Review Article

Journal of Hand Surgery

(European Volume)
The minimally invasive approach for distal 0(0) 1–10
! The Author(s) 2017
radius fractures and malunions Reprints and permissions:
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DOI: 10.1177/1753193417745259
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Philippe A. Liverneaux

Abstract
This article reviews the author’s currently used minimal invasive approach for volar plating of distal radius
fractures. A single longitudinal incision of 1.5 cm is drawn on the lateral aspect of the flexor carpi radialis
tendon in order to insert a plate under the pronator quadratus. With the wrist flexed, the plate is applied on
the anterior cortex of the radius to reduce the fracture. This approach offers the advantage of preserving
ligamentotaxis, which facilitates the reduction, and the small scar improves the cosmetics. It is mainly
indicated for extra-articular and simple intra-articular fractures of the distal radius. Relative contraindica-
tions are comminuted articular fractures in elderly osteoporotic patients. Functional and radiological results
are comparable with those obtained with an extended flexor carpi radialis approach. My colleagues and I have
used it for more than 2000 cases since 2012. This technique requires practise. Attempted conversion to a
larger incision is possible in case of difficulty, but this is seldom necessary.

Keywords
Fractures, distal radius, minimally invasive, internal fixation, minimally invasive approach

Date received: 1st November 2017; revised: 5th November 2017; accepted: 6th November 2017

Introduction
The displaced distal radius fractures that cannot be
reduced conservatively or remain unstable after
closed treatment need surgical intervention. The
volar approach is a commonly used surgical
approach for plate fixation. Aiming to reduce surgical
damage to the tissues volar to the distal radius and
potentially benefiting the healing, surgeons are
developing minimally invasive approaches for plating.
The author and colleagues are among the surgeons
who are developing one such minimally invasive
approach. Based on the surgical cases, this review
summarizes the current methods and outcomes and
discusses its future applications.
What is the minimal invasive approach?
Minimally invasive plate osteosynthesis (MIPO) of the
distal radius was mentioned by Geissler and
Fernandes (2000), but it is only after 2013 a number
of articles regarding this approach for distal radius
fractures emerged. This approach intends to
decrease the skin incision (Figure 1) and to preserve
the pronator quadratus and periosteum, which the-
oretically favours bone healing (Zenke et al., 2011), in
contrast to a conventional long skin incision, which
has been used extensively (Johnson et al., 2017;
Tanaka et al., 2016; Teunis et al., 2017; Yoon et al.,
2017). The cosmetic advantage of the minimally inva-
sive technique is obvious (Yoshikawa et al., 2008).
This approach has been applied to volar plating of
distal radius fractures, as well as more recent new
surgical techniques for distal radius fractures
(Liverneaux et al., 2106).
Techniques of the minimally invasive
approach
The minimally invasive flexor carpi radialis (FCR)
approach was initially designed for A2 type fractures
in the A0 classification (Zemirline et al., 2014a).
Different variants have been described over the
Department of Hand Surgery, University of Strasbourg, Illkirch,
France
Corresponding Author:
Philippe A. Liverneaux, Department of Hand Surgery, FMTS,
University of Strasbourg, Icube CNRS 7357, 10 avenue Baumann,
67400 Illkirch, France.
Email: philippe.liverneaux@chru-strasbourg.fr
2 Journal of Hand Surgery (Eur) 0(0)

Figure 1. Flexor carpi radialis (FCR) approaches. (a) Conventional FCR approach. (b) Extended FCR approach. (c)
Minimally invasive FCR approach: the incision is lateral to the FCR tendon with its most distal point 2 cm proximal to the
tip of the radial styloid. This minimal invasive incision measures about 1.5 cm.

