wall separating theflexor and extensor compartments of the forearm. At thelevel of the radial metaphysis, the radial septum is acomplex fascial structure that includes the first extensorcompartment and the insertion of the brachioradialis.More distally, the radial septum forms the radial inser-tion of the carpal ligament and ends as the FCR tendonsheath approaches the tuberosity of the scaphoid. Theproximal radial fragment has a dependable endostealblood supply that permits its subperiosteal release andsubsequent mobilization. Pronating this fragment out ofthe way provides wide exposure of the fracture surfaces.This allows the volar reduction and fixation of even themost complex dorsally displaced distal radius fractures.

Address correspondence and reprint requests to Dr. Jorge L. Orbay,Miami Hand Center, 8905 SW 87 Ave., Suite 100, Miami, Florida33176; e-mail: [email protected]

Techniques in Hand and Upper Extremity Surgery 5(4):204–211, 2001 © 2001 Lippincott Williams & Wilkins, Inc., Philadelphia

204 Techniques in Hand and Upper Extremity Surgery

� INDICATIONS/CONTRAINDICATIONSThis technique is indicated for distal radius fractures inwhich simpler forms of management would produce un-acceptable results. Unstable fractures in young and activepatients, which need optimal restoration of the bonyanatomy; in polytraumatized patients with complex re-habilitation issues, which might include lower-extremityinjuries; or in elderly patients who need a quick return tofunctional independence are all good indications for thistechnique. We define fractures as unstable if, after anattempt at close reduction, they persist with radiographicevidence of more than 15 degrees of angulation in any

plane, a greater than 2-mm articular step-off, or greaterthan 2 mm of shortening. Also, fractures with severecomminution, severe articular displacement, or poorbone quality can be considered unstable. Patients withinveterate fractures or nascent malunions are also goodcandidates for this technique.

� TECHNIQUE

The skin incision is made directly over the course of theFCR tendon and is 8–10 cm long. It should zigzag acrossthe wrist flexion creases (Fig. 3). The tendon tunnelsalong the forearm fascia, dividing it into a superficialdeep layer. This forms a strong fascial structure that al-lows for safe retraction. The superficial layer of thesheath is incised longitudinally, and the FCR tendon isretracted medially, protecting the median nerve. Thefloor of the sheath is then incised to gain deep access(Fig. 4). Proximally, the tendon sheath should be re-leased generously to facilitate exposure. Distally, bothlayers should be divided up to the tuberosity of thescaphoid. This structure underlies the crossing of thesuperficial radial artery and forms the distal limit of theradial septum.

The dissection is taken down to the surface of thedistal radius by developing the space between the flexorpollicis longus and the radial septum. Numerous muscu-lar perforators are found here and need to be cauterized.The radial origins of the most distal fibers of the flexorpollicis longus muscle are released for greater exposure.The space of Parona, the virtual space between the flexortendons and the volar surface of the pronator quadratus,is now developed. This is accomplished by blunt digital

FIG. 1. The distal volar radius (DVR) plate (Hand Inno-vations, Miami, FL) is a fixed-angle device designed spe-cifically for the general volar fixation of distal radius frac-tures. The purpose of this surgical strategy is to avoid thetendon complications common with the dorsal approach.The extended flexor carpi radialis approach allows themanagement of the most complex distal radius fractures.

FIG. 2. (A and B) A fall from a roof pro-duced this dorsally unstable distal radialfracture with a displaced, dorsal, die-punch fragment.

The Extended FCR Approach

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dissection and by sharp division of the proximal reflex-ion of the carpal bursa. This exposes the distal radius, thepronator quadratus muscle, and the anterior wrist capsule(Fig. 5). The pronator quadratus is mobilized by releas-ing its distal and lateral borders with an L-shaped inci-sion. It is then lifted from its bed by subperiosteal dis-section, exposing the fracture site. The distal border ofthe pronator quadratus forms a transverse line on thesurface of the radius. This line marks the proximal re-flection of the carpal bursa and signals the distal limit forsafe hardware placement (Fig. 6). With dorsally dis-placed injuries, the pronator quadratus muscle fibers arefrequently found torn and interposed in the fracture site.7

So far in this report we have described the classicFCR approach. Many fresh fractures (less than 10 daysold) can be managed easily with only this exposure, be-cause longitudinal traction in the presence of intact dor-

sal soft tissues will produce an adequate reduction. Thisis the well-known phenomenon of ligamentotaxis. On theother hand, fractures that present severe intraarticulardisplacement or organizing fracture hematomas will notreduce adequately with this simple technique.

