Ultrasound Assessment and Clinical Correlation of the Pronator Quadratus Muscle After Its Repair in the Treatment of Distal Radius Fractures
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Published:
Dec 27, 2025
Keywords:
Distal radius fracture, pronator quadratus repair, volar plate, open reduction and internal fixation, tendon friction, tendon rupture
Main Article Content
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.
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.
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How to Cite
Teruya, G., Ávila Posada, S., Bermeo, C., Viollaz, G. M., Gómez, D. J., & Muratore, Álvaro J. (2025). Ultrasound Assessment and Clinical Correlation of the Pronator Quadratus Muscle After Its Repair in the Treatment of Distal Radius Fractures. Revista De La Asociación Argentina De Ortopedia Y Traumatología, 90(6), 547-555. https://doi.org/10.15417/issn.1852-7434.2025.90.6.2107
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Clinical Research
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References
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https://doi.org/10.1016/j.hcl.2012.02.001
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3. Rozental TD, Blazar PE, Franko OI, Chacko AT, Earp BE, Day CS. Functional outcomes for unstable distal radial fractures treated with open reduction and internal fixation or closed reduction and percutaneous fixation. J Bone Joint Surg (Am) 2009;91(8):1837-46. https://doi.org/10.2106/jbjs.h.01478
4. Goslings JC, Mulders MA, Walenkamp MM, Bos FJ, Schep NW. Repair of the pronator quadratus after volar plate fixation in distal radius fractures: a systematic review. Strategies Trauma Limb Reconstr 2017;12(3):181-8. https://doi.org/10.1007/s11751-017-0288-4
5. Orbay J, Badia A, Khoury RK, Gonzalez E, Indriago I. Volar fixed-angle fixation of distal fractures: The DVR Plate.
Tech Hand Up Extrem Surg 2004;8(3):142-8. https://doi.org/10.1097/01.bth.0000126570.82826.0a
6. Ahsan ZS, Yao J. (2012). The importance of pronator quadratus repair in the treatment of distal radius fractures with volar plating. Hand 2012;7(3):276-80. https://doi.org/10.1007/s11552-012-9420-6
7. Fan J, Jiang B, Wang B, Chen K, Yuang F, Mei J, et al. Analysis of soft-tissue complications of volar plate fixation for managing distal radius fractures and clinical effect while preserving pronator quadratus. Acta Orthop Belg 2016;82(2):305-12. PMID: 27682293
8. Davis DI, Baratz M. Soft tissue complications of distal radius fractures. Hand Clin 2010;26(2):229-35. https://doi.org/10.1016/j.hcl.2009.11.002
9. Floquet A, Druart T, Lavantes P, Vendeuvre T, Delaveau A. Flexor tendon rupture after volar plating of distal radius fracture: A systematic review of the literature. Hand Surg Rehabil 2021;40(5):535-46. https://doi.org/10.1016/j.hansur.2021.05.008
10. Yu YR, Makhni MC, Tabrizi S, Rozental TD, Mundanthanam G, Day CS. Complications of low-profile dorsal versus volar locking plates in the distal radius: A comparative study. J Hand Surg 2011;36(7):1135-41. https://doi.org/10.1016/j.jhsa.2011.04.004
11. Rubensson CC, Ydreborg K, Boren L, Karlander LE. Flexor tendón repair after rupture caused by volar plate fixation of the distal radius. J Plast Surg Hand Surg 2014;49(2):112-5. https://doi.org/10.3109/2000656x.2014.951050
12. Azzi AJ, Aldekhayel S, Boehm KS, Zadeh T. Tendon rupture and tenosynovitis following internal fixation of distal radius fractures. Plast Reconstr Surg 2017;139(3):717e-724e. https://doi.org/10.1097/PRS.0000000000003076
13. Hershman SH, Immerman I, Bechtel C, Lekic N, Paksima N, Egol KA. The effects of pronator quadratus repair on outcomes after volar plating of distal radius fractures. J Orthop Trauma 2013;27(3):130-3. https://doi.org/10.1097/bot.0b013e3182539333
14. Shi F, Ren L. Is pronator quadratus repair necessary to improve outcomes after volar plate fixation of distal radius fractures? A systematic review and meta-analysis. Orthop Traumatol Surg Res 2020;106(8):1627-35. https://doi.org/10.1016/j.otsr.2020.06.003