recent years. Our current method of this surgical
approach is as follows.
The semi-elective surgery is performed under
regional anaesthesia, unless complications, such as
a skin opening or acute compression of the median
nerve, are associated and that require immediate
care. A 1.5 cm line is drawn on the lateral aspect of
the FCR tendon, about 2 cm proximally to the tip of
the radial styloid (Figure 2). After incision of the skin,
the skin is separated from the underlying fascia using
scissors for a length of about 5 cm proximally and
2 cm distally. The superficial part of the FCR sheath
is cut longitudinally to the same extent. The FCR
tendon is retracted ulnarly. The deep part of the
FCR sheath is similarly cut. All muscular, vascular
and nerve structures except the radial artery are
retracted ulnarly. The pronator quadratus is cut
transversally and elevated at its distal aspect using
a periosteal-elevator, preserving its ulnar and radial
attachments.
A volar locking plate is prepared with four aiming
guides or a specific jig in its distal portion. The prox-
imal end of the plate is then inserted under the pro-
nator quadratus. The distal part is first inserted
radially and then ulnarly, ensuring the absence of
interposition of tendons, particularly the flexor polli-
cis longus (FPL) between the plate and radius.
The plate is positioned just proximal to the
watershed line and secured temporarily to the
distal fragment using two 1.8 mm K-wires; one
through the most ulnar aiming guide and the other
through the most radial one (Figure 2). Fluoroscopic
examination ensures satisfactory positioning of the
plate. This step may need to be repeat as necessary
until optimal positioning is obtained. The two central
distal fragment screws are placed. The two tempor-
ary Kirchner (K) wires are removed and replaced by
screws. The proximal part of the plate is exposed by
maximum flexion of the wrist to take advantage of
skin elasticity, and the two proximal screws are
placed (Figures 3 and 4). The skin is closed by an
intradermal continuous suture of absorbable 3-0
suture, pulling on its ends to reduce the size of the
incision. The minimally invasive FCR approach for
distal radius plating does not require suction drain-
age (Prunières et al., 2017) or post-operative splint
(Duprat et al., 2017), and it allows for unresisted
active motion as soon as the effects of the anaesthe-
sia have worn off. Rehabilitation is only necessary
when the range of motion is not full after a few
weeks (Zemirline et al., 2014a).
The removal of the hardware can, if needed, be
performed using a minimally invasive approach
(Medda et al., 2017).
Liverneaux 3

Figure 2. A minimally invasive FCR approach for a dorsally displaced fracture with a volar locking plate. Step 1. (a) The
FCR tendon between the two retractors. (b) The pronator quadratus is exposed when the FCR, flexor pollicis longus (FPL)
and other tendons are retracted to the ulnar side of the skin incision. (c) The pronator quadratus is elevated at its distal
aspect using a periosteal elevator. (d) A volar locking plate, prepared with two aiming guides at its distal part, is inserted
by placing its proximal part under the pronator quadratus. (e) The entire plate is inserted underneath the pronator
quadratus. (f) The plate is positioned just proximal to the watershed line and secured temporarily to the radial epiphysis
using a 1.8 mm K-wire through the most ulnar aiming guide. The position of the plate is assessed with fluoroscopy and is
modified if necessary until the K-wire is in the subchondral bone.

Figure 3. Minimally invasive FCR approach. Step 2. (a) A second 1.8 mm K-wire is inserted through the most radial
aiming guide. The position of the plate is assessed with fluoroscopy and is modified if necessary until the K-wire is in
subchondral bone (see the inserted drawing). Other screws are placed similarly. (b) Reduction of the fracture onto the
plate. The wrist is flexed to mobilize the incision proximally. The plate is applied and orientated on the anterior cortex of
the metaphysis by pressure with a bone impactor, thereby reducing the dorsal tilt (see the insertion).
4 Journal of Hand Surgery (Eur) 0(0)

Figure 4. Minimally invasive FCR approach. Step 3. (a) A 2-mm drill bit is introduced into the most proximal drill guide
and driven through the two cortices of the metaphysis. It is left in place to stabilize the plate. (b) A second drill bit is driven
into the most distal guide through both cortices. (c) The distal drill is withdrawn and the distal screw is inserted. (d)
Completion of plate fixation. (e) The lateral view showing all screws inserted as planned. (f) The skin is closed by
intradermal continuous suture with an absorbable 3-0 suture.