The need for the extended FCR approach arises incases. The fracture plane is used for exposure; this is alsoknown as “intrafocal technique.” This is analogous to theapproach for a tibial plateau fracture. Here the metaph-yseal fragment is “opened like a book,” allowing thejoint surface to be viewed from within the fracture. TheFCR approach is extended in three steps: the release ofthe radial septum, the subperiosteal release of the proxi-mal radial fragment, and its mobilization into pronation.This last maneuver provides direct access to the fracture

FIG. 3. The skin incision is made directly over the courseof the flexor carpi radialis tendon, zigzags across the flex-ion creases, and is 8–10 cm long.

FIG. 4. The dissection goes deep to the forearm fasciathrough the sheath of the FCR tendon and is continueddown between the flexor pollicis longus and the radialseptum. Note distally the superficial branch of the radialartery (*).

FIG. 5. The space of Parona is developed by exposingthe distal radius, (1) the pronator quadratus muscle, (2)and the anterior wrist capsule (3). The distal and lateralborders of the pronator quadratus muscle are marked forrelease.

FIG. 6. The pronator quadratus is elevated exposing thefracture. This completes the classic part of the flexor carpiradialis approach. Note the transverse line formed by thedistal edge of the pronator quadratus muscle (*). The lineindicates the distal limit for the safe application of hard-ware.

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IIndriago

Note

IIndriago

Highlight

surfaces, permitting reduction of articular displacement,bone grafting, and the removal of fracture callus.

Proximally, the radial septum is a simple fascial wallseparating the flexor from the extensor compartmentsand is released easily from its radial insertion. Just proxi-mal to the styloid process, the septum becomes a com-plex fascial structure formed in part by the first extensorcompartment and by the insertion of the brachioradialis.The radial artery is vulnerable in this area. To release theradial septum here, the first extensor compartment isopened and its tendons retracted. The insertion of thebrachioradialis is found on the floor of this compartment.It limits dorsal exposure and produces a deforming force.Therefore its release greatly facilitates the exposure and

reduction of the fracture. Distal to the styloid process, theradial septum becomes less distinct and also serves as theinsertion of the carpal ligament. It is released by dissect-ing toward the tuberosity of the scaphoid (Fig. 7).

The periosteum is released around the proximal ra-dial fragment to permit its mobilization. This is donesafely, as this fragment is provided with a dependableendosteal blood supply. The surgeon should preserve thesoft tissue attachments to the dorsal aspect of the distalfragment and to comminuted dorsal fragments (Fig. 8).

The proximal radial fragment is mobilized into pro-nation to complete the exposure. The use of a bone clampas a handle facilitates this action, and the fracture can bedisimpacted if necessary (Fig. 9). Once the proximal ra-dial fragment is out of the way, the surgeon has directaccess to the fracture surfaces. It is possible to manipu-late articular fragments directly. These can be moldedagainst the carpus, which serves as a template, to obtainreduction (Fig. 10). Access to the dorsal aspect of thefracture site is also obtained. This allows the debride-

FIG. 7. Extension of the flexor carpi radialis approachrequires the release of the radial septum. Proximally, thisstructure is a simple fascial wall, separating the flexor andextensor compartments (1) More distally, it becomes acomplex fascial structure that includes the insertion of thebrachioradialis (2) and the first extensor compartment (3).Finally, it becomes the radial insertion of the carpal liga-ment (4).

FIG. 8. The dependable endosteal blood supply of theproximal radial fragment permits its generous release andmobilization.

FIG. 9. Pronating the proximal fragment out of the waywith the help of a bone clamp provides comfortable ac-cess to the fracture surfaces.

FIG. 10. Articular fragments (*) can be manipulated di-rectly. The carpus can serve as template for reduction.



ment of organized hematoma or callus to accomplishreduction in the case of an inveterate fracture. In the caseof a true nascent malunion, the ossified callus and hy-pertrophic dorsal periosteum can be removed (Fig. 11).Bone graft can also be applied, if necessary, through thisapproach. The proximal radial fragment is finally supi-nated back into position “closing the book” (Fig. 12).

