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) Position Anesthesia General anesthesia Bier block 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 forearm 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 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