SURGICAL APPROACHES TOFOREARM ,WRIST AND HAND

DR.RAJESH

PG, MS(ORTHO)

GMC,SEC

INDICATIONS RADIAL OSTEOTOMY TUMOR / ABSCESS BIOPSY AND EXCISION ORIF OF RADIUS FXS ANTERIOR EXPOSURE OF BICIPITAL TUBEROSITY

SUPERFICIAL RADIAL NERVE COMPRESSION

SYNDROME (WARTENBERG SYNDROME) 

INTERVAL DISTALLY BETWEEN

BRACHIORADIALIS AND FCR PROXIMALLY BETWEEN

BRACHIORADIALIS AND PT

VOLAR APPROACH TO RADIUS(HENRY)

POSITION PLACE SUPINE ON TABLE AND SUPINATE ARM AND PLACE ON ARMBOARD EXSANGUINATE ARM

INCISIONLONGITUDINAL INCISION

BEGIN JUST LATERAL TO BICEPS TENDON ON FLEXOR CREASE OF ELBOW

END AT RADIAL STYLOID PROCESS 

SUPERFICIAL DISSECTION INCISE THE DEEP FASCIA IN LINE WITH

SKIN INCISION DEVELOP A PLANE BETWEEN BR AND

FCR DISTALLY MOVE PROXIMAL TO DEVELOP PLANE

BETWEEN PT AND BR IDENTIFY THE SUPERFICIAL RADIAL

NERVE BENEATH BR LIGATE THE BRANCHES OF THE RADIAL

ARTERY TO AID LATERAL RETRACTION OF BR

DEEP DISSECTION - PROXIMAL THIRD FOLLOW THE BICEPS TENDON TO ITS

INSERTION ON THE BICIPITAL TUBEROSITY

 RADIAL TO THE INSERTION OF BICEPS TENDON INCISE THE BURSA TO GAIN ACCESS TO THE PROXIMAL PART OF RADIUS (RADIAL ARTERY WHICH RUNS ALONG THE ULNAR SIDE OF THE BICEPS TENDON)

 FULLY SUPINATE THE FOREARM TO DISPLACE THE PIN RADIALLY AND BRING THE ORIGIN OF THE SUPINATOR MUSCLE INTO THE ANTERIOR ASPECT OF THE RADIUS

INCISE THE SUPINATOR MUSCLE ALONG THE LINE IF ITS BROAD INSERTION AND CONTINUE SUBPERIOSTEAL DISSECTION LATERALLY

DEEP DISSECTION - MIDDLE THIRD PRONATE THE FOREARM TO BRING THE

INSERTION OF THE PRONATOR TERES, ALONG THE RADIAL ASPECT OF THE RADIUS, INTO VIEW

DETACH THE PRONATOR INSERTION FROM BONE AND RETRACT MEDIALLY

DEEP DISSECTION - DISTAL THIRD PARTIALLY SUPINATE THE FOREARM DISSECT THE PERIOSTEUM OFF THE

LATERAL ASPECT OF THE DISTAL THIRD OF THE RADIUS, LATERAL TO THE PRONATOR QUADRATUS AND FLEXOR POLLICIS LONGUS

DANGERSPOSTERIOR INTEROSSEOUS NERVE 

THE POSTERIOR INTEROSSEOUS NERVE ENTERS THE SUPINATOR MUSCLE BENEATH A FIBROUS ARCH KNOWN AS THE ARCADE OF FROHSE. 

COMPRESSION OF THE NERVE AT THIS POINT PRODUCES AS POSTERIOR INTEROSSEOUS NERVE ENTRAPMENT SYNDROME

STEP TO PROTECT THE PIN INCLUDE DISSECTING SUPINATOR OFF RADIUS SUBPERIOSTALLY DO NOT PLACE RETRACTORS ON POSTERIOR SURFACE OF RADIAL NECK AVOID EXCESSIVE RADIAL RETRACTION OF SUPINATOR SUPINATING THE FOREARM TO MOVE PIN AWAY FROM THE SURGICAL FIELD 

SUPERFICIAL RADIAL NERVE  VULNERABLE WITH MANIPULATION OF MOBILE WAD OF THREE DAMAGE TO IT CAN CAUSE A PAINFUL NEUROMA RUNS DOWN FOREARM UNDER BODY OF BRACHIORADIALIS

