CLINICAL RESEARCH
Ultrasound Assessment and Clinical
Correlation of the Pronator Quadratus Muscle After Its Repair in the Treatment
of Distal Radius Fractures
Gustavo J. Teruya,
Santiago Ávila Posada, Christopher Bermeo, Gonzalo M. Viollaz, Diego J. Gómez,
Álvaro J. Muratore
Upper
Limb Team, Hospital Británico de Buenos Aires, Autonomous City of Buenos Aires,
Argentina
ABSTRACT
Introduction: Repair
of the pronator quadratus in distal radius fractures treated with volar plates
is controversial, particularly given its proposed
protective role against implant-related complications.
Objective: To assess, through
ultrasound, the impact of pronator quadratus
reinsertion in patients with distal radius fractures treated with volar plates. Materials and
Methods: Forty-two patients were analyzed: 28 with pronator
quadratus reinsertion (Group I) and 14 without reinsertion (Group II). Evaluations
included friction between the flexor tendons and the plate, quality of the
interposing tissue, changes in the flexor tendons, and clinical signs of
friction. Results:
The distance between the plate and the tendons was <2 mm in 42.9% of cases.
In Group I, 45% exhibited tendon friction, 10% had fibrosis of the separating
tissue, 80% had mild tendon attrition, and 20% severe attrition. In Group II,
71% exhibited friction, 36.4% had tissue fibrosis, 45.5% had mild attrition,
and 54.5% severe attrition. The quality of the separating tissue was superior
in Group I, with better preservation of contractile muscle and less fibrosis,
findings associated with lower functional impairment and reduced tendon
friction. Ultrasound abnormalities did not always correlate with clinical
symptoms. Conclusions: Repair of the pronator quadratus improves the quality of
the separating tissue between the flexor tendons and the volar plate, favoring preservation of contractile muscle.
Although no differences were observed in tendon friction or rupture rates, the
findings suggest a protective effect.
Keywords: Distal
radius fracture; pronator quadratus repair; volar plate; open reduction and
internal fixation; tendon friction; tendon rupture.
Level of Evidence: III
Evaluación ecográfica y correlación clínica del músculo
pronador cuadrado luego de su reparación en el tratamiento de fracturas de
radio distal
RESUMEN
Introducción: La
reparación del pronador cuadrado en fracturas de radio distal tratadas con
placas volares es controvertida por su supuesto efecto
protector frente a complicaciones del implante. Objetivo: Evaluar
ecográficamente el impacto de la reinserción del
pronador cuadrado en pacientes con fractura de radio distal tratados con placas
volares. Materiales
y Métodos: Se analizó a 42
pacientes: 28 con reinserción (grupo I) y 14 sin reinserción (grupo II). Se
evaluaron la fricción entre los tendones flexores y la
placa, la calidad del tejido separador, los cambios en los tendones flexores y
los signos clínicos de fricción. Resultados: La distancia entre
la placa y los tendones fue <2 mm en el 42,9%. En el grupo I, el 45% tenía
fricción tendinosa; el 10%, fibrosis del tejido separador; el 80%, atrición
leve de los tendones y el 20%, severa. El 71% del grupo II tenía fricción; el
36,4%, fibrosis del tejido separador; el 45,5%, atrición leve y el 54,5%,
severa. La calidad del tejido separador fue superior en el grupo I, con mejor
preservación del tejido contráctil y menor fibrosis, asociado a menor deterioro
funcional y fricción tendinosa. No siempre se correlacionaron las alteraciones
ecográficas con la fricción clínica. Conclusiones: La reparación del
pronador cuadrado mejora la calidad del tejido separador entre tendones y la
placa, con predominio de músculo contráctil. Aunque no hubo diferencias en la
fricción o rotura tendinosa, los resultados sugieren un efecto protector.
Palabras clave: Fractura
de radio distal; reparación de pronador cuadrado; placa volar; reducción
abierta con fijación interna; fricción tendinosa; rotura tendinosa.
Nivel de Evidencia: III
INTRODUCTION
Distal
radius fractures are the most common fractures of the upper limb and account
for 18% of all fractures in adults older than 65 years.1,2 Open reduction and internal fixation
with a volar locking plate has become the preferred surgical treatment, as it
provides better functional outcomes and lower complication rates compared with
techniques such as external fixation or percutaneous fixation.3,4 However, the traditional surgical
approach requires detaching the pronator quadratus muscle from its radial insertion
to optimize fracture exposure and facilitate plate placement.5,6
Complications
associated with volar plates include neurovascular injury, infection, complex
regional pain syndrome, fracture, and soft-tissue problems such as flexor
tendon irritation or rupture.7,8
Between 0.3% and 5.6% of patients develop tendon rupture, with an incidence of
approximately 1.5% in some studies. The flexor pollicis longus tendon is most
commonly affected, followed by the flexor digitorum profundus. These injuries
are associated with factors such as improper plate positioning, screw prominence,
implant design, and loss of fracture reduction.12
Currently,
there is controversy regarding the relevance of repairing the pronator
quadratus muscle with respect to functional outcomes and complication rates.
