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The Extended Flexor Carpi Radialis Approach: A New Perspective for the Distal
Radius Fracture
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T E C H N I Q U E
䡲 HISTORICAL PERSPECTIVE the distal part of the Henry approach. The traditional
FCR approach provides access to the volar aspect of the
Volar fixation of dorsally unstable distal radius fractures distal radius, the volar wrist capsule, and the scaphoid. In
is a new method of treatment that provides the benefits of comparison with dorsal approaches, which present a high
stable internal fixation without the complications of the incidence of extensor tendon problems,2–6 the FCR ap-
dorsal approach. A new, fixed-angle fixation device, the proach is relatively free of complications.
distal volar radius (DVR) plate, (Fig. 1) has been intro- We extend the FCR approach by releasing the radial
duced for this purpose. Experience gained by applying septum, by mobilizing the proximal radial fragment, and
this technique to clinically complex cases led us to the by using the fracture plane for exposure or what is known
realization that more exposure, especially in a dorsal di- as intrafocal technique. Therefore, understanding the
rection, was necessary than that provided by the tradi- anatomy of the radial septum is important. On its proxi-
tional volar approaches. The need to reduce fractures mal aspect, it is a simple fascial wall separating the
with significant articular displacement (Fig. 2) and the flexor and extensor compartments of the forearm. At the
need to release dorsal callus in inveterate fractures or level of the radial metaphysis, the radial septum is a
nascent malunions led us to use an extended form of the complex fascial structure that includes the first extensor
flexor carpi radialis (FCR) approach. compartment and the insertion of the brachioradialis.
Volar displaced distal radius fractures are commonly More distally, the radial septum forms the radial inser-
managed with volar buttress plates through the FCR ap- tion of the carpal ligament and ends as the FCR tendon
proach.1 This approach goes deep to the forearm fascia sheath approaches the tuberosity of the scaphoid. The
through the FCR tendon sheath and is continuous with proximal radial fragment has a dependable endosteal
blood supply that permits its subperiosteal release and
subsequent mobilization. Pronating this fragment out of
the way provides wide exposure of the fracture surfaces.
Address correspondence and reprint requests to Dr. Jorge L. Orbay,
Miami Hand Center, 8905 SW 87 Ave., Suite 100, Miami, Florida This allows the volar reduction and fixation of even the
33176; e-mail: MIAHANDS@ix.netcom.com most complex dorsally displaced distal radius fractures.
䡲 TECHNIQUE
The skin incision is made directly over the course of the
FCR tendon and is 8–10 cm long. It should zigzag across
the wrist flexion creases (Fig. 3). The tendon tunnels
along the forearm fascia, dividing it into a superficial
FIG. 1. The distal volar radius (DVR) plate (Hand Inno- deep layer. This forms a strong fascial structure that al-
vations, Miami, FL) is a fixed-angle device designed spe-
lows for safe retraction. The superficial layer of the
cifically for the general volar fixation of distal radius frac-
tures. The purpose of this surgical strategy is to avoid the sheath is incised longitudinally, and the FCR tendon is
tendon complications common with the dorsal approach. retracted medially, protecting the median nerve. The
The extended flexor carpi radialis approach allows the floor of the sheath is then incised to gain deep access
management of the most complex distal radius fractures. (Fig. 4). Proximally, the tendon sheath should be re-
leased generously to facilitate exposure. Distally, both
layers should be divided up to the tuberosity of the
䡲 INDICATIONS/CONTRAINDICATIONS scaphoid. This structure underlies the crossing of the
This technique is indicated for distal radius fractures in superficial radial artery and forms the distal limit of the
which simpler forms of management would produce un- radial septum.
acceptable results. Unstable fractures in young and active The dissection is taken down to the surface of the
patients, which need optimal restoration of the bony distal radius by developing the space between the flexor
anatomy; in polytraumatized patients with complex re- pollicis longus and the radial septum. Numerous muscu-
habilitation issues, which might include lower-extremity lar perforators are found here and need to be cauterized.
injuries; or in elderly patients who need a quick return to The radial origins of the most distal fibers of the flexor
functional independence are all good indications for this pollicis longus muscle are released for greater exposure.
