Introduction. The flexor carpi radialis (FCR) approach is widely used for volar plate fixation of distal radius fractures. However, patients sometimes complain of postoperative numbness at the thenar eminence. We propose this is derived from injury to the palmar cutaneous branch of the median nerve (PCBm). Materials and methods. From March 2010 to March 2012, we performed 10 operations of volar plate fixation for distal radius fractures using the FCR approach. We detected the PCBm intraoperatively and investigated the anatomy. Results. On average, the PCBm arises from the median nerve 44 mm proximal to the distal wrist crease. It arose from the radial side of the median nerve in nine cases and the ulnar side in one case. In all cases, it ran between the FCR and the palmaris longus tendon under the antebrachial fascia. Nerve supply to the FCR sheath was not observed in the field of operation. Discussion. Numerous studies report the necessity to preserve the PCBm during carpal tunnel release surgery, but the relationship between the FCR approach and the PCBm has not been emphasized. Our results generally agree with past reports on PCBm anatomy. In our experience, the FCR tendon should be retracted to the ulnar side to prevent PCBm injury. If the FCR tendon is retracted radially, the PCBm should be detected and retracted gently. Some studies report that the PCBm joins the FCR sheath at the level of the distal wrist crease. Thus, the distal sheath incision should not be extended blindly

The Essex-Lopresti injury is rare. It consists of fracture of the head of the radius, rupture of the interosseous membrane and disruption of the distal radioulnar joint. The injury is often missed because attention is directed towards the fracture of the head of the radius. We present a series of 12 patients with a mean age of 44.9 years (26 to 54), 11 of whom were treated surgically at a mean of 4.6 months (1 to 16) after injury and the other after 18 years. They were followed up for a mean of 29.2 months (2 to 69). Ten patients had additional injuries to the forearm or wrist, which made diagnosis more difficult. Replacement of the head of the radius was carried out in ten patients and the Sauve-Kapandji procedure in three. Patients were assessed using standard outcome scores. The mean post-operative Disabilities of the Arm, Shoulder and Hand score was 55 (37 to 83), the mean Morrey Elbow Performance score was 72.2 (39 to 92) and the mean Mayo wrist score was 61.3 (35 to 80). The mean grip strength was 68.5% (39.6% to 91.3%) of the unaffected wrist.

Most of the patients (10 of 12) were satisfied with their operation and in 11 the pain was relieved. When treating the chronic Essex-Lopresti injury, we recommend accurate realignment of the radius and ulna and replacement of the head of the radius. If this fails a Sauve-Kapandji procedure to arthrodese the distal radioulnar joint should be undertaken to stabilise the forearm while maintaining mobility.