Although some authors suggest that pronator quadratus repair provides a
protective layer between the flexor tendons and the plate, no comparative study
to date has demonstrated a reduction in tendon rupture rates after repair.4,13-15 Nevertheless, in a pilot study,
Swigart et al. reported that up to 83% of North American hand surgeons
routinely repair the pronator quadratus.16
Ultrasound
studies have shown greater retraction and reduced length of the pronator
quadratus muscle, along with a shorter distance between the flexor tendons and
the plate, when the muscle is not repaired. These findings may reflect areas of
tendon-implant conflict, supporting the need for further research to assess a
potential protective effect.17,18
We
hypothesized that patients undergoing open reduction and internal fixation with
reinsertion of the pronator quadratus muscle would demonstrate significant
ultrasound differences in flexor tendon quality and in the muscle tissue
superficial to the plate compared with patients in whom the pronator quadratus
was not reinserted.
The aim
of this study was to evaluate ultrasound findings in patients treated at our
center with open reduction and internal fixation for distal radius fractures,
with specific emphasis on closure of the pronator quadratus muscle. A secondary
objective was to compare these findings with those of a control group in which
the pronator quadratus muscle was not repaired.
MATERIALS AND METHODS
This
retrospective study began with a thorough review of the medical records in our
hospital’s database. Forty-two patients with extra-articular distal radius
fractures classified as AO 23-A2 underwent open reduction and internal fixation
using the same type of implant (volar plate) between March 2020 and March 2022.
All
procedures were performed by the same surgical team at our center. Patients
with a history of radiocarpal joint injections, neurological disorders,
previous wrist infections, or <2 years of follow-up were excluded. The study
design included two groups:
Group I:
patients with extra-articular distal radius fractures treated with
osteosynthesis using a volar distal radius plate, with reinsertion of the
pronator quadratus using interrupted Vicryl® 3.0 sutures to ensure complete
coverage of the volar plate.
Group II:
patients with extra-articular distal radius fractures treated with
osteosynthesis using a volar distal radius plate, without reinsertion of the
pronator quadratus.
The
decision to repair the pronator quadratus muscle was made intraoperatively
based on muscle viability, structural integrity, and the feasibility of
achieving a tension-free anatomical repair. If the muscle was torn, had tissue
loss, or showed clear degenerative changes, repair was not performed.
Both
groups followed a strict immobilization protocol with a forearm–palmar plaster
splint for the first 2 weeks. After this period, and provided wound conditions
allowed, sutures were removed. Patients were then protected for an additional 2
weeks using an intermittent rigid wrist immobilizer, which could be removed for
rehabilitation and personal hygiene. During this phase, patients were
encouraged to perform active flexion-extension exercises of the fingers and
metacarpophalangeal joints, as well as pinch-type grasping with all digits.
All
patients completed an 8-week rehabilitation protocol
supervised by upper-limb specialists. This included assisted passive wrist
range of motion exercises during the first week, followed by active range of
motion without resistance or weight bearing. All fractures were treated with
the same implant: an anatomical titanium plate with a fixed-angle locking
system (Pro-Anatomic®, South America Implants S.A., Canning, Buenos Aires,
Argentina). Anatomical reduction was confirmed both in the immediate postoperative
period and during late follow-up.
Analysis of Imaging Studies
Radiological
evaluation included anteroposterior and lateral wrist projections obtained both
in the immediate postoperative period and at 12-month follow-up. In all cases,
acceptable fracture reduction was confirmed, defined as volar tilt 0°–11°,
radial inclination >20°, and ulnar variance between –2 and +2 mm. To assess
volar implant prominence and its potential implications for flexor tendon
friction, Soong’s classification was applied in all postoperative radiographic
assessments.
A Toshiba
Xario 200 ultrasound system (18-MHz linear transducer) was used to evaluate the
interaction between the flexor tendons and the implant. To ensure objectivity,
initial ultrasound assessments were performed on the volar aspect of the wrist
with the hand in anatomical position. Dynamic examinations were then conducted,
asking patients to actively flex and extend their fingers to identify any areas
of tendon conflict. All ultrasound studies were performed by a diagnostic
imaging specialist who was not part of the surgical team and was blinded to
whether pronator quadratus repair had been performed.