RADIAL ARTERY RUNS DOWN MIDDLE OF FOREARM UNDER BRACHIORADIALIS

DORSAL APPROACH TO RADIUS(THOMPSON)

ACCESS PROVIDES EXPOSURE

TO PROXIMAL 1/3 OF RADIUS

INDICATIONS ORIF OF RADIAL FRACTURES TREATMENT OF NONUNION ACCESS TO THE PIN AS IT

PASSES THROUGH THE ARCADE OF FROHSE FOR

NERVE PARALYSISRESISTANT TENNIS

ELBOW RADIAL OSTEOTOMY OSTEOMYELITIS AND BONE

TUMORS

INTERNERVOUS PLANE PROXIMALLY BETWEEN

ECRB (RADIAL NERVE) AND EDC (PIN NERVE) 

DISTALLY BETWEEN ECRB (RADIAL NERVE) AND EPL (PIN

NERVE) DISTALLY  APPROACH

 POSITION PLACE PATIENT SUPINE

IF ARM IS ON ARM BOARD, THEN PRONATE THE FOREARM

IF ARM IS ACROSS CHEST, THE SUPINATE THE FOREARM

INCISION STRAIGHT OR GENTLY CURVED INCISION

FROM POINT( 1.5) ANTERIOR TO THE LATERAL

EPICONDYLE OF THE HUMERUS TO POINT JUST DISTAL TO LISTER'S

TUBERCLE( mid point of the wrist)

SUPERFICIAL DISSECTION PROXIMALLY DEVELOP INTERVAL

BETWEEN ECRB AND THE EDC PROXIMALLY EXPOSE PROXIMAL

THIRD OF THE RADIUS AND OVERLYING SUPINATOR

DISTALLY DEVELOP PLANE BETWEEN THE ECRB AND EPL AND EXPOSES LATERAL ASPECT OF DISTAL THIRD OF THE RADIUS

DEEP DISSECTION - PROXIMAL THIRD TWO METHODS EXIST TO PROTECT PIN

PROXIMAL TO DISTAL: DETACH ORIGIN OF ECRB AND ECRL FROM LATERAL EPICONDYLE AND IDENTIFY AND DISSECT PIN AS IT ENTERS SUPINATOR MUSCLE

DISTAL TO PROXIMAL: IDENTIFY NERVE AS IT EXITS SUPINATOR AND DISSECT IT PROXIMALLY OUT OF SUPINATOR SUBSTANCE

 PRONATE ARM TO EXPOSE ANTERIOR ASPECT OF RADIUS AND MOVE PIN AWAY FROM ORIGIN OF SUPINATOR

CAN SUPINATE AFTER SUCCESSFUL IDENTIFICATION OF NERVE AND AFTER BONY EXPOSURE IS COMPLETE

DETACH SUPINATOR MUSCLE AT INSERTION ON ANTERIOR ASPECT OF RADIUS

SUBPERIOSTEALLY STRIP SUPINATOR TO EXPOSE PROXIMAL THIRD OF RADIUS

DEEP DISSECTION - MIDDLE THIRD MAKE INCISION ALONG SUPERIOR AND

INFERIOR BORDERS OF APL AND EPB AND RETRACT THEM OFF BONE TO EXPOSEMIDDLE THIRD OF RADIUS

DANGERS POSTERIOR INTEROSSEOUS

NERVE INJURY USUALLY

FROM RETRACTION IN 25% OF PATIENTS THE NERVE

ACTUALLY TOUCHES THE DORSAL ASPECT OF THE RADIUS

PLATES PLACED HIGH ON THE DORSAL SURFACE MAY TRAP THE NERVE

PIN MUST BE IDENTIFIED WITHIN THE SUPINATOR MUSCLE

APPROACH TO ULNA

INIDICATIONS ORIF OF ULNAR SHAFT FXS ULNAR OSTEOTOMY ULNAR LENGTHENING (KIENBOCK'S

DISEASE) ULNAR SHORTENING (FOR RADIAL

MALUNION) OSTEOMYELITIS AND TUMORS OF ULNA

INTERNERVOUS PLANE BETWEEN ECU AND FCU 

POSITION PLACE SUPINE ON TABLE PLACE ARM ACROSS CHEST TO

EXPOSE SUBCUTANEOUS BORDER OF ULNA

APPROACH LINEAR LONGITUDINAL INCISION OVER

SUBCUTANEOUS BORDER OF ULNA LENGTH BASED ON PROCEDURE

SUPERFICIAL DISSECTION INCISE DEEP FASCIA IN DISTAL INCISION

IN LINE WITH SKIN INCISION DIVIDE PLANE BETWEEN ECU AND FCU DISSECT DOWN TO SUBCUTANEOUS

BORDER OF ULNA ( DIVIDE FIBERS OF ECU TO REACH BONE)

