PROCEDURE REFERENCE
Distal Radius Volar Plate Fixation
This page lists the exact terms the evaluator accepts for each step. Use it to study before you rehearse — then test yourself in the app.
ACTION
What the surgeon does at this step
INSTRUMENT
Which tool is used
TARGET
Where on the anatomy the action is directed
SAFETY
The safety check or structure to protect
Step 01 of 12
Volar Approach / Incision
You are beginning the volar approach. What incision do you make, and what critical structure must you identify and protect?
CLINICAL NOTE
The palmar cutaneous branch of the median nerve runs between the FCR and palmaris longus tendons, within a few millimetres of where you are cutting. Injury causes a patch of palmar numbness that is difficult to explain away.
SAMPLE ANSWER (100 PTS)
I make a longitudinal volar incision over the FCR tendon on the palmar aspect of the wrist, using a scalpel. As I incise through the skin I must identify and protect the palmar cutaneous branch of the median nerve, which crosses this field just ulnar to the FCR.
Step 02 of 12
FCR Sheath and Interval Development
The skin incision is made. Now describe the next dissection step — what structure do you open, what interval do you develop, and what vascular structure must you protect?
CLINICAL NOTE
The radial artery sits just radial to the FCR. Name it by name when you describe protecting it — a pronoun is not enough for the evaluator to credit the safety bucket.
⚠ WATCH OUT
Do not describe the interval as 'ulnar to the FCR.' The interval is between the FCR and the radial artery. Describing it as ulnar to the FCR is flagged as an unsafe answer and zeros the attempt.
SAMPLE ANSWER (100 PTS)
I open the FCR tendon sheath and develop the interval between the FCR tendon and the radial artery using tenotomy scissors. I identify and protect the radial artery, retracting the radial artery laterally throughout the dissection.
Step 03 of 12
Pronator Quadratus Elevation
You have developed the FCR interval. What muscle must you now incise and elevate, along which border, and what must you confirm about the surgical plane?
CLINICAL NOTE
Staying in the subperiosteal plane keeps you on bone and away from the wrist joint. If you enter the joint at this stage you have gone too far distally.
Step 04 of 12
Fracture Reduction
The distal radius fracture is now exposed. Describe how you reduce the fracture, what three parameters of alignment you restore, and how you confirm adequate reduction.
CLINICAL NOTE
The three parameters — radial length, volar tilt, and radial inclination — are the same ones used to grade reduction on post-operative X-ray. Know all three by name.
Step 05 of 12
Provisional Fixation
Reduction is achieved. How do you provisionally hold the fracture, and what landmark must you respect regarding plate positioning?
CLINICAL NOTE
The watershed line is the ridge on the volar surface of the distal radius where the flexor tendons are in closest contact with the bone. Plate placement distal to it puts the flexor tendons under direct mechanical wear.
Step 06 of 12
Volar Plate Application
K-wires are holding the reduction. Now describe how you apply the volar locking plate, where it must be positioned, and the key positioning rule you must verify.
CLINICAL NOTE
Flexor pollicis longus tendon rupture is the most documented late complication of this procedure. The mechanism is direct plate impingement when the plate sits distal to the watershed line. Name the consequence explicitly.
Step 07 of 12
Proximal Plate Fixation — Cortical Screws
The plate is positioned. Describe how you first secure the plate proximally, where the screws go, and how you verify screw length is correct.
CLINICAL NOTE
Bicortical purchase in the shaft gives solid proximal fixation. The depth gauge confirms you have purchase in both cortices without breaching the far cortex.
Step 08 of 12
Distal Locking Screw Placement
The plate is proximally secured. Now describe how you insert the distal locking screws, where they must be placed, and how you confirm they have not entered the joint.
CLINICAL NOTE
The screws need to be subchondral — close enough to support the articular surface, but not through it. Both PA and lateral views are needed because neither alone is sufficient to rule out joint penetration.
⚠ WATCH OUT
State the safety check positively: 'confirm no joint penetration on PA and lateral views.' Do not say 'rule out intra-articular screw placement' — the evaluator reads 'intra-articular screw placement' as the unsafe answer and will zero the step.
Step 09 of 12
Fluoroscopic Verification of Screw Lengths
Distal screws are placed. Describe how you verify all screw lengths are correct, what specific views you use, and what you are looking for on each view.
CLINICAL NOTE
The lateral view alone misses dorsal screw protrusion in a meaningful number of cases. The skyline view is taken with the wrist flexed and the beam directed down the dorsal surface of the radius — it gives a direct view of the screw tips against the dorsal cortex. A protruding screw tip here is a risk factor for EPL tendon rupture.
Step 10 of 12
Pronator Quadratus Repair
Fluoroscopic verification is complete and all screws are confirmed safe. Describe how you repair the pronator quadratus, what you are covering, and what you must confirm about the closure.
CLINICAL NOTE
The pronator quadratus acts as a soft tissue buffer between the plate and the overlying flexor tendons. A solid repair here is protective — a watertight closure with no hardware visible or palpable through the repair is the standard.
Step 11 of 12
Wound Closure
The pronator quadratus is repaired. Describe how you close the wound, what layers you close, and what you must confirm before closing.
CLINICAL NOTE
Layered closure reduces dead space and skin tension. Confirming hemostasis before skin closure is a non-negotiable final check — name it explicitly, do not assume it is implied by 'closing the wound.'
Step 12 of 12
Dressing and Splinting
The wound is closed. Describe how you dress the wound, what type of splint you apply, the wrist position, and what post-operative neurovascular check you perform.
CLINICAL NOTE
The neurovascular check after splinting is a clinical hand-off step — you are confirming that the splint itself has not compromised perfusion or nerve function. Name all three: capillary refill, sensation, and motor function.