Dorsal approach to wrist
Incision
8 cm longitudinal incision midway between the radial and ulnar styloid processes, beginning ~ 3 cm proximal to the wrist.
Internervous Plane
No true internervous plane, but the nerve supply to the extensor muscles is well proximal to the level of surgery.
Dangers
The superficial radial nerve emerging from the dorsal margin of brachio-radialis. Radial artery is at risk during superficial dissection around the radial side of the wrist.
Limits / Extension
Can extend the exposure proximally over the distal 1/3 of the radius, reflecting abductor pollicus longus and extensor pollicus brevis.
Volar approach
Incision
Just to the ulnar side of the thenar skin crease, about 1/3 of the way into the hand.
Internervous Plane
No true internervous plane as the muscles involved are innervated proximally and the nerve is dissected out in the Carpal tunnel.
Dangers
The palmar cutaneous branch of the median nerve. The motor branch of the median nerve which shows considerable anatomical variation. The superficial palmar arch crosses the palm at the level of the distal border of the outstretched thumb.
Limits / Extension
Can extend the incision proximally between flexor carpi radialis and palmaris longus to expose the median nerve, which is under the surface of flexor digitorum communis.
Ulnar nerve
Incision
Make a cured incision following the radial border of the hypothenar eminence, extending into the volar aspect of the distal forearm.
Internervous Plane
No true internervous plane and the vessel and nerve are dissected out.
Dangers
The ulnar nerve and artery are at risk in the dissection.
Limits / Extension
The incision can be extended proximally to expose the ulna nerve to the elbow between the muscle bellies of flexor carpi ulnaris and flexor digitorum superficialis.
Scaphoid
Incision
Make a straight or curvilinear incision 2 – 3 cm long based on the tuberosity of the scaphoid and extending proximally between the tendons of flexor carpi radialis and the radial artery. May dissect through the bed of the tendon of flexor carpi radialis.
Internervous Plane
No true internervous plane as the only muscle mobilised is flexor carpi radialis.
Dangers
The radial artery should be protected. Dorsal approach to the scaphoid leads to increased risk of interference with the blood supply and there is also increased risk of damage to the radial nerve.
Limits / Extension
Exposure is limited and not easily extended. Can expose the radial styloid process for excision or obtaining graft material for augmentation of the styloid repair.