DEEP DISSECTION INCISE PERIOSTEUM OVER ULNA PERFORM SUBPERIOSTEAL DISSECTION IN THE PROXIMAL FIFTH OF THE ULNA,

PART OF THE INSERTION OF THE TRICEPS WILL NEED TO BE DETACHED TO GAIN ACCESS TO THE BONE

DANGERS ULNAR NERVE

PROXIMALLY PASSES THROUGH TWO HEADS OF FCU

TRAVELS DOWN FOREARM UNDER FCU AND ON TOP OF FDP 

PROTECT BY DISSECTING FCU SUBPERIOSTALLY

ULNAR ARTERY TRAVELS DOWN FOREARM WITH

ULNAR NERVE (RADIAL SIDE) PROTECT BY DISSECTING FCU

SUBPERIOSTALLY

POST APPROACH TO PROXIMAL 3RD ULNA AND RADIAL HEAD(BOYDS)

INDICATION PROXIMAL THIRD ULNA FRXS WITH RADIAL

HEAD DISLOCATION(MONTEGGIA) ISOLATED RADIAL HEAD AND NECK FRXS

INCISION INCISION GIVEN ABOUT 2.5CM ABOVE ELBOW

JOINT JUST LATERAL TO TRICEPS TENDON EXTEND OVER OLECRONON TO JN OF

PROXIMAL AND MIDDLE 3RD OF ULNA POSTERIORALY

DISSECTION DEVELOP THE INTERVAL BETWEEN THE ULNA

ON MEDIAL SIDE , ANCONEUS AND ECU LATERALLY

STRIP THE ANCONEUS SUBPERIOSTEALLY TO EXPOSE THE RADIAL HEAD

DISTAL TO RADIAL HEAD, REFLECT THE SUPINATOR SUBPERIOSTEALLY FROM ULNA

PEEL THE SUPINATOR FROM THE PROXIMAL 4TH OF RADIUS, WITH PIN INCORPORATED IN THE MUSCLE MASS

REFLECT SUPINATOR, ANCONEUS AND ECU RADIALLY TO EXPOSE LAT.BORDER OF ULNA AND PROXIMAL FOURTH OF RADIUS

DANGERS RECURRENT INTEROSSEOUS

ARTERY – DIVIDE THE ARTERY DORASL INTEROSSEOUS ARTERY

SMITH – PETERSEN MEDIAL APPROACH TO WRIST

INDICATION ARTHODESIS OF WRIST

POSITION PT SUPINE ON THE TABLE FORE ARM PRONE ON THE BOARD

INCISION CURVILINEAR INCISION CENTERED

OVER THE ULNAR STYLOID, PARALLEL TO THE ULNA PROXIMALLY , OVER 5TH M.C BASE DISTALLY

SUPERFICIAL DISSECTON WHILE INCISING SKIN AND

SUBCNTANEOUS TISSUE AVOID INJURY TO DORSAL BRANCH OF ULNAR.N

INCISE THE FASCIA

DEEP DISSECTION OPEN THE CAPSULE

LONGITUDINALLY DO NOT INJURE THE TFC

ATTACHED TO THE ULNAR STYLOID 2.5CM OF ULNA RESECTED

OBLIQUELY(PROXIMAL TO STYLOID PROCESS)