Variants of the minimally invasive approach
The surgical technique described for simple extra-
articular fractures can be applied to the treatment
of other fresh osteoarticular lesions and extended
to other types of fractures and to malunions.
To decide the best direction of skin incision, we
treated 30 extra-articular distal radius fractures in
patients of mean age 74 years (Galmiche et al.,
2017). Fifteen fractures were operated by single lon-
gitudinal incision, and 15 by a transverse approach
extended by a longitudinal approach for proximal
screws. The longitudinal approach had several
advantages. The final incision was shorter with an
average of 1.4 cm with the single longitudinal
approach and 2 cm with the transverse approach.
Considering appearance, it could not be confused
with a suicide attempt scar and does not require a
second incision to place the proximal screws. It
avoided the palmar cutaneous branch of the median
nerve, which is retracted ulnar, and the sensory
branches of the superficial radial nerve, which is lat-
eral to the incision. The incision can be enlarged
proximally and/or distally as necessary if the fracture
extends proximally. Associated intracarpal injuries
can be treated surgically. A scaphoid fracture can
be fixed using a percutaneous screw. A scapholunate
ligament tear can be repaired using an arthroscopic
technique with a temporary pinning (Zemirline et al.,
Liverneaux 5

Figure 5. A number of manoeuvres help reduction of the fracture. (a) Tyre changer manoeuvre. A periosteal elevator
inserted on the volar aspect of the fracture site (left image) to reduce the fracture (right image). (b) Dorsal leverage
manoeuvre. A percutaneous K-wire is inserted on the dorsal aspect of the fracture site (left image) to reduce the fracture
(right image). (c) Radial leverage manoeuvre. A percutaneous K-wire inserted on the radial aspect of the fracture site to
reduce the fracture. Left image: before radial leverage; right image: after the leverage. (d) Compression manoeuvre. A
compression screw passing through the oblique hole to fit the plate securely to the radius. See differences in the position
of the proximal part of the plate in the left and right images. (e) Hook probe manoeuvre. An intra focal K-wire helps reduce
the centrally displaced osteochondral fragment (left image). Right image shows arthroscopic view of reduced fragment to
confirm reduction with this manoeuvre. (f) Reduction after the hook probe manoeuvre in radiograph.