A
standardized imaging protocol was applied to all patients, including the following parameters (Table 1):
-
Flexor
friction: Yes / No
-
Quality
of the tissue interposed between the plate and the flexors: contractile muscle
vs. fibrosis
-
Minimum
plate–flexor distance (mm): 0, 0–2, 2–4, or >4
-
Flexor
tendon quality: normal, mild degeneration, or severe degeneration. Mild
degeneration was defined as the presence of atrophic tendon changes, quantified
by measuring tendon thickness at the volar lip of the distal radius. Severe
degeneration was defined as attritional changes associated with tendon
thinning, fibrillation, focal intratendinous alterations, or tendon rupture.23
Ultrasound
evaluation was performed in all patients in both groups, and findings were
subsequently compared. At completion of the rehabilitation protocol, functional
outcomes were assessed using the Disabilities
of the Arm, Shoulder and Hand (DASH) questionnaire. Scores for all patients
were recorded as part of postoperative clinical follow-up.
Statistical Analysis
A
descriptive and comparative study was conducted. The distribution of
quantitative variables was assessed using the Shapiro–Wilk test. When variables
showed normal distribution and homogeneity of variances (evaluated using
Levene’s test), they were expressed as mean ± standard deviation and compared
using Student’s t test for
independent samples. When these assumptions were not met, variables were
expressed as median and interquartile range and compared using the Mann-Whitney
U test. For each variable, the
measurement method used is specified.
Qualitative
variables are expressed as absolute and relative frequencies (%). Given the
small sample size, Fisher’s exact test was used for all between-group
comparisons. A p value <0.05 was
considered statistically significant. Statistical analyses were performed using
IBM SPSS Statistics®, version 26.0.
Surgical Technique
All
patients were operated on at our center by the same surgical team, under
regional anesthesia and in the supine position, with the arm supported on a
radiolucent table to facilitate intraoperative fluoroscopic assistance.
Using the
modified Henry approach, the fracture site was exposed and the pronator
quadratus muscle was carefully elevated in an “L”-shaped fashion.24,25 After identifying the fracture,
reduction was achieved (directly or indirectly) and temporarily stabilized
using Kirschner wires under fluoroscopic control. In all cases, an anatomical
titanium volar plate with a fixed-angle locking system (Pro-Anatomic®)
was used, corresponding to the implant available at our institution during the
study period. Although this type of plate does not allow for screw redirection,
which may influence its placement relative to the watershed line, its design
allowed adequate reduction of the fracture in all cases.
Based on
treatment of the pronator quadratus, patients were divided into two groups:
Group I: repair of the pronator quadratus muscle using interrupted Vicryl®
3-0 sutures, ensuring full coverage of the plate after fracture stabilization.
Group II: no repair of the pronator quadratus muscle.
It is
important to note that in some cases the pronator quadratus exhibited
pre-existing injuries, such as partial tears or discontinuity, likely related
to the initial trauma. Additionally, in older patients, signs of muscular
degeneration with fatty infiltration were observed, which made repair difficult
or unfeasible.
RESULTS
Forty-two
patients were analyzed [mean age, 52.9 years (±19.4)]. Most were women (66.7%),
and involvement was slightly more frequent in the right upper limb (52.4%). The
most relevant finding was the significant difference in the quality of the
tissue interposed between the radius and the flexor tendons (Table 2).
All
patients in Group I (with repair) and only 29% of Group II had viable
contractile tissue; the remaining 71% corresponded to fibrotic tissue (p < 0.001). Clinical flexor tendon
friction was present in 45% of Group I and 71% of Group II, a difference that
reached statistical significance (p =
0.042). In Group I, 77.5% showed no ultrasound abnormalities and only 22.5%
showed mild friction. In Group II, mild friction was observed in 43% of
patients, whereas 57% had no abnormalities. In no case were ultrasound
abnormalities detected without a corresponding clinical manifestation. With
respect to contact between the flexor tendons and the plate, 71% of Group II
had direct contact, whereas 29% had interposed muscle tissue. No direct
correlation was identified between clinical friction and the presence of tissue
interposition. Overall, Group I demonstrated greater preservation of
contractile tissue and a lower prevalence of fibrosis compared with Group II,
in which fibrotic tissue predominated and a higher incidence of clinical
friction was observed (Table 3).
Although
the plates used featured a fixed-angle locking system, which limits screw
redirection, postoperative assessments showed that most implants were
positioned proximal to the watershed line. Only four cases were classified as
Soong 1 (three in Group I and one in Group II), and no cases were classified as
Soong 2.