RADIO CARPEL JOINT EXPOSED BY REFLECTION OF CAPSULE AND LIGAMENTS FROM CARPUS AND RADIUS

DANGERS DORSAL BRANCH OF ULNAR.N WHICH WINDS AROUND THE WRIST

JUST DISTAL TO ULNAR HEAD

COMPARTMENT SYNDROME

THE FOREARM CONTAINS MUSCLE COMPARTMENTS CONSTRAINED BYSTRONG FASCIA

MOST COMMONLY AFFECTED IS ANT COMPARTMENT

ALL THE THREE COMPARTMENTE SHOULD BE RELEASED

LONGITUDINAL INCISION EXT FROM LAT SIDE OF ELBOW CREASE TO RADIAL STYLOID PROCESS

SPLIT THE FASCIA OVER THE FCR AND PL AND THEN FASCIA OVER THE FDS

POSTERIOR COMPARTMENT DECOPRESSION DONE BYLONGITUDINAL INCISION FROM LAT HUMERAL EPICONDYL TO LISTERS TUBERCLE

INCISE THE FASCIA OVER THE LINE OF SKIN INCISION

EXTENSILE INCISION ANT INCISION CAN BE

EXTENDED DISTALLY TO WRIST CREASE AND HAND (TO RELEASE CARPAL TUNNEL AND DEEP PALMAR FASCIA

PROXIMALLY TO THE ANT LAT APPROACH TO HUMERUS

FCR APPROACH TO DISTAL RADIUS

INDICATIONS ORIF OF FXS AND DISLOCATIONS OF DISTAL

RADIUS AND CARPUS

POSITION PLACE SUPINE ON TABLE SUPINATE ARM AND PLACE ON

ARMBOARD EXSANGUINATE ARM (IF USING

TOURNIQUET) 

INCISION MAKE INCISION ALONG PALPABLE

FLEXOR CARPI RADIALIS (FCR) TENDON SHEATH

MAKE ULNAR OR RADIAL CURVE SO YOU DON'T CROSS PERPENDICULAR TO FLEXION CREASE

SUPERFICIAL DISSECTION INCISE SKIN FLAPS AND

SUBCUTANEOUS FAT SECTION FIBERS OF VOLAR FCR

TENDON SHEATH IN LINE WITH TENDON 

RETRACT FCR TENDON ULNARLY AND INCISE THROUGH THE DORSAL ASPECT OF THE FCR SHEATH

CAN RETRACT FCR RADIALLY IF CARPAL TUNNEL ACCESS IS NECESSARY

DEEP DISSECTION AND ACCESS TO VOLAR WRIST JOINT UNDERNEATH THE FCR SHEATH IS

THE FLEXOR POLLICIS LONGUS (FPL) - THIS MUST BE RETRACTED ULNARLY

AFTER THE FPL IS BLUNTLY RETRACTED, THE PRONATOR QUADRATUS (PQ) IS SEEN 

INCISE THE RADIAL AND DISTAL BORDERS OF THE PQ, ELEVATING THE MUSCLE OFF THE VOLAR RADIUS 

PROXIMAL EXTENSION DISSECTION

EXTEND INCISION UP MIDDLE OF ARM INCISE DEEP FASCIA BETWEEN PL AND FCR RETRACT PL AND FCR TO EXPOSE FDS

INDICATIONS TO FURTHER EXPOSE MEDIAN NERVE OR

RADIUS MEDIAN NERVE IS IMMEDIATELY UNDER THE

DEEP SURFACE OF FDS

DISTAL EXTENSION INDICATIONS

TO FURTHER EXPOSE THE SCAPHOID

DISSECTION EXTEND INCISION OBLIQUELY IN A RADIAL

DIRECTION ACROSS THE FLEXOR CREASE CONTINUE THIS IN LINE WITH THE THUMB RAY ELEVATE THE THENAR MUSCULATURE OFF

THE VOLAR WRIST CAPSULE OPEN CAPSULE IF NECESSARY

DORSAL APPROACH TO WRIST

INDICATIONSWRIST FUSIONSYNOVECTOMY AND REPAIR OF

EXTENSOR TENDONSEXCISION OF LOWER END OF RADIUSPROXIMAL ROW CARPECTOMY

ORIF OF DISTAL RADIUS FX (DISPLACED INTRA-ARTICULAR DORSAL LIP FXS)

CARPAL FX AND DISLOCATIONS

DANGERSRADIAL ARTERYRADIAL NERVE (SUPERFICIAL RADIAL

NERVE)POSTERIOR INTEROSSEOUS NERVE

POSITION PT SUPINE ON TABLE PRONATE FOREARM AND

PLACE ON ARMBOARD EXSANGUINATE ARM

INCISION MAKE ~ 8 CM INCISION MIDLINE

(HALFWAY BETWEEN RADIAL AND ULNAR STYLOID)

