Volar locking plating is the standard operation for displaced distal radius fractures in most adults. The approach is safe, the plate sits on the flat volar surface of the radius, and the fixed-angle construct holds the reduction while the patient moves the wrist early. The results still depend on technique: an inadequate reduction, a plate sitting past the watershed line, or a screw a few millimeters too long will each find its way into a complication clinic. This guide walks through the procedure as it is performed in practice — the FCR approach, the reduction sequence, plate position and screw placement — using the volar plating systems we supply at BoneCraft as the hardware reference. The operating surgeon makes the final call on every step.
Preoperative assessment
PA and lateral radiographs define the fracture pattern; a CT scan is added for intra-articular fractures, because the number and position of articular fragments decide the screw layout. The plan answers three questions before the incision: whether the fracture is reducible by closed manipulation under anesthesia, which fragments need individual support — the lunate facet and the radial styloid above all — and whether the pattern suits a standard volar plate or a fragment-specific tactic. Fractures with die-punch fragments, volar marginal shearing fragments or marked dorsal comminution need their own plan and occasionally a combined approach.
The FCR approach
The patient is supine with the arm on a hand table and a tourniquet on the upper arm. The incision runs over the flexor carpi radialis tendon, from the distal wrist crease proximally for six to eight centimeters. The FCR sheath is opened, the tendon is retracted ulnarly — protecting the median nerve behind it — and the floor of the sheath is incised. The flexor pollicis longus is swept ulnarly with the finger, exposing the pronator quadratus over the radius. The pronator is released from its radial attachment with an L-shaped incision, leaving a small cuff for later repair, and lifted subperiosteally to expose the whole volar surface of the distal radius. The brachioradialis tendon can be released from the radial styloid when the deforming force of that muscle blocks reduction.
Reduction sequence
Reduction restores three parameters in order: radial height, volar tilt and articular congruity. Longitudinal traction through finger traps re-establishes length; palmar translation of the hand on the forearm corrects dorsal displacement; and the position is checked under fluoroscopy. Impacted articular fragments are lifted through the fracture line with a small elevator and supported with graft or substitute where a void remains. A temporary K-wire through the radial styloid can hold the provisional reduction while the plate is positioned. The lateral view is decisive: volar tilt must be restored to roughly eleven degrees, and any residual dorsal tilt must be corrected before the plate goes on, because the plate will hold whatever it finds.
Plate selection and position
The plate is chosen by fracture pattern. A standard anatomic volar plate serves most extra-articular and simple articular fractures; plates with extended distal fragment coverage serve multi-fragment articular patterns. Position is judged against the watershed line, the most distal ridge of the volar radius. A plate that projects distal to this line sits proud and rubs the flexor tendons, and the flexor pollicis longus ruptures reported in the literature trace back to this single positioning error. The plate should sit proximal to the watershed line and flush against the bone, confirmed on a true lateral view before any screw is placed.
| Parameter | Target | How it is checked |
|---|---|---|
| Volar tilt | Restored toward 11° | True lateral fluoroscopy |
| Radial height | Restored to match the opposite side | PA fluoroscopy |
| Plate position | Proximal to the watershed line, flush on bone | True lateral, direct vision |
| Distal screw length | Subchondral support without dorsal penetration | Skyline and lateral fluoroscopy |
BoneCraft stocks the volar plating range for this workflow: the anatomic distal radius plate in standard, narrow and wide versions, the DVR anatomic volar locking plate with its crossing screw planes for multi-fragment patterns, and the volar rim plate for very distal fragments. The complete range sits in the wrist and hand collection.
Screw placement
The shaft of the plate is fixed first with a cortical screw in the slotted hole, which allows small adjustments of plate height before the position is locked. Distal locking screws or smooth pegs are then placed through the guide block. Their job is subchondral support: the distal row should sit just below the subchondral bone, rafting the articular surface from beneath. Screw length is measured with the depth gauge and checked on a skyline or dorsal tangential view, because a screw that feels safe on the lateral view can still protrude through the dorsal cortex and saw through the extensor tendons with motion. The lunate facet fragment, which carries the volar ulnar corner of the joint, must be captured by at least one distal screw; losing this fragment lets the carpus subluxate volarly. Proximal shaft screws complete the construct, and the whole fixation is checked under live fluoroscopy through a full arc of wrist motion.
Closure and aftercare
The pronator quadratus is repaired over the plate where its muscle cover remains, adding a layer between the hardware and the flexor tendons. Skin is closed, and the wrist is splinted briefly for comfort. Stable fixed-angle constructs generally tolerate early active motion within the first two weeks; the rehabilitation protocol is set by the operating surgeon according to fracture stability and bone quality.
The complications that technique prevents
Flexor tendon rupture comes from a plate proud of the watershed line. Extensor tendon rupture comes from dorsally protruding screws. Volar subluxation of the carpus comes from an uncaptured lunate facet fragment. Each of these is visible and preventable at the table: plate position on the true lateral, screw length on the skyline view, and fragment capture on a careful review of the final images. Secondary loss of reduction is rare with a properly applied fixed-angle construct, and most reported failures involve one of the three errors above.
Sourcing volar plating systems
BoneCraft is an independent distributor of genuine Zimmer Biomet trauma implants, including the volar distal radius plating families referenced in this guide. Hospitals and distributors who need anatomic plates, DVR plates, rim plates and locking screws from stock can contact our team for availability and lot documentation.
Frequently asked questions
Which approach is used for volar plating of the distal radius?
The FCR approach is the standard. The interval runs through the flexor carpi radialis sheath down to the pronator quadratus, which is lifted to expose the volar surface of the radius. An extended carpal tunnel release can be added through the same incision when median nerve symptoms require it.
What is the watershed line and why does it matter?
The watershed line is the most distal transverse ridge on the volar radius. A plate distal to it projects into the flexor tendon space and can abrade the flexor pollicis longus until it ruptures. Keeping the plate proximal and flush to this line is the single most important positioning rule.
How are the distal screws checked for dorsal penetration?
With skyline or dorsal tangential fluoroscopy views. The standard lateral view can hide a protruding screw behind the Lister tubercle, so the tangential views are the reliable check before closure.
Which fragment must always be captured by the distal screws?
The lunate facet fragment at the volar ulnar corner. If this fragment escapes fixation, the carpus can subluxate volarly with it, which is a recognized mechanism of failure after volar plating.
When can the wrist move after volar locking plating?
Many stable constructs tolerate active motion within the first two weeks. The exact timing is set by the operating surgeon based on fracture pattern, bone quality and the quality of the fixation achieved.
Are smooth pegs or threaded screws better in the distal row?
Both provide subchondral support. Smooth pegs are easier to remove and gentler if joint penetration occurs; threaded screws give stronger fragment purchase. The choice follows the system design and the surgeon's assessment of bone quality.
Does every distal radius fracture need surgery?
No. Stable fractures with acceptable alignment after closed reduction can be managed in a cast. Surgery is indicated for unstable patterns, articular displacement and fractures that lose position — a decision made by the treating surgeon from the images and the patient's functional demands.
Zimmer Biomet, ZPLP and DVR are trademarks of their respective owner. BoneCraft is an independent distributor of genuine Zimmer Biomet products and is not affiliated with, sponsored by, or endorsed by the trademark owner.
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