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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
   
 

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