Distal Radius Fracture Fixation: Approach Selection and Technical Pearls

Distal radius fractures are among the most common fractures treated operatively in upper-extremity practice, and the volar locking plate has become the default construct for the majority of unstable patterns — but "default" doesn't mean the technical decisions are trivial.

Approach selection

The flexor carpi radialis (FCR) approach remains the workhorse for volar plating, offering reliable access to the distal fragment with acceptable protection of the median nerve when dissection stays radial to the FCR tendon sheath. For fracture patterns with significant dorsal comminution or a displaced dorsal ulnar fragment not adequately controlled from volar, a combined or dorsal approach is worth considering rather than forcing a volar-only solution.

Reduction before fixation

Ligamentotaxis via traction, combined with direct manipulation of the distal fragment, generally restores acceptable alignment for most fracture patterns. Watch for the volar ulnar corner fragment specifically — it's the fragment most commonly under-reduced with a standard volar plate, and the one most associated with loss of reduction if inadequately captured.

Plate positioning

Plate position relative to the "watershed line" matters more for long-term flexor tendon irritation than most other technical variables in this procedure. Proximal plate placement, adequate screw-length checking on multiple imaging views (not just standard AP/lateral — a tangential or skyline view catches dorsal screw prominence that standard views can miss), and avoiding rushing past this check are disproportionately responsible for avoidable reoperations.

When locking fixation isn't the right answer

Not every distal radius fracture needs a locking plate. Stable, minimally displaced patterns — particularly in lower-demand or elderly patients — may do well with closed reduction and casting, or with simpler fixation. Over-instrumentation of straightforward patterns adds cost and hardware-related complication risk without a clear functional benefit in that subgroup.

Where planning technology adds value here

For malunited or highly comminuted patterns, pre-operative 3D planning and patient-specific guides (discussed in our earlier piece on 3D-printed guides for complex fractures) are increasingly useful for corrective osteotomy planning — less so for routine acute fixation, where freehand technique with the principles above remains entirely appropriate.