2014b). Immobilization is then necessary until the
ligament has healed.
For more complex fractures of the distal
radius, some tips and tricks can help (Figure 5).
When the classic manoeuver of reduction of the epi-
physiometaphyseal fragment has failed, the reduc-
tion can be obtained by using the ‘tyre changer’
effect of a periosteal elevator inserted on the volar
aspect of the fracture site, or by using leverage by
inserting a percutaneous K-wire on the dorsal or
radial aspect of the fracture site, as is done for intra-
focal pinning of dorsally displaced fractures
(Kapandji, 1976). When the plate is not fully contact-
ing the radius, a compression screw passing through
the oblong hole is helpful. When the reduction of
osteochondral fragments has failed after the distal
screws have been placed, the reduction can be
obtained either by putting pressure on the fragments
with an intra focal K-wire, or by traction on the frag-
ments using an arthroscopic hook probe (Figure 5).
When it comes to metaphysiodiaphyseal extra-
articular or articular fractures, a second small inci-
sion over the proximal screws can be useful (Pire
et al., 2017). When the reduction is unstable, a
direct temporary pinning is useful to stabilize the
fragments while the plate is put in place.
In treating distal radius fracture malunions, the
minimally invasive approach is extended to 2 cm in
order to introduce an oscillating saw and an osteo-
tome. The technique differs according to the dis-
placement (Taleb et al., 2015). In the case of a
dorsal displacement (Figure 5), the first step is to
introduce the plate under the pronator quadratus.
The screws are all placed as they would be for a
fresh fracture. The plate and screws are then
removed.
The second step consists of a complete osteotomy
at the level of the healed fracture. Under fluoroscopic
control, the osteotomy is started with the oscillating
saw and then completed with the osteotome in order
to avoid burning trabecular bone. The plate is then
replaced under the pronator quadratus and the distal
6 Journal of Hand Surgery (Eur) 0(0)
screws are tightened using the incisions prepared
before the osteotomy.
The third step consists of the automatic reduction
of the malunion by applying and then locking the
plate to the diaphysis as it would be done for a
fresh fracture. The post-operative follow-up is the
same as for a fresh fracture.
If the displacement is volar, the technique is more
difficult. The first two steps are inverted, because the
deformity does not allow the plate to apply to the
volar aspect of the radius. The osteotomy must be
performed first, which causes instability of the oste-
otomy site. This can be managed by a temporary
direct pinning. The subsequent steps are performed
as they would be for a fresh fracture.
The planning of the direction and position of the
osteotomy by digital techniques is available,
including custom-made cutting guides obtained
from computed tomographic images (Stockmans
et al., 2013). These techniques are helpful for com-
plex intra-articular malunions. In dorsally displaced
extra-articular fractures, the anatomic shape of the
plates is sufficient to obtain a reduction. No
numerical calculation is needed. To correct the
ulnar variance and the dorsal tilt, the only measure
to observe is positioning the plate at the watershed
line. Osteotomies using a minimally invasive FCR
approach are only possible presently, without
planning tools, for simple extra-articular malunions.
Some surgeons use an arthroscope to visualize com-
plex intra-articular osteotomies of malunions of the
distal radius (Del Piñal and Clune, 2017).
Technical keys and pitfalls
All minimally invasive techniques require
considerable training (Thornhill, 2004). The minimally
invasive FCR approach is not an exception, and train-
ing on anatomical parts is recommended to avoid
tendon and/or articular complications. It is wise to
start using this technique on simple extra-articular
fractures, reducing the size of the incision every
five fractures, all the way down to 1 cm (Naito
et al., 2016).
Several manoeuvres have been described to
reduce the fracture. Some surgeons prefer to first
reduce the fracture approximately by external man-
oeuvres, apply the plate to the anterior cortex of the
radius, and then restore the volar tilt using posterior
pins. In our experience this manoeuvre is time con-
suming and does not always result in restoration of
the volar tilt. This is why we prefer to deal first with
the epiphysis. We slide the plate under the pronator
quadratus just proximal to the watershed line without
worrying about the reduction of the distal fragment
on the diaphysis. When the distal fragment has been
fixed by the plate, it is easy to reduce the plate and
fragment on the diaphysis as previously described
and depicted in Figure 4. This manoeuvre is very
fast. Only when we encounter imperfect reductions