CAN EXTEND PROXIMALLY OR DISTALLY AS NEEDED

DANGERS RADIAL ARTERY PALMAR CUTANEOUS

BRANCH OF MEDIAN NERVE ARISES 5 CM PROXIMAL TO WRIST

JOINT RUNS ULNAR TO FCR CANNOT LIGATE IF ALLEN'S TEST

REVEALS NO/POOR ULNAR ARTERY CONTRIBUTION TO HAND

CARE MUST BE TAKEN WHEN RETRACTING DURING PROCEDURE

VOLAR WRIST CAPSULE LIGAMENTS DO NOT REMOVE FROM VOLAR

DISTAL RADIUS UNLESS ACCESS TO WRIST JOINT IS NEEDED

ERRANT RELEASE WILL LEAD TO RADIOCARPAL INSTABILITY

DEEP SURGICAL DISSECTION DISSECTION DEPENDS ON THE PROCEDURE TO

BE CARRIED OUT

SYNOVECTOMY INCISE THE EXT RETINACULAM OVER SECOND

EXT COMPARTMENT(ECRB&ECRL) SEQUENTIALLY DEROOF ALL THE

COMPARTMENTS FROM RETENACULAM PLACE THE RETINACULAM BETWEEN THE EXT

TENDONS AND DISTAL ENDS OF RADIUS & ULNA TO PROVIDE PROTECTION FOR TENDONS

FULL EXPOSURE OF WRIST JOINT INCISE RETINACULAM OVER 4TH

COMPARTMENT(EXT COMM & EXT INDI) MOBILZE AND RETRACT THE TENDONS ULNAR

AND RADIAL DIRECTION TO EXPOSE UNDERLYING RADIUS AND CAPSULE

INCISE CAPSULE LONGITUDINALLY AND DISSECT THE DORSAL RADIOCARPAL LIGAMENT TO EXPOSE DISTAL END OF RADIUS AND CARPAL BONES

TENDONS OF ECRL AND ECRB MUSCLES ATTACHED TO BASES OF 2ND &3RD MCS AND LIE IN A TUNNEL ,RETRACTED LATERALLY

VOLAR APPROACH TO WRIST

INDICATIONS DECOMPRESSION OF MEDIAN NERVE FLEXOR TENDON SYNOVECTOMY CARPAL TUNNEL TUMOR EXCISION CARPAL TUNNEL NERVE AND TENDON

REPAIR DRAINAGE OF SEPSIS TRACKING UP FROM

THE MID-PALMER SPACE ORIF OF FXS AND DISLOCATIONS OF

DISTAL RADIUS AND CARPUS ESPECIALLY VOLAR LIP INTRA-

ARTICULAR FXS

SUPINATE ARM AND PLACE ON ARMBOARD

INCISION MAKE INCISION JUST ULNAR TO

THE THENAR CREASE IN HAND AND ULNAR TO PALMARIS LONGUS IN WRIST

BEGIN 4CM DISTAL TO FLEXION CREASE

MAKE ULNAR CURVE SO YOU DONT CROSS PERPENDICULAR TO FLEXION CREASE

ALSO HELPS PROTECT PALMER CUTANEOUS BRANCH

END 3 CM PROXIMAL TO FLEXION CREASE 

SUPERFICIAL DISSECTION INCISE SKIN FLAPS SECTION FIBERS OF SUPERFICIAL PALMAR

FASCIA IN LINE WITH INCISION RETRACT CURVED FLAPS MEDIALLY TO

EXPOSE INSERTION OF PL INTO FLEXOR RETINACULUM

RETRACT PL TENDON TOWARD ULNA TO EXPOSE MEDIAN NERVE UNDER PL AND FCR

PASS A BLUNT OBJECT BETWEEN MEDIAN NERVE AND RETINACULUM.

INCISE ENTIRE LENGTH OF RETINACULUM ON ULNAR SIDE OF NERVE

PROXIMAL EXTENSION INDICATIONS

TO FURTHER EXPOSE MEDIAN NERVE

DISSECTION EXTEND INCISION UP MIDDLE OF

ARM INCISE DEEP FASCIA BETWEEN PL

AND FCR RETRACT PL AND FCR TO EXPOSE

FDS MEDIAN NERVE ADHERES TO DEEP

SURFACE OF FDS

DEEP DISSECTION AND ACCESS TO VOLAR WRIST JOINT IDENTIFY MOTOR BRANCH OF MEDIAN

NERVE (WHERE MEDIAN NERVE EMERGES FROM CARPAL TUNNEL

MOBILIZE MEDIAN NERVE AND RETRACT RADIALLY (SO DONT STRETCH MOTOR BRANCH)