Once adequate reduction has been obtained, fixationis applied on the volar surface of the radius (Fig. 13). TheDVR plate has fixed angle pegs, directed to key regionsof the distal radius, to assure fixation of the commonfracture fragments. The most radial peg is directed intothe styloid process, and the most ulnar peg is directedinto the dorsal dye punch fragment. The volar dye punchfragment is supported by the plate’s volar lip, and, ifnecessary, additional fixation can be applied. This volarfragment is, in our experience, the most difficult tofix. Comminuted fractures therefore can be stabilizedeffectively.

Proper reduction of the fracture and positioning ofthe hardware is confirmed with fluoroscopy (Fig. 14). Itis necessary to obtain the correct views. For the lateralview, the forearm must be elevated 20 degrees from thehorizontal and the articular surface visualized tangen-tially to assure proper placement of the pegs in the sub-chondral bone. The brachioradialis and pronator quadra-tus are finally sutured back in place to retain the bonegraft, to cover the implant, and to separate it from theflexor tendons (Fig. 15)(Fig. 16 and 17). Internal fixationof an associated scaphoid fracture can be achieved byincising the volar capsule. Carpal tunnel release shouldbe performed through a separate incision, because it has

FIG. 11. The approach allows access to the dorsal aspectof the fracture, the debridement of organized hematomaor fracture callus, and the application of bone graft.

FIG. 12. After proper articular reduction is obtained andbone graft applied, the proximal fragment is reduced backin place. This produces a stable situation allowing theapplication of the plate.

FIG. 13. The distal volar radius (DVR) plate is appliedproximal to the transverse line formed by the distal borderof the pronator quadratus.

FIG. 14. Proper placement of the pegs in the subchondralbone is confirmed fluoroscopically.

J. L. Orbay et al.


been our experience that complete release of the radialinsertions of the carpal ligament is associated with flexorpollicis longus dysfunction, and the palmar cutaneousnerve is at risk if the incision is extended ulnarly anddistally into a standard carpal tunnel release. Continua-tion of the dissection on the plane of the interosseousmembrane toward the ulnar side can expose the distalulna. In the case of a distal ulna fracture that cannot befixed in an elderly patient, the distal ulna can be excisedfrom this approach; and it is also possible to perform anulnar shortening osteotomy through this incision.

� COMPLICATIONSWith vigilance and careful technique, most complica-tions can be avoided. Flexor tendon problems have not

occurred with our technique. We have seen dorsal tendonirritation from an excessively long peg. This is managedwith hardware removal. Full-blown RSD has also notoccurred. Its milder forms presenting as slow progress inrehabilitation or pain and swelling out of proportion tothe injury are occasionally seen. This problem respondswell to early treatment, which in our center includesintensive physiotherapy, calcitonin, and sympatheticblocks. We expect full digital motion by the first week,and its absence is managed aggressively. All our patientsregained full digital motion by the end of treatment.There were no cases of deep infections, shortening, orloss of reduction when the DVR plate was used. Nobreakage of the implant occurred.

Concomitant ligamentous injuries, both intercarpaland distal radioulnar, frequently occur. They should belooked for and managed early. Persistent pain long aftera distal radius fracture can be caused by one of theseeasily missed injuries. Carpal tunnel syndrome is notuncommon after distal radius fractures. We search forparesthesias before surgery and very frequently releasethe carpal tunnel in high-risk patients.

� REHABILITATION

Finger motion and forearm rotation is commenced im-mediately after surgery. After removal of the postope-rative dressing, a short splint is frequently used for symp-tomatic relief. Extra-articular fractures generally haveless soft-tissue swelling and return to function faster.Intraarticular fractures often have more soft-tissue reac-tion and benefit from a more prolonged period of wristsplinting. The use of the hand for light activities of daily

FIG. 16. (A and B) The result is ana-tomic restoration of the articular surfaceand correct radial length.

FIG. 15. The brachioradialis and the pronator quadratusare returned to their original positions, covering the plateand protecting the flexor tendons.



living is encouraged at the first postoperative visit, andpatients are then given reasonable weight-lifting restric-tions. The weight limit is increased progressively, and norestrictions are applied after radiographic union isachieved. This usually occurs between the fourth andtenth weeks. Most patients are able to touch their palmswith their fingertips at the first postoperative visit. Fail-ure to do so results in a referral to formal physiotherapy.

