Volar Locked Plating for Distal Radius Fractures: Should the Pronator Quadratus Be Spared?

Distal radius fractures (DRFs) account for about 17.5% of all adult fractures and represent the most common fracture of the upper extremity. For severely displaced or unstable fractures, open reduction and internal fixation (ORIF) is often indicated. Volar locking plate fixation through the flexor carpi radialis (FCR) approach is widely used and considered a standard technique for distal radius fixation. Classically, the pronator quadratus (PQ) muscle is released from the radial side of the distal radius to expose the fracture and is later repaired after plate fixation. However, this repair is often not feasible or reliable. Some authors have suggested that failure to restore the PQ may leave the plate exposed to the flexor tendons, increasing the risk of tendon irritation or rupture.

To address these concerns, minimally invasive PQ-sparing approaches have been developed. Imatani et al. first described a technique for volar plating without detaching the PQ, and Dos Remedios et al. reported a similar approach. Theoretically, preserving the PQ creates a cushion between the plate and the flexor tendons and maintains the muscle's function. Several studies have reported better early functional outcomes and less pain post-operatively with PQ-sparing than the traditional approach.

In this prospective case series at a Level I trauma center with a dedicated hand surgery service, the PQ-sparing volar plating technique for distal radius fractures is evaluated. The study's main objectives were to determine whether the PQ can be preserved without compromising fracture reduction, to describe how a volar locking plate can be applied without releasing the PQ, to identify potential benefits of PQ preservation, and to assess any drawbacks of this approach.

Inclusion criteria

• isolated closed distal radius fractures

Exclusion criteria

• fractures >3 weeks old,
• age >60 years (reflecting our practice of treating most low-demand elderly patients nonoperatively unless the fracture was highly unstable),
• pathologic fractures (e.g. metastatic lesions).