MOBILIZE AND RETRACT FLEXOR TENDONS

DANGERS PALMER CUTANEOUS BRANCH OF MEDIAN

NERVE ARISES 5 CM PROXIMAL TO WRIST JOINT RUNS ULNAR TO FCR GREATEST THREAT WHEN YOU DONT

CURVE YOUR INCISION ULNAR

MOTOR BRANCH OF MEDIAN NERVE SIGNIFICANT ANATOMIC VARIATION RISK TO NERVE MINIMIZE IF INCISION

THROUGH RETINACULUM MADE ULNAR TO MEDIAN NERVE

SUPERFICIAL PALMER ARCH

INDICATIONS ULNAR N DECOMPRESSION IN GUYONS

CANAL EXPLORATION OF NRVE IN CASE OF

TRAUMA

POSITION PLACE THE HAND ON BOARD IN SUPINATED

INCISIONMAKE 5CMS CURVED INCISION OVER RADIAL BORDER OF HYPOTHENAR EMINENCE AND CROSSING WRIST JOINT OBLIQUELY ON TO THE FOREARM

VOLAR APPROACH TO ULNAR NERVE

SUPERFICIAL DISSECTION DEEPEN THE INCISION IDENTIFY FCU TENDON MOBILIZE AND RETRACT FCU

TENDON ULNARWARDS NERVE AND ARTERY EXPOSED

DEEP SURGICAL DISSECTION TRACE THE NERVE AND ARTERY

DISTALLY INCISING OVERLYING FIBROUS

TISSUE AND VOLAR CARPAL LIGAMENT

TAKE CARE TO PROTECT NERVE AND ARTERY

GUYON CANAL IS DECOMPRESSED

DANGERS ULNAR NERVE IS VULNERABLE DURING

TWO PHASES OF DISSECTION WHEN THE FASCIA ON THE RADIAL SIDE

OF THE FCU TENDON IS INCISED WHEN THE VOLAR CARPEL LIGAMENT IS

INCISED

EXTENSILE MEASURES PROXIMAL EXTENSION

INCISE SKIN LONGITUDINALLY UP TO THE MIDDLE OF THE FOREARM

INCISE THE DEEP FASCIA IDENTIFY THE RADIAL BORDER OF

FCU TENDON DEVELOP A PLANE BETWEEN FCU

AND FDS RETRACT FCU TOWARDS THE ULNA

TO REVEAL ULNAR NERVE THIS INCISION CAN EXPOSE ULNAR N

UPTO ELBOW JOINT

VOLAR APROACH TO SCAPHOID

ADVANTAGES AVOID DAMAGING THE DORSAL

BLOOD SUPPLY TO THE SUPERFECIAL RADIAL NERVE

DISADVANTAGE THREAT TO RADIAL ARTERY

INDICATIONS BONE GRAFTING FOR NON UNION

SCAPHOID EXCISION OF PROXIMAL 1/3 OF

SCAPHOID EXCISION OF RADIAL STYLOID ORIF OF FRACTURES OF

SCAPHOID

POSITION SUPINATED HAND ON BOARD

WHILE PT IS IN SUPINATION

LANDMARKS TUBEROSITY OF SCAPHOID - JUST

DISTAL TO SKIN CREASC FCR OVER THE SCAPHOID

INCISION 3 CM CURVILINEAR INCISION OVER THE

RADIALASPECT OF WRISTFROM TUBEROSITY OF SCAPHOID TO RADIAL TO FCR

SUPERFICIAL DISSECTION INCISE DEEP FASCIA IDENTIFY RADIAL. A, AND RETRACT

LATERALLY IDENTIFY FCR TENDON AND INCISE RETINACULUM OVER FCR, RETRACT

MEDIALLY

DEEP DISSECTION INCISE CAPSULE OVER SCAPHOID EXPOSES DISTAL 2/3 RD OF BONE(NON

ARTICULAR) TO GAIN BEST VIEW OF PROXIMAL 1/3/RD

BONE - PLACE THE WRIST IN MARKED DORSIFLEXION

DANGERS RADIAL ARTERY

DORSOLATERAL APPROACH TO SCAPHOID