technique. We define fractures as unstable if, after an The space of Parona, the virtual space between the flexor
attempt at close reduction, they persist with radiographic tendons and the volar surface of the pronator quadratus,
evidence of more than 15 degrees of angulation in any is now developed. This is accomplished by blunt digital
FIG. 3. The skin incision is made directly over the course FIG. 5. The space of Parona is developed by exposing
of the flexor carpi radialis tendon, zigzags across the flex- the distal radius, (1) the pronator quadratus muscle, (2)
ion creases, and is 8–10 cm long. and the anterior wrist capsule (3). The distal and lateral
borders of the pronator quadratus muscle are marked for
release.
dissection and by sharp division of the proximal reflex-
ion of the carpal bursa. This exposes the distal radius, the sal soft tissues will produce an adequate reduction. This
pronator quadratus muscle, and the anterior wrist capsule is the well-known phenomenon of ligamentotaxis. On the
(Fig. 5). The pronator quadratus is mobilized by releas- other hand, fractures that present severe intraarticular
ing its distal and lateral borders with an L-shaped inci- displacement or organizing fracture hematomas will not
sion. It is then lifted from its bed by subperiosteal dis- reduce adequately with this simple technique.
section, exposing the fracture site. The distal border of The need for the extended FCR approach arises in
the pronator quadratus forms a transverse line on the cases. The fracture plane is used for exposure; this is also
surface of the radius. This line marks the proximal re- known as “intrafocal technique.” This is analogous to the
flection of the carpal bursa and signals the distal limit for approach for a tibial plateau fracture. Here the metaph-
safe hardware placement (Fig. 6). With dorsally dis- yseal fragment is “opened like a book,” allowing the
placed injuries, the pronator quadratus muscle fibers are joint surface to be viewed from within the fracture. The
frequently found torn and interposed in the fracture site.7 FCR approach is extended in three steps: the release of
So far in this report we have described the classic the radial septum, the subperiosteal release of the proxi-
FCR approach. Many fresh fractures (less than 10 days mal radial fragment, and its mobilization into pronation.
old) can be managed easily with only this exposure, be- This last maneuver provides direct access to the fracture
cause longitudinal traction in the presence of intact dor-
FIG. 7. Extension of the flexor carpi radialis approach FIG. 9. Pronating the proximal fragment out of the way
requires the release of the radial septum. Proximally, this with the help of a bone clamp provides comfortable ac-
structure is a simple fascial wall, separating the flexor and cess to the fracture surfaces.
extensor compartments (1) More distally, it becomes a
complex fascial structure that includes the insertion of the
brachioradialis (2) and the first extensor compartment (3). reduction of the fracture. Distal to the styloid process, the
Finally, it becomes the radial insertion of the carpal liga- radial septum becomes less distinct and also serves as the
ment (4).
insertion 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-
surfaces, permitting reduction of articular displacement, dial fragment to permit its mobilization. This is done
bone grafting, and the removal of fracture callus. safely, as this fragment is provided with a dependable
Proximally, the radial septum is a simple fascial wall endosteal blood supply. The surgeon should preserve the
separating the flexor from the extensor compartments soft tissue attachments to the dorsal aspect of the distal
and is released easily from its radial insertion. Just proxi- fragment and to comminuted dorsal fragments (Fig. 8).
mal to the styloid process, the septum becomes a com- The proximal radial fragment is mobilized into pro-
plex fascial structure formed in part by the first extensor nation to complete the exposure. The use of a bone clamp
compartment and by the insertion of the brachioradialis. as a handle facilitates this action, and the fracture can be
The radial artery is vulnerable in this area. To release the disimpacted if necessary (Fig. 9). Once the proximal ra-
radial septum here, the first extensor compartment is dial fragment is out of the way, the surgeon has direct
opened and its tendons retracted. The insertion of the access to the fracture surfaces. It is possible to manipu-
brachioradialis is found on the floor of this compartment. late articular fragments directly. These can be molded
It limits dorsal exposure and produces a deforming force. against the carpus, which serves as a template, to obtain
Therefore its release greatly facilitates the exposure and reduction (Fig. 10). Access to the dorsal aspect of the
fracture site is also obtained. This allows the debride-
FIG. 11. The approach allows access to the dorsal aspect FIG. 13. The distal volar radius (DVR) plate is applied
of the fracture, the debridement of organized hematoma proximal to the transverse line formed by the distal border
or fracture callus, and the application of bone graft. of the pronator quadratus.
living is encouraged at the first postoperative visit, and fractures from the dorsal side originates from the need to
patients are then given reasonable weight-lifting restric- apply the buttress plates on the unstable surface.
