Wrist/Hand Approaches

Question 1

position for dorsal approach to the wrist

Answer 1

supine

arm board

tourniquet

Question 2

incision for dorsal approach to the wrist

Answer 2

8 cm longitudinal incision dorsal aspect of wrist crossing the joint midway between radial and ulnar styloids beginning 3 cm proximal to the wrist

*note that you don’t need to curve across this crease

Question 3

internervous plane for dorsal approach to the wrist

Answer 3

none

use intermuscular plane between ECRB and ECRL

Question 4

superficial dissection for dorsal approach to the wrist

Answer 4

skin and subcutaneous tissue above extensor retinaculum

Question 5

deep dissection for dorsal approach to the wrist

Answer 5

for synovectomy:

incise extensor retinaculum over ECRB and ECRL in second extensor compartment just radial to lister’s tubercle - you can deroof each compartment as needed laterally and medially from here

for joint exposure:

incise extensor retinaculum over ED and EI in fourth extensor compartment and retract separately. then incise the joint capsule

Question 6

danger

Answer 6

1) superficial radial nerve emerges from under brachioradialis just proximal to wrist joint
2) radial artery crosses wrist laterally - stay below periosteum and it will be hard to damage

Question 7

position for volar approach to the wrist

Answer 7

supine

arm board

partial tourniquet

Question 8

incision for volar approach to the wrist

Answer 8

begin just ulnar to the thenar crease about 1/3 of the way into the hand then curve ulnarly across the flexor crease then midline up the wrist.

Question 9

internervous plane for volar approach to the wrist

Answer 9

none

Question 10

superficial dissection for volar approach to the wrist

Answer 10

incise skin - be wary of palmar cutaneous branch of medial nerve

expose insertion of palmaris longus and retract ulnarly

ID median nerve between PL and FCR

pass blunt retract into carpal tunnel superficial to median nerve

incise retinaculum starting ulnarly to avoid motor branch to thenar eminence

Question 11

deep dissection for volar approach to the wrist

Answer 11

ID motor branch and release if necessary

if you need to approach the joint, retract median nerve radially

mobilize and retract flexor tendons

incise base of tunnel

Question 12

danger for volar approach to the wrist

Answer 12

1) palmar cutaneous branches of median arise 5 cm proximal to wrist joint run on ulnar side of FCR befor crossing flexor retinaculum
2) motor branch of median nerve
3) superficial palmar arch crosses plam at level of outstretched thumb - cut flexor retinaculum only under direct vision

Question 13

position for volar approach to ulnar nerve

Answer 13

supine

arm board

tourniquet

Question 14

incision for volar approach to ulnar nerve

Answer 14

Question 15

internervous plane for volar approach to ulnar nerve

Answer 15

none

Question 16

superficial dissection for volar approach to ulnar nerve

Answer 16

ID tendon of FCU and incise fascia on radial border and retract ulnarly to reveal ulnar nerve and artery

Question 17

deep dissection for volar approach to ulnar nerve

Answer 17

trace nerve and artery distally incising over fibrous tissue (the volar carpal ligament)

Question 18

danger for volar approach to ulnar nerve

Answer 18

1) ulnar nerve at 2 locations - during approach through FCU and during detachment of volar carpal ligament