• Figure 1A shows an AP radiograph of a displaced distal radius fracture. An associated styloid fracture may or may not convey instability. An intraoperative stress test of the distal ulna may indicate if fixation of the styloid area is needed. Although this AP image is consistent with a typical extra-articular fracture known as Colles’ fracture, the lateral view shows comminution of the dorsal cortex extending to the joint line (see Fig. 1B). This is a bad prognostic sign for redisplacement if not treated with stable fixation.

• In the lateral view (see Fig. 1B), dorsal tilt (and shortening) is obvious. Carpal instability pattern (CIA) is secondary to the distal radius angulation. Dorsal comminution is obvious. This amount of dorsal tilt and comminution denotes an unstable pattern, leading to a high rate of redisplacement with cast treatment alone.

• The flexor pollicis longus (FPL) tendon lies just beneath the FCR sheath. Retraction of the FPL tendon ulnarly will reveal the deep layer of the palmar approach and hence the pronator quadratus (PQ) (Fig. 2A).

• The PQ is released sharply from the radius, leaving a small cuff of tissue radially. It is reflected back as an ulnar-based flap. Care must be taken not to detach the palmar extrinsic radiocarpal ligaments (Fig. 2B).

• The use of the FCR for the palmar approach keeps the radial artery safely out of the surgical plane just radial to the dissection (see Fig. 2).

• The palmar cutaneous branch of the median nerve is only at risk if the dissection strays to the ulnar side of the FCR (see Fig. 2).

• Occasionally, particularly for fractures, treated in delayed fashion, dissection can be carried out radial to or below the radial artery, and a brachioradialis tenotomy can then be performed. The brachioradialis tenotomy will release one of the main deforming vectors on the fracture. Care must be taken to avoid injury to the first dorsal compartment during this radial dissection (Fig. 3).

• The third extensor compartment and its content, the extensor pollicis longus (EPL), are identified beneath the extensor retinaculum just ulnar to Lister’s tubercle. Sharp dissection is used to release the EPL tendon in its entirety from the third compartment. Blunt dissection beneath the subcutaneous tissue of the radial-sided flap will avoid inadvertent injury to the dorsal branches of the superficial radial nerve (Fig. 4).

• A transverse arthrotomy can be performed just distal to the dorsal rim of the radius to allow for accurate intra-articular reduction under direct visualization (Fig. 5).