| Introduction |
- Indications
- ORIF of fxs and dislocations of distal radius and carpus
|
| Plane |
- Internervous plane between
- flexor carpi radialis (median nerve)
- flexor pollicis longus (AIN)
|
| Anesthesia |
- General anesthesia
- Bier block
|
| Position |
- Position
- place supine on table
- supinate arm and place on armboard
- Tourniquet
- exsanguinate arm (if using tourniquet)
|
| Approach |
- 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
- indications
- to further expose median nerve or radius
- dissection
- extend incision up middle of arm
- incise deep fascia between PL and FCR
- retract PL and FCR to expose FDS
- 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
|
.jpg)
.jpg)
|
| Dangers |
- Palmar cutaneous branch of median nerve
- arises 5 cm proximal to wrist joint
- runs ulnar to FCR
- Radial artery
- 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
|