Comparison of Dorsal and Volar Approaches to the Proximal Radius

Exposure of the proximal radius may be accomplished by either the volar or dorsal approach. Approaches to the proximal radius are necessary for a variety of reasons, including fracture fixation, treatment of nonunion or delayed union, tumor biopsy and treatment, osteomyelitis treatment, repair of bicipital tuberosity, nerve exploration, and radial osteotomy.¹ Proximal forearm fractures represent 5% of fractures yearly.² Diaphyseal fractures of the radius occur in 50% of proximal forearm fractures or 2.5% of all fractures yearly.²

The posterior or dorsal approach to the proximal radius was first described by Thompson³ in 1918. This approach is traditionally recommended for fracture fixation of the proximal radius because of theoretically improved exposure and because the dorsal aspect of the bone is the tensile surface.¹ The posterior interosseous nerve can be visualized and protected using this approach; however, it is at risk, as proximal posterior plate placement may be irritating to the nerve. In the event that plate removal becomes necessary, it may be difficult to sufficiently isolate and protect the posterior interosseous nerve through scar.⁴ Furthermore, Spinner⁵ reported that the posterior interosseous nerve is located directly adjacent to the radial neck in 25% of patients, putting the nerve at risk of entrapment under a plate if fracture fixation requires proximal plate positioning. The interval between the extensor carpi radialus brevis and the extensor digitorum communis may also be technically difficult to develop proximally.⁴

The anterior or volar approach to the proximal radius was first described by Henry⁶ in 1927. It is preferred for biceps repair and boasts a distal extensile approach with adequate soft tissue coverage. Impingement on the bicipital tuberosity and biceps tendon, in addition to positioning on the compression side of the bone, makes the anterior or anterolateral position for plate placement less desirable.⁶ The posterior interosseous nerve may be at risk during this approach, and tension on the nerve during retraction of the supinator may cause a neuropraxia. In the quarter of the population where the nerve lies posteriorly juxtaposed to the radial neck, retractor placement during the anterior approach can compress the nerve against the bone.¹

The surgeon must understand the advantages and disadvantages of each approach to ensure proper exposure (Table...