volarly, dorsally or laterally do we use tricks like
those described in Figure 5.
Arthroscopy may be useful in some fractures not
only to check for an associated ligament tear but also
to help reduce an osteochondral fragment. Some
surgeons proceed in three stages. The first is to
place the wrist horizontally to reduce the fracture
approximately by external manoeuvres, then apply
the plate on the anterior cortex of the radius. The
second stage is to place the wrist vertically in trac-
tion to achieve fixation by temporary pins any osteo-
chondral fragments under arthroscopy. Vertical
traction is incompatible with flexing of the wrist, so
restoration of the volar tilt requires a third step in a
horizontal position without traction. In our experience
this technique is time consuming and does not
always result in restoration of volar tilt. This is why
we prefer to proceed in two steps. The first step con-
sists of completely fixing the plate to the distal frag-
ment(s) and then on the diaphysis. Then arthroscopy
is performed as a second step. If the articular reduc-
tion of the radial glenoid is imperfect, it is sufficient
to remove the imperfect screw(s), to reduce with
osteochondral fragment(s) under arthroscopy with a
probe, then to replace the screw(s) (Figure 5).
When you see on the fluoroscopy that the distal
part of the plate is not well fit on the anterior
cortex of the radius, it often implies that a flexor
tendon (most often FPL tendon) is trapped under
the plate. In this case, in order to save time, do not
completely remove the plate. Simply remove all the
screws, push the tendon(s) stuck under the plate
ulnarly with an elevator, and then replace all the
screws. After this manoeuvre, a fluoroscopic view
can confirm that the plate is now well applied on
the anterior cortex of the radius. Whatever the
situation, it is always possible to convert to a
longer incision in case of a difficult reduction (Orbay
et al., 2001).
If a long plate is necessary, two incisions can be
made (Figure 6). In the patients with malunion of the
fracture, an osteotomy of the volar cortex can be
achieved using an oscillating saw through this min-
imal incision (Figure 7).
The merits and expanding application of
the minimal invasive approaches
Minimally invasive techniques are becoming preva-
lent in all surgical specialties. They are justified for
Liverneaux
cosmetic reasons, but also for technical and physio-
logical reasons. Limiting the size of the approach
preserves ligament and muscle attachments on the
distal radius and carpus, thus facilitating fracture
Figure 6. Two incisions are used for long plates. The
picture shows closure of the two incisions.
Figure 7. An osteotomy of the volar cortex of the radius using an oscillating saw through the minimal incision. The
osteotomy can be completed with an osteotome through this approach. (a) Operative picture. (b) An X-ray film showing the
osteotomy.
7
reduction and stability of reduction due to ligamento-
taxis (Bindra, 2005; Geissler and Fernandes, 2000;
Kapandji, 1976). This approach is different from an
extended FCR approach; the latter requires stripping
the distal radius off the muscles in order to place a
volar locking plate (Wijffels et al., 2012). A limited
approach can theoretically reduce bone ischemia,
the source of necrosis of small articular fragment
or pseudarthrosis. This is sometimes observed in
extensive approaches with marked bone stripping in
patients with comorbidities (Segalman and Clark,
1998). A limited approach also preserves the hema-
toma of the fracture site favouring bone healing
(Kolar et al., 2010).
With almost 500 cases published to date (online
supplementary Table 1), indications of MIPO tech-
niques in distal radius fractures are expanding.
Some consider they can only be used for simple
extra-articular fractures (Imatani et al., 2005).
Others extend their indications to articular fractures
(Zenke et al., 2011) and diaphysiometaphyseal
fractures (Wei et al., 2016). A supplemental arthros-
copy is recommended for articular fractures with
fragments that are not spontaneously reduced
when the plate is placed (Zemirline et al., 2014a).
A double proximal and distal approach is recom-
mended for fractures with a diaphyseal extension
(Pire et al., 2017). The surgeons who are familiar
with conventional approaches; a higher level of sur-
gical expertise for surgical treatment of this fracture
is not required (Tang and Giddins, 2016). The minimal
invasive approach can be performed as outpatient
surgery in most cases, and/or in a wide-awake sur-
gical settings (Lalonde, 2017).
8 Journal of Hand Surgery (Eur) 0(0)
Outcomes of the approaches
No randomized, comparative study has been pub-
lished. Zenke et al. (2011) compared the results of
the conventional approach to a MIPO approach. They
found no significant difference between the patients
with the two approaches in terms of pain, range of
