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Dorsal approach to the wrist

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Introduction

Indications

  • Synovectomy and repair of extensor tendons.
  • Wrist fusion.
  • Excision of lower end of radius.
  • Proximal row carpectomy.
  • ORIF of distal radius fracture (displaced intra-articular dorsal lip fractures), carpal fracture and dislocations.

Advantages
Provides excellent exposure of:

  • Extensor tendons passing over wrist.
  • Dorsal wrist joint and dorsal carpus.
  • Dorsal surface of proximal ends of metacarpals.

Position of patient

  • The patient is placed supine, with the the arm on an arm board and the forearm pronated.
  • Inflate a tourniquet after exsanguinating the limb.

Landmarks and incision

Landmarks

  • Palpate the radial and ulnar styloid, the most common distal extension of the lateral and medial sides of the wrist, respectively.

Incision

  • Make a midline incision on the dorsum of the wrist (halfway between the radial and ulnar styloid); start 3 cm proximal to the wrist joint and extend 5 cm distal.

Internervous plane

  • Plane between ECRL and ECRB (radial nerve)

Superficial dissection

  • Incise the subcutaneous fat in line with the skin incision to expose the extensor retinaculum that covers the tendons in the six compartments on the dorsal aspect of the wrist.

Deep dissection

  • The extensor retinaculum incised over the extensor carpi radialis longus and brevis muscles in the second compartment of the wrist. The compartment is on the radial side of Lister's tubercle.
  • To expose the other compartments, incise the ulnar edge of the cut retinaculum by sharp dissection in an ulnar direction to deroof sequentially the four compartments on the ulnar side.
  • Dissect the radial edge of the cut extensor retinaculum radially to deroof the first compartment.
  • The extensor retinaculum is preserved during closure; it can be sutured underneath the extensor tendons to prevent them from being abraded by the bones.

Dangers

Radial nerve (superficial radial nerve)

  • Damage to cutaneous nerves occurs only if the dissection begin within the fat. If the incision is taken down to the extensor retinaculum before the ulnar and radial flaps are elevated, the nerves are protected by the full thickness of the fat.
  • Cutting a cutaneous nerve may result in a painful neuroma.

Radial artery

  • As long as the dissection at the level of the wrist joint remains below the periosteum, the artery is difficult to damage.

How to enlarge the approach

  • Proximally, the incision can't be extended to expose the rest of the radius.
  • Retracting the APL and EPB, crossing the operative field obliquely, expose the distal half of the dorsal aspect of the radius.
  • Distally, the incision can be extended to expose the entire dorsal surface of the metacarpalsand, retract the extensor tendons.

Figures

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