ADVANTAGE EXCELLENT EXPOSURE OF SCAPHOID

BONE

DISADVANTAGES ENDANGERS THE SUP.RADIAL.N MAY INTERFERE WITH THE DORSAL

BLOOD SUPLY

INDICATIONS BONE GRAFTING FOR NON UNION EXCISION OF PROXIMAL NON UNITED

BONE EXCISION OF RADIAL STYLOID ORIF OF SCAPHOID

POSITION PT SUPINE ON TABLE ARM EXTENDED FORE ARM PRONATED

LANDMARKS RADIAL STYLOID PROCESS ANATOMICAL SNUFF – BOX

INCISION GENTLY CURVED, S-SHAPED INCISION

CENTERED OVER SNUFF-BOX, FROM BASE OF 1ST M.C TO 3CM ABOVE THE SNUFF-BOX

INTERNERVOUS PLANE TWO TENDONS(EPL AND EPB) ARE BOTH

SUPLIED BY PIN, WELL PROXIMAL TO WRIST -> NO INTERNERVOUS PLANE

SUPERFICIAL DISSECTION IDENTIFY EPL AND EPB TENDONS INCISE FASCIA IN BETWEEN AND NOT TO

DAMAGER THE SUPERFECIAL.RADIAL.N RETRACT TENDONS-IDENTIFY RADIAL

ARTERY OVER THE SCAPHOID

DEEP DISSECTION INCISE CAPSULE LONGITUDINALLY EXPOSE THE PROXIMAL END OF SCAPHOID

AND DISTAL END OF RADIUS PLACE THE WRIST IN ULNAR DEVIATION

AND STRIP THE CAPSULE OFF THE RADIUS

DANGERS SUPERFICIAL RADIAL.N – LIES OVER THE

TENDON OF EPL

VOLAR APPROACH TO FLEXOR TENDONS

ADVANTAGES BEST POSSIBLE EXPOSURE TO FLEXORS

TENDONS WITH SHEATHS EXPOSURE OF NEURO VASCULAR BUNDLE SKIN INCISION MAY BE EXTENDED INTO

PALM AND WRIST- ESPRCIALLY IN CASE OF TRAUMA

SKIN LACERATIONS INCORPORATED IN TO THE INCISION

DISADVANTAGES SURGERY ON PHALANGES IS NOT SELDOM

NECESSARY IN THIS APPROACH MAY LEAD TO ADHESIONS WITH IN THE

FLEXOR SHEATHS

INDICATIONS EXPLORATION AND REPAIR OF FLEXOR

TENDONS AND NEUROVASULAR BUNDLE FOR DRAINAGE OF PUS FROM FLEXOR

SHEATHS EXCISION OF TUMOURS EXCISION OF PALMAR FASCIA IN

DUPUYTREN’S CONTRACTURES

POSITION ADJUST THE HEIGHT OF THE TABLE TO

MAKE SURGEON COMFORTABLE IN SITTING

GOOD LIGHTING IG ESSENTIAL

LANDMARKS DISTAL PHALANGEAL CREASE –

PROXIMAL TO DIP PROXIMAL PHALANGEAL CREASE -

PROXIMAL TO PIP PALMAR DIGITAL CREASE – DISTAL TO

MCP JOINT

INCISION MAKE METHYLENE BLUE OUT LINE ON

PROPOSED INCISION THE ANGLES OF ZIGZAG SHOULD BE IN

900 TO EACH OTHER (LESS THAN 900 MAY POSE SKIN NECROSIS)

THE ANGLE SHOULD NOT BE TOO FAR IN DORSAL DIRECTION

SUPERFICIAL DISSECTION ELEVATE THE FLAPS WITH SKIN HOOKS

ALONG WITH SUBCUTANEOUS TISSUE DO NOT MOBILIZE FLAPS UNTIL THE

FLEXOR SHEATHS REACHED

DEEP DISSECTION FLEXOR TENDONS LIE WITHIN THE

FLEXOR SHEATH ALONG WITH DOUBLE SYNOVIAL LAYER

NEUROVASCULAR BUNDLE IS DISSECTED FROM VOLAR SUBCUTANEOUS FAT WITH A SMALL PAIR OF SCISSORS – FOR NEUROVASCULAR BUNDLE REPAIR

