Role of Pronator Quadratus Repair in Volar Locking Plate Treatment of Distal Radius Fractures

Abstract

Distal radius fractures are the most common type of upper extremity fractures, and their incidence is increasing. There has been a rise in the surgical treatment of distal radius fractures, primarily with volar locking plate fixation. Although this procedure is commonly done among orthopaedic surgeons, the role of pronator quadratus repair after fixation remains controversial. The pronator quadratus serves as a secondary forearm pronator and a dynamic stabilizer of the distal radioulnar joint. Aside from a functional role, repair of the pronator quadratus has been proposed to serve as a biologic barrier between the volar locking plate and the flexor tendons to minimize tendon irritation. In this narrative review, we discuss the current treatment trends, the surgical approach for volar locking plate treatment of distal radius fractures, and the anatomy and function of the pronator quadratus. We discuss the case for and against the repair of the pronator quadratus, both for function and prevention of flexor tendon irritation and rupture. The preponderance of high-level evidence demonstrates no benefit to pronator quadratus repair for pain relief or function. The current evidence does not conclusively support or refute pronator quadratus repair as a biologic barrier from the flexor tendons. Distal radius fractures are the most common fractures of the upper extremity, with an incidence of 16.2 per 10,000 people. These fractures are bimodally distributed across age groups and account for approximately 25% of fractures in pediatric patients and 18% of fractures in geriatric patients. 1 A recent literature synthesis of the epidemiology of distal radius fractures suggests that the incidence of these fractures is increasing worldwide. 2 These injuries are associated with notable morbidity to the patient and economic burden to the healthcare system. [3][4][5] Although most distal radius fractures may be treated nonoperatively, there are a number of surgical indications. These include open fractures, partial articular shear fractures and fracture-dislocations, die-punch fractures, concomitant fractures, unacceptable fracture parameters in a young or active elderly patient, subsequent loss of reduction after initial closed reduction, or anticipated loss of reduction based on fracture characteristics. 6 Surgical

The Outcome of under 10 mm Single-Incision Surgery Using a Non-Specialized Volar Plate in Distal Radius Fractures: A Retrospective Comparative Study

“…Given that the pronator quadratus functions as a secondary forearm pronator and dynamically stabilizes the distal radioulnar joint, and an intact pronator quadratus can serve as a biological barrier for the flexor tendons, the question of whether the integrity or repair of the pronator quadratus contributes to clinical outcomes is a frequently debated topic [22][23][24]. Despite diverse perspectives in the literature [25][26][27][28], current high-level evidence suggests that the integrity or repair of the pronator quadratus does not definitively impact clinical results [22][23][24]29]. In our clinical practice, displaced fractures of the distal radius often coincide with a partial tear of the pronator quadratus.…”

Treatment of distal radius fractures with steel plate fixation through the bone channel of the inferior pronator quadratus

“…At present, for patients with distal radius fracture, the palmar modi ed Henry approach is used to place steel plate xation (10,11). However, there has always been a debate on whether to retain the pronator quadratus (12,13). Despite no consensus in retaining the pronator quadratus, 83% of the American hand surgeons repair the pronator quadratus following volar plate xation (14,15).…”

Does pronator quadratus repair affect functional outcome following volar plate fixation of distal radius fractures? A systematic review and meta-analysis

“…Volar locking plate internal fixation has become the primary surgical method for the action of distal radius fractures for its better rehabilitation effect, firmer fixation, and fewer complications (3). However, during the surgery, it is often necessary to cut the pronator quadratus (PQ) muscle near its radial attachment and ulnar retraction to expose the fracture site for better reduction and fixation (4). Due to the poor tissue condition of the PQ muscle and the difficulty of suturing, some clinicians choose not to suture the PQ after fixation of the distal radius fracture (5).…”