At
clinical follow-up, the mean DASH score was 14.2 (SD ± 5.8), corresponding to a
mild level of disability and consistent with a favorable clinical outcome. No
significant differences were found between groups (p = 0.187). Most patients resumed their usual activities without
major restrictions, and no reoperations were required.
DISCUSSION
In this
study, we compared imaging findings in patients with distal radius fractures
treated with open reduction and internal fixation, differentiating between
those in whom the pronator quadratus was repaired and those in whom it was not.
The main difference between the two cohorts was the quality of the tissue
interposed between the radius and the flexor tendons, specifically regarding
coverage of the volar plate. In the repair group, viable contractile tissue was
significantly more frequent, a difference that reached statistical significance
compared with the non-repair group. No significant differences were found in
flexor tendon friction, structural tendon quality, or minimum plate-tendon
distance.
The
literature regarding pronator quadratus repair after volar plate fixation
remains controversial. Some studies suggest potential benefits, whereas others
do not support routine repair. In a recent meta-analysis by Shi and Ren, the
authors concluded that pronator quadratus repair does not improve postoperative
functional scores, grip strength, pronation strength, or range of motion
following volar plate fixation for distal radius fractures.14
Among
complications associated with volar distal radius plates, injury of the flexor
pollicis longus tendon is one of the most significant. However, in a systematic
review by Azzi et al., including a large patient cohort, the incidence of this
complication was reported to be below 1%. Moreover, studies such as that by
Brown et al. indicate that tendon ruptures can occur even when the pronator
quadratus is repaired, despite the theorized protective effect against
tendon-implant friction.26
Although
the limited sample size of our study did not allow us to confirm a protective
effect of pronator quadratus repair, it is worth noting that no tendon injuries
were observed in any patient. Larger studies will be required to determine
whether the contractile tissue identified overlying the plate after pronator
quadratus repair contributes to a protective effect by reducing flexor tendon
contact with the implant and lowering rupture rates.
This
study has several limitations, including the small number of cases, limited
follow-up, and the potential for information bias due to reliance on the
accuracy of medical records. Nonetheless, it also has meaningful strengths: the
inclusion of a control group allowed for more robust comparisons, and the use
of a blinded sonographer, unaware of whether the pronator quadratus had been
repaired, significantly reduced assessment bias.
CONCLUSIONS
In the
postoperative ultrasound assessment, significant differences were observed
between the groups. In Group I, the tissue interposed between the flexor
tendons and the plate was of higher quality, with more viable contractile
muscle and less fibrosis compared with Group II, a difference that reached
statistical significance. Clinical flexor tendon friction was also lower in the
repair group, supporting the potential protective role of the pronator
quadratus.
Although
no differences were identified in tendon rupture or functional outcomes (DASH
scores), the preservation of viable contractile tissue may contribute to
reducing tendon friction. However, this hypothesis could not be definitively
confirmed due to the small sample size and limited follow-up period.
Future
studies with larger cohorts, multivariate analyses, and eventually randomized
controlled trials will be required to more accurately determine the clinical
impact of pronator quadratus reinsertion on preventing implant-related
complications and on functional wrist outcomes.
Acknowledgments
We thank Dr. Gerardo Gayraud for
his valuable collaboration in performing the ultrasound studies used in this
investigation.
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G. Teruya ORCID ID:
https://orcid.org/0000-0001-7342-1859
D. J. Gómez ORCID ID:
https://orcid.org/0000-0003-0258-6802
S. Ávila Posada ORCID ID: https://orcid.org/0009-0008-8035-3522
Á. Muratore ORCID ID:
https://orcid.org/0000-0001-7540-7137
G. Viollaz ORCID ID: https://orcid.org/0000-0002-4573-883X
Received on January 26th, 2025.
Accepted after evaluation on September 20th, 2025 • Dr.
Christopher Bermeo • md.cbermeo@gmail.com • https://orcid.org/0009-0001-2231-7362
How to
cite this article: Teruya G, Ávila Posada S, Bermeo C, Viollaz G, Gómez DJ,
Muratore Á. Ultrasound Assessment and Clinical Correlation of the Pronator
Quadratus Muscle After Its Repair in the Treatment of Distal Radius Fractures. Rev Asoc Argent Ortop Traumatol
2025;90(6):547-555. https://doi.org/10.15417/issn.1852-7434.2025.90.6.2107
Article
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Identification: https://doi.org/10.15417/issn.1852-7434.2025.90.6.2107
Published: December, 2025
Conflict
of interests: The authors declare no conflicts of interest.
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Ortopedia y Traumatología.
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