wrist motion, grip strength, DASH scores and radio-
logic characteristics. They consider the MIPO tech-
nique as technically more demanding, but did not
evaluate the satisfaction of their patients for the cos-
metic result.
Among the 477 published cases, 42 (8.8%)
complications are reported (online supplementary
Table SI), including skin opening, nerve or vascular
compression and severe displacement. This incidence
of complications is equivalent to the incidence pub-
lished for using the conventional approach. No com-
plication is specific of the MIPO technique. Pain is the
most frequent complication with 14 cases of type I
complex regional pain syndromes and 2 unexplained
painful syndromes of the ulnar aspect of the wrist.
There were nine cases with flexor tendon tenosynovitis
and two cases of FPL ruptures. Cosmetically the
healed incisions are pleasant (Figure 8). Some authors
insist on the importance of ensuring intra-operatively
that the flexor tendons are not trapped under the plate
Figure 8. The appearance of a healed incision.
(Zenke et al., 2011; Zemirline et al., 2014b). Flexor ten-
dons should be checked for signs of entrapment at the
beginning and at the end of the procedure and be
marked with vessel loops if necessary. Chiu et al.
(2013) reported a case of a FPL tendon trapped under
the plate.
Osteo-articular complications are reported:
three cases of intra-articular screws, two cases of
joint stiffness, one displacement of distal screw and
six secondary displacements. Two cutaneous compli-
cations of delayed healing are reported in the flexion
crease of the wrist probably due to maceration (Wei
et al., 2016). Wei et al. (2014) reported a case of
numbness of the thenar eminence, probably caused
by injury of the cutaneous branch of the median
nerve, which can be avoided by placing the incision
lateral to the FCR tendon.
We have operated more than 2000 cases so far
since 2012. In our published series of 144 distal
radius fractures (Lebailly et al., 2014), the outcomes
were comparable with those of the literature report-
ing this minimally invasive approach. The mean age
of our patients was 63 years (range 16–103). The
dominant side was affected in 50% of cases.
According to the arbeitsgemeinschaft für osteo-
synthesefragen (AO) classification, there were 83
type A fractures, two type B and 59 type C.
Associated lesions included six scapholunate liga-
ment ruptures, four of which were recent, one trian-
gular fibro cartilage complex (TFCC) tear (Palmer
type 1B), one scaphoid fracture, four ulnar neck frac-
tures, two median and one ulnar nerve contusion.
Average tourniquet time was 48 min (17–136). Mean
operative dosimetry was 2.6 mG (0.6–8.6). The mean
tourniquet time was 43 min for type A fractures, 55
for type C fractures and 105 min when an associated
procedure was performed (five arthroscopies and
one scaphoid screw).
Plate removal was performed in 10 of our patients
through an incision of about 13 mm. Mean pain score
was 2 (0 to 6). The Quick DASH score was average 25
(0 to 82). Average range of motion in flexion was 86%,
extension 86%, pronation 96% and supination 91%.
Global grip strength of the hand was 67% (0 to 167)
of the contralateral side. On X-rays, the mean radial
slope was 22 (7 to 45), the radial tilt was 8 (–7 to 20).
There was no infection, but complications included
nine cases (6%) of complex regional pain syndrome
(CRPS) type I, which all resolved. Other specific com-
plications included two secondary displacements, of
which one was re-operated with a good final outcome.
There were nine patients with tenosynovitis of the FPL
or extensor tendons. All resolved after plate removal.
No tendon rupture was noted. Two intra-articular
screws had to be removed at 3 months. One
Liverneaux
epiphyseal screw required removal 1 month after sur-
gery due to loosening.
Future perspectives
Minimally invasive techniques are in full development
currently, as well as computer-assisted or robotic
procedures with which they may eventually be asso-
ciated. The minimally invasive approach for distal
radius fractures and malunions that we developed
is only one among other steps towards a generaliza-
tion of minimally invasive techniques in wrist
surgery.
Acknowledgements Juan José Hidalgo Diaz drew the
figures. Paul Vernet translated the manuscript. Ismaël
Naroura collected data.
Declaration of conflicting interests The author(s)
declared the following potential conflicts of interest with
respect to the research, authorship, and/or publication of
this article: Philippe Liverneaux has conflicts of interest
with Newclip Technics, Biomodex, Argomédical, Zimmer
Biomet
Funding The authors received no financial support for the
research, authorship, and/or publication of this article.
Supplementary material Supplementary material is
available at journals.sagepub.com/doi/suppl/10.1177/
1753193417745259.
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