� DISCUSSION

Until recently, buttress plates were the only form ofstable internal fixation available for distal radius frac-tures. The principle that volarly displaced fractures areapproached from the volar side and dorsally displaced

fractures from the dorsal side originates from the need toapply the buttress plates on the unstable surface.

Stable internal fixation traditionally has been re-served for the volarly displaced fractures. Most surgeonshave avoided the use of dorsal plates as they have beenfrequently associated with extensor tendon complica-tions.8 Despite different designs of dorsal implants, theiruse commonly requires reoperation for removal. Tendonproblems seem more inherent to the dorsal approachrather than to the specific implant characteristics. Attri-tional tendonitis occurs on the dorsal aspect of the distalradius, because there is little space available for the ap-plication of implants. There is more space on the volaraspect. Here the flexor tendons are well separated fromthe bone surface by the pronator quadratus muscle and

FIG. 17. (A, B, and C) Rehabilitationconsists of immediate postoperative fin-ger and forearm motion, the early func-tional use of the hand, and the short-term use of wrist support to manageedema and facilitate early function.

J. L. Orbay et al.


protected by the concave shape of the distal radius. Theseanatomic characteristics allow the safe application of vo-lar plates. Volar fixation of these injuries also has otheradvantages. The volar approach preserves the dorsal softtissues, allowing for ligamentotaxis and the maintenanceof fragment vascularity. Rehabilitation seems to be has-tened by the volar approach, and the volar scar is betteraccepted than the dorsal.

The DVR plate offers stable internal fixation to dor-sally displaced distal radius fractures through a volarapproach. It accomplishes this by using the fixed-angleprinciple9 to prevent toggling of the distal fragmentand by a robust design that enables it to carry the highloads generated by this loading configuration. Expandingthe indications for volar plate fixation to dorsal fracturesreveals that the standard volar approaches do not alwaysoffer sufficient exposure. This is particularly true inthe management of fractures with severe articular dis-placement and those with advanced callus formation.We have used an extended form of the FCR approachfor the management of these fractures. Releasing the ra-dial septum and mobilizing the proximal radial fragmentto provide intrafocal exposure extends this approach.This maneuver provides the exposure necessary for thesurgical management of complex clinical situations. Thestandard FCR approach is well known in the surgicalcommunity, and the extended form is easily mastered.

The inclusion of the extended FCR approach in thesurgeon’s armamentarium provides him with the abilityto safely manage distal radius fractures with stable in-ternal fixation, regardless of their direction of instability.This enables him to simplify the treatment of thepolytraumatized patient, obtain better anatomic results

for high-energy injuries, and expedite a return to inde-pendent function for the elderly patient.

� REFERENCES

1. Jupiter JB, Fernandez DL, Toh CL, et al. Operative treat-ment of volar intra-articular fractures of the distal end ofthe radius. J Bone Joint Surg [Am] 1996;78:1817–28.

2. Ring D, Jupiter JB, Brennwald J, et al. Prospective multi-center trial of a plate for dorsal fixation of distal radiusfractures. J Hand Surg [Am] 1997;22:777–84.

3. Carter PR, Frederick HA, Laseter GF. Open reduction andinternal fixation of unstable distal radius fractures with alow-profile plate: A multicenter study of 73 fractures. JHand Surg[Am] 1998;23:300–7.

4. Kambouroglou GK, Axelrod TS. Complications of theAO/ASIF titanium distal radius plate system (II plate) ininternal fixation of the distal radius: A brief report. J HandSurg [Am] 1998;23:737–41.

5. Hove LM, Nilsen PT, Furnes O, et al. Open reduction andinternal fixation of displaced intraarticular fractures of thedistal radius. Acta Orthop Scand 1997;68:59–63.

6. Axelrod TS, McMurtry RY. Open reduction and internalfixation of comminuted, intraarticular fractures of the dis-tal radius. J Hand Surg [Am] 1990;15:1–10.

7. Fernandez DL. Should anatomic reduction be pursued indistal radial fractures? J Hand Surg [Br] 2000;25:1–6.

8. Fernandez DL, Jupiter JB. Compression fractures of thearticular surface. In: Fractures of the Distal Radius. NewYork; Springer 1996;189–220.

9. Gesenway D, Putnam MD, Mente PL, et al. Design andbiomechanics of a plate for the distal radius. J Hand Surg[Am] 1995;20:1021–27.



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