Distal Radius Fracture Pattern Correlates with Pronator Quadratus Injury Severity

Abstract

Purpose

The purpose of this study was to determine if the distal radius fracture pattern is associated with the degree of pronator quadratus (PQ) injury in distal radius fractures that underwent open reduction internal fixation.

Materials and Methods

A retrospective review of patients with distal radius fractures who underwent open reduction internal fixation at a single institution through a standard volar approach was performed, yielding 148 patients. The extent of PQ injury was graded for each fracture intraoperatively (type 1: intact PQ with no visible muscle damage, type 2: transverse tear through the muscle at the level of the fracture site, and type 3: muscle damage and tears in multiple planes). The fractures were classified according to the Orthopaedic Trauma Association (OTA) classification of distal radius fractures. Thirty-seven patients with an intact PQ (type 1) were compared with 111 patients with an injured PQ (types 2 and 3).

Results

Partial-articular fractures were associated with less severe PQ injury (type 1 PQ injury: partial-articular 50.0%, extra-articular 25.0%, complete-articular 21.3%, p = 0.040). Volar fracture angulation was protective for PQ injury (type 1 PQ injury: volar 50.0% vs. dorsal 17.0%, p = 0.0001). In dorsally displaced fractures, increased dorsal translation was associated with more severe PQ injury (type 1 PQ injury: 3.9 ± 2.9 mm, type 2 PQ injury: 6.5 ± 4.7 mm, p = 0.006). Age, sex, dorsal tilt, and mechanism of injury were not associated with PQ injury severity.

Conclusion

Distal radius fracture angulation, OTA fracture classification, and millimeters of dorsal translation correlate with the degree of PQ injury.

Level of Evidence

Level IV.

Keywords

pronator quadratus injury - distal radius fracture - distal radius fracture classification - pronator quadratus injury repair

Publication History

Received: 05 March 2025

Accepted: 18 August 2025

Article published online:
08 September 2025

• References

• 1 Azad A, Kang HP, Alluri RK, Vakhshori V, Kay HF, Ghiassi A. Epidemiological and treatment trends of distal radius fractures across multiple age groups. J Wrist Surg 2019; 8 (04) 305-311
• 2 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 Am 2012; 37 (09) 1868-1873
• 3 Lu C-K, Liu W-C, Chang C-C, Shih C-L, Fu Y-C, Jupiter JB. A systematic review and meta-analysis of the pronator quadratus repair following volar plating of distal radius fractures. J Orthop Surg Res 2020; 15 (01) 419
• 4 McConkey MO, Schwab TD, Travlos A, Oxland TR, Goetz T. Quantification of pronator quadratus contribution to isometric pronation torque of the forearm. J Hand Surg Am 2009; 34 (09) 1612-1617
• 5 Maniglio M, Truong V, Zumstein M, Bolliger L, McGarry MH, Lee TQ. Should we repair the pronator quadratus in a distal radius fracture with an ulnar styloid base fracture? A biomechanical study. J Wrist Surg 2021; 10 (05) 407-412
• 6 Meinberg EG, Agel J, Roberts CS, Karam MD, Kellam JF. Fracture and dislocation classification compendium-2018. J Orthop Trauma 2018; 32 (Suppl. 01) S1-S170
• 7 Thorninger R, Madsen ML, Wæver D, Borris LC, Rölfing JHD. Complications of volar locking plating of distal radius fractures in 576 patients with 3.2 years follow-up. Injury 2017; 48 (06) 1104-1109
• 8 Hjelle AM, Gjertsen JE, Apalset EM. et al. No association between osteoporosis and AO classification of distal radius fractures: an observational study of 289 patients. BMC Musculoskelet Disord 2020; 21 (01) 811
• 9 Zhang D, Meyer MA, Earp BE, Blazar P. Role of pronator quadratus repair in volar locking plate treatment of distal radius fractures. J Am Acad Orthop Surg 2022; 30 (15) 696-702
• 10 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 (N Y) 2022; 17 (1_suppl): 31S-36S
• 11 Wu B, Kang ZY, Wei SK, Xiong TL. [Comparison of functional recovery of distal radius fracture by suture of pronator muscle through modified Henry approach]. Zhongguo Gu Shang 2022; 35 (01) 49-53
• 12 Belloti JC, Tamaoki MJS, Franciozi Cda S. et al. Are distal radius fracture classifications reproducible? Intra and interobserver agreement. Sao Paulo Med J 2008; 126 (03) 180-185
• 13 Plant CE, Hickson C, Hedley H, Parsons NR, Costa ML. Is it time to revisit the AO classification of fractures of the distal radius? Inter- and intra-observer reliability of the AO classification. Bone Joint J 2015; 97-B [phone]
• 14 Wæver D, Madsen ML, Rölfing JHD. et al. Distal radius fractures are difficult to classify. Injury 2018; 49 (Suppl. 01) S29-S32