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Indications
  • Access
    • provides exposure to
      • extensor tendons passing over wrist
      • dorsal wrist joint
      • dorsal carpus
      • dorsal surface of proximal ends of metacarpals
  • Indications
    • synovectomy and repair of extensor tendons
    • wrist fusion
    • posterior interossesous nerve (PIN) neurectomy
    • excision of lower end of radius
    • proximal row carpectomy
    • proximal pole scaphoid fx
    • ORIF of distal radius fx (displaced intra-articular dorsal lip fxs)
    • ORIF of carpal fx and dislocations
   
Internervous Plane
  • No true intermuscular plane
    • dissection carried out between the third and fourth extensor compartments
  • Relevant anatomy
    • radial styloid
    • ulnar styloid
    • Lister's tubercle
    • extensor tendon compartments 
   
Preparation
  • Anesthesia
    • regional blocks
    • general sedation
  • Position
    • place supine on table
    • pronate arm and place on armboard
  • Turnoquite
    • exsanguinate arm
   
Approach
  • Incision
    • make ~ 8 cm incision midline (halfway between radial and ulnar styloid)
      • can extend proximally or distally as needed
  • Superficial dissection
    • incise subcutaneous fat inline with skin incision
    • expose extensor retinaculum
  • Deep dissection
    • incise extensor retinaculum over the extensor digitorum communis and extensor indicis proprius (fourth compartment)
    • mobilize tendons radially and ulnarly to expose the underlying radius and joint capsule
    • incise the joint capsule longitudinally on the dorsal radius and carpus
    • continue dissection below the capsule (dorsal radiocarpal ligament) toward the radial and ulnar sides of the radius to expose the entire distal radius and carpal bones
 



Dangers
  • Radial nerve (superficial radial nerve)
    • emerges from beneath brachioradialis tendon just above the wrist joint before traveling to dorsum of the hand
    • distal extent of approach at base of 3rd metacarpal
  • Dorsal cutaneous branches
    • supplied by both radial and ulnar nerves
    • lie in subcutaneous fat
    • injury may lead to painful neuromas
  • Radial artery
    • crosses wrist joint laterally
    • avoid by maintaining dissection below the periosteum
  • Interosseous ligaments
    • can destabilize carpus
    • avoid by raising flaps
  • Scaphoid devascularization
    • avoid by not detaching capsular attachment on dorsal ridge of scaphoid
   
 

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