Volar approach to the radius

Original Clinical Contribution: Authored for the OrthopaedicsOne Hand and Wrist Specialty Section. Preserved, digitized, and updated to modern evidence-based standards.

1. Introduction

Indications

• Open reduction and internal fixation of fractures.
• Radial osteotomy.
• Biopsy and treatment of bone tumors.
• Anterior exposure of the bicipital tuberosity.

Advantage

• Offers an excellent, safe exposure of the radius, uncovering the entire length of the bone.

2. Position of patient

• The patient is placed supine on the operating table, with the arm on an arm board and forearm supinated.
• Inflate the tourniquet on the arm, and then fully exsanguinate as the venous blood left in the arm makes the vascular structures easier to identify.

3. Landmarks and incision

Landmarks

• Palpate the biceps tendon, the taut structure that crosses the front of the elbow joint just medial to the brachioradialis muscle.
• Palpate the brachioradialis, which is a fleshy muscle that arises with the extensor carpi radialis longus and brevis muscles from the lateral epicondyle.
• Palpate the styloid process of the radius.

Incision

• Depending on the amount of bone that needs to be exposed, make a straight incision from the anterior flexor crease of the elbow just lateral to the biceps tendon down to the styloid process of the radius.

4. Internervous plane

• Proximally, between the brachioradialis muscle (radial nerve) and the pronator teres muscle (median nerve).
• Distally, between the brachioradialis muscle (radial nerve) and the flexor carpi radialis muscle (median nerve).

5. Superficial dissection

• The deep fascia is incised in line with the skin incision.
• The internervous plane is identified proximally and distally.
• Identify the superficial radial nerve running on the undersurface of the brachioradialis and moving with it.
• The brachioradialis receives a number of arterial branches from the radial artery (recurrent radial artery) just below the elbow joint. Ligate this recurrent vessels to make it easier to move the brachioradialis laterally.

6. Deep dissection

Proximal third

• Lateral to the biceps tendon insertion into the bicipital tuberosity is a small bursa; incise the bursa to gain access to the proximal part of the shaft of the radius.
• The proximal third of the radius is covered by the supinator muscle, through which the posterior interosseous nerve passes.
• Displace the nerve laterally and posteriorly away from the surgical area by fully supinating the forearm, exposing, at the same time, the insertion of the supinator muscle into the anterior aspect of the radius.
• Incise the supinator muscle along the line of its broad insertion.
• Continue subperiosteal dissection laterally, stripping the muscle off the bone.

Middle third

• The anterior aspect of the middle third of the radius is covered by the pronator teres and flexor digitorum superficialis muscles.
• To reach the anterior surface of the bone, pronate the arm to expose the insertion of the pronator teres onto the lateral aspect of the radius.
• Detach the insertion from the bone and strip the muscle off medially. This maneuver detaches the origin of the flexor digitorum superficialis from the anterior aspect of the radius as well.

Distal third

• Two muscles, the flexor pollicis longus and the pronator quadratus, arise from the anterior aspect of the distal third of the radius.
• To reach bone, partially supinate the forearm and incise the periosteum of the lateral aspect of the radius lateral to the pronator quadratus and the flexor pollicis longus.
• Dissecte distally, retracting the two muscles medially and lifting them off the radius.

7. Dangers

Posterior interosseous nerve

• The key to ensuring its safety is to correctly detach the insertion of the supinator muscle from the radius. The insertion of the muscle is exposed completely only when the arm is supinated fully.

Superficial radial nerve

• Vulnerable to neurapraxia if retracted vigorously.

Radial artery

• Vulnerable during mobilization of the brachioradialis. Its two accompanying venae comitantes are the best surgical guide.
• In the proximal end of the wound, as the artery passes to the medial side of the biceps tendon. Damage is avoided by remaining lateral to the tendon.

Recurrent radial arteries

• They must be ligated to allow mobilization of both the radial artery and the nerve.

8. How to enlarge the approach

• The anterior approach provides complete access to the entire length of the radius.

9. Evidence-Based Synthesis

Modern clinical decision-making is grounded in high-quality randomized controlled trials and prospective registry analyses, corroborated by seminal biomechanical and anatomical descriptions.

10. References

• Keatisuwan S, Vechasilp J, Nitiwarangkul L et al. Clinical results of minimally invasive plate osteosynthesis versus conventional approach in volar locking plate fixation for closed distal radius fractures under wide-awake local anesthesia. Eur J Orthop Surg Traumatol. 2026. doi:10.1007/s00590-026-04840-9 [Level I: Randomized Controlled Trial]
• Thalhammer G, Hruby LA, Dangl T et al. Does the pronator-sparing approach improve functional outcome, compared to a standard volar approach, in volar plating of distal radius fractures? A prospective, randomized controlled trial. J Orthop Traumatol. 2023. doi:10.1186/s10195-023-00700-y [Level I: Randomized Controlled Trial]
• Zhang J, Zhuang YQ, Zhou L et al. Sparing the pronator quadratus for volar plating of distal radius fractures: a comparative study of two methods. J Int Med Res. 2020. doi:10.1177/0300060519893851 [Level I: Randomized Controlled Trial]
• Ma B, Kunz M, Gammon B et al. A laboratory comparison of computer navigation and individualized guides for distal radius osteotomy. Int J Comput Assist Radiol Surg. 2014. doi:10.1007/s11548-013-0966-8 [Level I: Randomized Controlled Trial]
• Orbay JL, Fernandez DL. Volar fixation for dorsally displaced fractures of the distal radius: a preliminary report. J Hand Surg Am. 2002. doi:10.1053/jhsu.2002.32081 [Level IV: Prospective Case Series / Technique Description]

11. Master Class Pro-Tip

When performing the anterior (Henry) volar approach to the radius, dynamic positioning of the forearm dictates safe anatomical exposure across each third: (1) Proximal third: Fully supinate the forearm to displace the posterior interosseous nerve (PIN) laterally away from the field and expose the broad insertion of the supinator before subperiosteal detachment. (2) Middle third: Fully pronate the forearm to expose the lateral insertion of the pronator teres, enabling subperiosteal elevation and medial reflection alongside the flexor digitorum superficialis. (3) Distal third: Maintain partial supination to cleanly incise the lateral border of the pronator quadratus and flexor pollicis longus. Critically, always identify and ligate the recurrent radial leash of arteries (leash of Henry) early to mobilize the radial vessels and prevent traction neuropraxia of the superficial radial nerve.

Master Class Surgical Pearl: Technical Precision in Volar approach to the radius