15. Meyer MA, Benavent KA, Janssen SJ, Chruscielski CM, Blazar PE, Earp BE. Pronator quadratus repair does not affect reoperation rates following volar locking plate fixation of distal radius fractures. Hand 2021;17(1_suppl):31S-36S. https://doi.org/10.1177/15589447211017239
16. Swigart CR, Badon MA, Bruegel VL, Dodds SD. Assessment of pronator quadratus repair integrity following volar plate fixation for distal radius fractures: A prospective clinical cohort study. J Hand Surg 2012;37(9):1868-73. https://doi.org/10.1016/j.jhsa.2012.06.005
17. Sonntag J, Hern J, Woythal L, Branner U, Lange KHW, Brorson S. The pronator quadratus muscle after volar plating: Ultrasound evaluation of anatomical changes correlated to patient-reported clinical outcome. Hand 2019;16(1):32-7. https://doi.org/10.1177/1558944719840737
18. Goorens C, Van Royen K, Grijseels S, Provyn S, De Mey J, Scheerlinck T, et al. Ultrasonographic evaluation of the distance between the flexor pollicis longus tendon and volar prominence of the plate as a function of volar plate positioning and pronator quadratus repair — A cadaver study. Hand Surg Rehabil 2018;37(3):171-4. https://doi.org/10.1016/j.hansur.2017.12.008
19. Perugia D, Guzzini M, Civitenga C, Guidi M, Cristina D, Daniele F. Is it really necessary to restore radial anatomic parameters after distal radius fractures? Injury 2014;45Suppl 6:S21-6. https://doi.org/10.1016/j.injury.2014.10.018
20. Sharma H, Khare GN, Singh S, Ramaswamy AG, Kumaraswamy V, Singh AK. Outcomes and complications
of fractures of distal radius (AO type B and C): Volar plating versus nonoperative treatment. J Orthop Sci 2014;19(4):537-44. https://doi.org/10.1007/s00776-014-0560-0
21. Bentohami A, Bijlsma TS, Goslings JC, De Reuver P, Kaufmann LW, Schep N. Radiological criteria for acceptable reduction of extra-articular distal radial fractures are not predictive for patient-reported functional outcome. J Hand Surg Eur Vol 2012;38(5):524-9. https://doi.org/10.1177/1753193412468266
22. Kumar S, Khan A, Sonanis S. Radiographic and functional evaluation of low profile dorsal versus volar plating for distal radius fractures. J Orthop 2016;13(4):376-82. https://doi.org/10.1016/j.jor.2016.06.017
23. Bhat AK, Acharya AM, Mane PP, Karegowda LH. Correlation of flexor pollicis longus tendon status by ultrasonography with plate position on radiographs following volar plate fixation of distal radius fractures with pronator quadratus repair. Indian J Orthop 2021;55(4):1015-21. https://doi.org/10.1007/s43465-021-00369-7
24. Shim B, Kim D, Lee S, Cho M, Hwang J. Comparison of the conventional Henry approach and trans-flexor Carpi radialis approach for the treatment of distal radius fracture: a retrospective cohort study. Medicine 2022;101(49):e31936. https://doi.org/10.1097/md.0000000000031936
25. Ilyas AM. Surgical approaches to the distal radius. Hand 2010;6(1):8-17. https://doi.org/10.1007/s11552-010-9281-9
26. Brown EN, Lifchez SD. Flexor pollicis longus tendon rupture after volar pla-ting of a distal radius fracture: pronator quadratus plate coverage may notadequately protect tendons. Eplasty 2011;11:e43. PMID: 22096615
https://doi.org/10.1016/j.hcl.2012.02.001
2. Court-Brown CM, Caesar B. Epidemiology of adult fractures: A review. Injury 2006;37(8):691-7. https://doi.org/10.1016/j.injury.2006.04.130
3. Rozental TD, Blazar PE, Franko OI, Chacko AT, Earp BE, Day CS. Functional outcomes for unstable distal radial fractures treated with open reduction and internal fixation or closed reduction and percutaneous fixation. J Bone Joint Surg (Am) 2009;91(8):1837-46. https://doi.org/10.2106/jbjs.h.01478
4. Goslings JC, Mulders MA, Walenkamp MM, Bos FJ, Schep NW. Repair of the pronator quadratus after volar plate fixation in distal radius fractures: a systematic review. Strategies Trauma Limb Reconstr 2017;12(3):181-8. https://doi.org/10.1007/s11751-017-0288-4