tions. The weight limit is increased progressively, and no Stable internal fixation traditionally has been re-
restrictions are applied after radiographic union is served for the volarly displaced fractures. Most surgeons
achieved. This usually occurs between the fourth and have avoided the use of dorsal plates as they have been
tenth weeks. Most patients are able to touch their palms frequently associated with extensor tendon complica-
with their fingertips at the first postoperative visit. Fail- tions.8 Despite different designs of dorsal implants, their
ure to do so results in a referral to formal physiotherapy. use commonly requires reoperation for removal. Tendon
problems seem more inherent to the dorsal approach
rather than to the specific implant characteristics. Attri-
䡲 DISCUSSION tional tendonitis occurs on the dorsal aspect of the distal
Until recently, buttress plates were the only form of radius, because there is little space available for the ap-
stable internal fixation available for distal radius frac- plication of implants. There is more space on the volar
tures. The principle that volarly displaced fractures are aspect. Here the flexor tendons are well separated from
approached from the volar side and dorsally displaced the bone surface by the pronator quadratus muscle and
protected by the concave shape of the distal radius. These for high-energy injuries, and expedite a return to inde-
anatomic characteristics allow the safe application of vo- pendent function for the elderly patient.
lar plates. Volar fixation of these injuries also has other
advantages. The volar approach preserves the dorsal soft
tissues, allowing for ligamentotaxis and the maintenance 䡲 REFERENCES
of fragment vascularity. Rehabilitation seems to be has- 1. Jupiter JB, Fernandez DL, Toh CL, et al. Operative treat-
tened by the volar approach, and the volar scar is better ment of volar intra-articular fractures of the distal end of
accepted than the dorsal. the radius. J Bone Joint Surg [Am] 1996;78:1817–28.
The DVR plate offers stable internal fixation to dor- 2. Ring D, Jupiter JB, Brennwald J, et al. Prospective multi-
sally displaced distal radius fractures through a volar center trial of a plate for dorsal fixation of distal radius
approach. It accomplishes this by using the fixed-angle fractures. J Hand Surg [Am] 1997;22:777–84.
principle9 to prevent toggling of the distal fragment 3. Carter PR, Frederick HA, Laseter GF. Open reduction and
and by a robust design that enables it to carry the high internal fixation of unstable distal radius fractures with a
loads generated by this loading configuration. Expanding low-profile plate: A multicenter study of 73 fractures. J
the indications for volar plate fixation to dorsal fractures Hand Surg[Am] 1998;23:300–7.
reveals that the standard volar approaches do not always 4. Kambouroglou GK, Axelrod TS. Complications of the
offer sufficient exposure. This is particularly true in AO/ASIF titanium distal radius plate system (II plate) in
the management of fractures with severe articular dis- internal fixation of the distal radius: A brief report. J Hand
placement and those with advanced callus formation. Surg [Am] 1998;23:737–41.
We have used an extended form of the FCR approach 5. Hove LM, Nilsen PT, Furnes O, et al. Open reduction and
for the management of these fractures. Releasing the ra- internal fixation of displaced intraarticular fractures of the
dial septum and mobilizing the proximal radial fragment distal radius. Acta Orthop Scand 1997;68:59–63.
to provide intrafocal exposure extends this approach. 6. Axelrod TS, McMurtry RY. Open reduction and internal
This maneuver provides the exposure necessary for the fixation of comminuted, intraarticular fractures of the dis-
surgical management of complex clinical situations. The tal radius. J Hand Surg [Am] 1990;15:1–10.
standard FCR approach is well known in the surgical 7. Fernandez DL. Should anatomic reduction be pursued in
community, and the extended form is easily mastered. distal radial fractures? J Hand Surg [Br] 2000;25:1–6.
The inclusion of the extended FCR approach in the 8. Fernandez DL, Jupiter JB. Compression fractures of the
surgeon’s armamentarium provides him with the ability articular surface. In: Fractures of the Distal Radius. New
to safely manage distal radius fractures with stable in- York; Springer 1996;189–220.
ternal fixation, regardless of their direction of instability. 9. Gesenway D, Putnam MD, Mente PL, et al. Design and
This enables him to simplify the treatment of the biomechanics of a plate for the distal radius. J Hand Surg
polytraumatized patient, obtain better anatomic results [Am] 1995;20:1021–27.