Unstable displaced extra-articular fractures

Displaced intra-articular fractures

Volar shearing fractures

Drawing of volar anatomy of forearm and wrist. The surgical interval is between the flexor carpi radialis (FCR) tendon and radial artery and brachioradialis (BR) insertion (Fig. 77-2).

The palmar cutaneous branch of the median nerve arises 5 cm proximal to the radial styloid between the palmaris longus and the FCR.

The flexor pollicis longus (FPL) muscle belly covers the pronator quadratus (PQ) and must be reflected from radial to ulnar.

The PQ muscle is sharply divided radially and is elevated from the distal radius to expose the fracture.

The BR inserts into the distal radius and may be detached to decrease the deforming forces on the distal fragment.

The operation is performed with the arm supinated on a hand table under tourniquet control.

An incision about 7 cm in length is made over the forearm between the radial artery and the FCR. The distal aspect of the incision stops at the volar wrist crease (Fig. 77-3). If the incision needs to be extended more distally, a V-shaped zigzag extension should be made.

The FCR tendon is exposed and released from its sheath. The dissection should remain on the radial aspect of the FCR (Fig. 77-4).

The radial artery and its accompanying venae comitantes are exposed and retracted radially. All ulnar crossing vessels are coagulated (Fig. 77-5).

The PQ is elevated from the distal radius by making an L-shaped incision and releasing it radially and distally (Fig. 77-6). The PQ is sharply released from the radius to expose the fracture (Fig. 77-7).