5. Orbay J, Badia A, Khoury RK, Gonzalez E, Indriago I. Volar fixed-angle fixation of distal fractures: The DVR Plate.
Tech Hand Up Extrem Surg 2004;8(3):142-8. https://doi.org/10.1097/01.bth.0000126570.82826.0a
6. Ahsan ZS, Yao J. (2012). The importance of pronator quadratus repair in the treatment of distal radius fractures with volar plating. Hand 2012;7(3):276-80. https://doi.org/10.1007/s11552-012-9420-6
7. Fan J, Jiang B, Wang B, Chen K, Yuang F, Mei J, et al. Analysis of soft-tissue complications of volar plate fixation for managing distal radius fractures and clinical effect while preserving pronator quadratus. Acta Orthop Belg 2016;82(2):305-12. PMID: 27682293
8. Davis DI, Baratz M. Soft tissue complications of distal radius fractures. Hand Clin 2010;26(2):229-35. https://doi.org/10.1016/j.hcl.2009.11.002
9. Floquet A, Druart T, Lavantes P, Vendeuvre T, Delaveau A. Flexor tendon rupture after volar plating of distal radius fracture: A systematic review of the literature. Hand Surg Rehabil 2021;40(5):535-46. https://doi.org/10.1016/j.hansur.2021.05.008
10. Yu YR, Makhni MC, Tabrizi S, Rozental TD, Mundanthanam G, Day CS. Complications of low-profile dorsal versus volar locking plates in the distal radius: A comparative study. J Hand Surg 2011;36(7):1135-41. https://doi.org/10.1016/j.jhsa.2011.04.004
11. Rubensson CC, Ydreborg K, Boren L, Karlander LE. Flexor tendón repair after rupture caused by volar plate fixation of the distal radius. J Plast Surg Hand Surg 2014;49(2):112-5. https://doi.org/10.3109/2000656x.2014.951050
12. Azzi AJ, Aldekhayel S, Boehm KS, Zadeh T. Tendon rupture and tenosynovitis following internal fixation of distal radius fractures. Plast Reconstr Surg 2017;139(3):717e-724e. https://doi.org/10.1097/PRS.0000000000003076
13. Hershman SH, Immerman I, Bechtel C, Lekic N, Paksima N, Egol KA. The effects of pronator quadratus repair on outcomes after volar plating of distal radius fractures. J Orthop Trauma 2013;27(3):130-3. https://doi.org/10.1097/bot.0b013e3182539333
14. Shi F, Ren L. Is pronator quadratus repair necessary to improve outcomes after volar plate fixation of distal radius fractures? A systematic review and meta-analysis. Orthop Traumatol Surg Res 2020;106(8):1627-35. https://doi.org/10.1016/j.otsr.2020.06.003
15. Meyer MA, Benavent KA, Janssen SJ, Chruscielski CM, Blazar PE, Earp BE. Pronator quadratus repair does not affect reoperation rates following volar locking plate fixation of distal radius fractures. Hand 2021;17(1_suppl):31S-36S. https://doi.org/10.1177/15589447211017239
16. Swigart CR, Badon MA, Bruegel VL, Dodds SD. Assessment of pronator quadratus repair integrity following volar plate fixation for distal radius fractures: A prospective clinical cohort study. J Hand Surg 2012;37(9):1868-73. https://doi.org/10.1016/j.jhsa.2012.06.005
17. Sonntag J, Hern J, Woythal L, Branner U, Lange KHW, Brorson S. The pronator quadratus muscle after volar plating: Ultrasound evaluation of anatomical changes correlated to patient-reported clinical outcome. Hand 2019;16(1):32-7. https://doi.org/10.1177/1558944719840737
18. Goorens C, Van Royen K, Grijseels S, Provyn S, De Mey J, Scheerlinck T, et al. Ultrasonographic evaluation of the distance between the flexor pollicis longus tendon and volar prominence of the plate as a function of volar plate positioning and pronator quadratus repair — A cadaver study. Hand Surg Rehabil 2018;37(3):171-4. https://doi.org/10.1016/j.hansur.2017.12.008
19. Perugia D, Guzzini M, Civitenga C, Guidi M, Cristina D, Daniele F. Is it really necessary to restore radial anatomic parameters after distal radius fractures? Injury 2014;45Suppl 6:S21-6. https://doi.org/10.1016/j.injury.2014.10.018
20. Sharma H, Khare GN, Singh S, Ramaswamy AG, Kumaraswamy V, Singh AK. Outcomes and complications
of fractures of distal radius (AO type B and C): Volar plating versus nonoperative treatment. J Orthop Sci 2014;19(4):537-44. https://doi.org/10.1007/s00776-014-0560-0
21. Bentohami A, Bijlsma TS, Goslings JC, De Reuver P, Kaufmann LW, Schep N. Radiological criteria for acceptable reduction of extra-articular distal radial fractures are not predictive for patient-reported functional outcome. J Hand Surg Eur Vol 2012;38(5):524-9. https://doi.org/10.1177/1753193412468266
22. Kumar S, Khan A, Sonanis S. Radiographic and functional evaluation of low profile dorsal versus volar plating for distal radius fractures. J Orthop 2016;13(4):376-82. https://doi.org/10.1016/j.jor.2016.06.017
23. Bhat AK, Acharya AM, Mane PP, Karegowda LH. Correlation of flexor pollicis longus tendon status by ultrasonography with plate position on radiographs following volar plate fixation of distal radius fractures with pronator quadratus repair. Indian J Orthop 2021;55(4):1015-21. https://doi.org/10.1007/s43465-021-00369-7
24. Shim B, Kim D, Lee S, Cho M, Hwang J. Comparison of the conventional Henry approach and trans-flexor Carpi radialis approach for the treatment of distal radius fracture: a retrospective cohort study. Medicine 2022;101(49):e31936. https://doi.org/10.1097/md.0000000000031936
25. Ilyas AM. Surgical approaches to the distal radius. Hand 2010;6(1):8-17. https://doi.org/10.1007/s11552-010-9281-9
26. Brown EN, Lifchez SD. Flexor pollicis longus tendon rupture after volar pla-ting of a distal radius fracture: pronator quadratus plate coverage may notadequately protect tendons. Eplasty 2011;11:e43. PMID: 22096615