| Introduction |
- 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-palmar space
- ORIF of fxs and dislocations of distal radius and carpus
- especially volar lip intra-articular fxs
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| Preparation & Position |
- Place supine on table
- Supinate arm and place on armboard
- Exsanguinate arm
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| Approach |
- 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 palmar cutaneous branch
- end 3 cm proximal to flexion crease
- Superficial dissection
- incise skin flaps
- incise fat
- 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
- 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 you dont stretch motor branch)
- mobilize and retract flexor tendons
- incise base of carpal tunnel
- 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
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| Dangers |
- Palmar 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 palmar arch
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