IMPORTANT TO PRESERVE THE A2 AND A4 PULLEYS

DANGERS DIGITAL VESSELS AND NERVES SKIN FLAPS SHOULD NOT BE CUT AT TOO

ACUTE ANGLES

DORSO LATERAL APPROACH TO FLEXOR SHEATHS

INDICATIONS OPEN REDUCTION AND STABILIZATION

OF PHALANGEAL FRXS EXPOSURE OF FIBROUS FLEXOR

SHEATHS EXPOSURE OF THE NEUROVASCULAR

BUNDLE

POSITION PT SUPINE ON TABLE ARM STRECHED OUT ON ARMBOARD EXANGUINATION AND TORNIQUE ARE

ESSENTIAL

LANDMARKS PROXIMAL AND DISTAL

INTERPHALANGEAL CREASES

INCISION MAKE A LONGITIDINAL INCISION OVER

LATERAL ASPECT OF FINGER STARTING AT DORSAL POINT OF

PROXIMAL SKIN CREASE TO DORSAL POINT OF DISTAL SKIN CREASE

INTERNERVOUS PLANE NO INTERNERVOUS PLANE AS THERE IS

NO INTERMUSCULAR PLANE DEVELOPED

SUPERFICIAL DISSECTION DEVELOP A VOLAR SKIN FLAP BY

INCISING THE SUBCUTANEOUS FAT NEUROVASCULAR BUNDLE LIE IN THE

VOLAR FLAP NOT TO INCISE JOINTS

DEEP DISSECTION INCISE FIBROUS FLEXOR SHEATH

LONGITUDINALL TO EXPOSE UNDERLYING TENDON

DANGERS PALMAR DIGITAL NERVE

TOO FAR VOLAR INCISION MAY ENDANGER THE PALMAR NERVE

VOLAR DIGITAL.A

DRAINAGE OF MIDPALMAR SPACE

INCISION MAKE A TRANSVERSE INCISION JUST

PROXIMAL TO THE DISTAL PALMAR CREASE OVER THE SWELLING

SURGICAL DISSECTION INCISE THE SKIN CAREFULLY , IT CROSSES

THE PATHS OF DIGITAL NERVE OPEN THE PALMAR FASCIA BY BLUNT

DISSECTION IDENTIFY LONG FLEXOR TENDON OF RING

FINGER ENTER THE PALMAR SPACE BY BLUNT

DISSECTION ON THE RADIAL SIDE OF TENDON

DANGERS DIGITAL NERVES AND VESSELS IMMEDIATELY

UNDER THE PALMAR APONEUROSIS PALMAR APONEUROSIS SHOULD NOT BE

INCISED

DRAINAGE OF THENAR SPACE

INCISION MAKE 4CMS CURVED INCISON ON ULNAR

SIDE OF THENAR CREASE

SURGICAL DISSECTION DEEPEN DISSECTION IN LINE WITH THE

SKIN INCISION PRESERVE THE DIGITAL NERVES TO THE

INDEX FINGER IDENTIFY FLEXOR TENDON OF INDEX

FINGER DEEP TO THE TENDON IS THENAR SPACE

OPEN BY BLUNT DISSECTION

DANGERS MOTOR BRANCH TO THENAR MUSCLE MAY BE ENCOUNTERED AT THE

PROXIMAL BORDER OF INCISION

DRAINAGE OF PARONYCHIA INTRODUCTION

INFEECTION OF NAIL FOLD M.C. INFECTION OF HAND CAUSED BY STAPH.AUREUS PUS DISTENDS THE CUTICLE AND

SOME TIMES NAIL BED

INCISION SHORT LONGITUDINAL INCISION ON

ONE OR BOTH SIDES OF NAIL BED

DISSECTION RAISE THE SKIN FLAP AT BASE OF

NAIL EVACUATE PUS BETWEEN NAIL

&CUTICLE EXCISE HALF OF NAIL IF NAIL BED

IS INVOLVED OCCASINALLY A NICK MAY SUFFICE

DRAINAGE TO FELON IT IS THE PULP SPACE INFECTION REQUIRES

SURGICAL INTERVENTION CAUSES BY A PENETRATING INJURY

IT IS OF 2 TYPES SUPERFICIAL INFECTION – POINT OUT

AT VOLAR SKIN DEEP INFECTION – MORE LIKELY TO

CAUSE OSTEO. MYELTIS OF PHALANX IF THE ABSCESS IS POINTED ON VOLAR PULP –

GIVE INCISE ON LAT.SIDE OF VOLAR SURFACE AND ENTER THE CAVITY AND DRAIN

IF NOT POSSIBLE(SURGICAL DRAINAGE REQ) INCISION

STRAIGH LAT.INCISION OVER DISTAL PHALIX OF FINGER

TIP OF FINGER TO 1CM DISTAL D.I.P JOINT OFF THE SEPTA FROM BONE WITH DEEP

DISSECTION CAREFULLY OPEN ALL LOCULS WOUND KEPT OPEN

THANK YOU