Dorsal Approach to the Wrist

  • The dorsal approach to the wrist provides excellent exposure of all the extensor tendons that pass over the dorsal surface of the wrist. It also allows access to the dorsal aspect of the wrist itself, the dorsal aspect of the carpus, and the dorsal surface of the proximal ends of the middle metacarpals.
  • The dorsal approach to the wrist uses include the following:
    1. Synovectomy and repair of extensor tendons.
    2. Wrist fusion.
    3. Posterior interosseous nerve (PIN) neurectomy.
    4. Excision of lower end of radius.
    5. Proximal row carpectomy.
    6. Proximal pole scaphoid fractures.
    7. ORIF of distal radius fractures (displaced intra-articular dorsal lip fractures).
    8. ORIF of carpal fractures and dislocations.

  • Place the patient supine on the operating table.
  • Pronate the forearm and put the arm on an arm board.

  • Landmarks:
    1. The radial styloid.
    2. The ulnar styloid.
  • Incision:
    • Make ~ 8 cm incision midline (halfway between radial and ulnar styloid):
      • Can extend proximally or distally as needed.

  • There is no true internervous plane for the dorsal approach to the wrist, because both the extensor carpi radialis longus muscle and the extensor carpi radialis brevis muscle are supplied by the radial nerve.
  • Dissection is carried out between the third and fourth extensor compartments of the wrist.

  • Incise subcutaneous fat inline with skin incision.
  • Expose extensor retinaculum.

  • 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.

  • Proximal Extension:
    • The dorsal approach to the wrist cannot be extended proximally to expose the rest of the radius, because it does not make use of an internervous plane.
    • It can be extended to expose the distal half of the dorsal aspect of the radius, however, by retracting the abductor pollicis longus and extensor pollicis brevis muscles, which cross the operative field obliquely.
  • Distal Extension:
    • To expose the entire dorsal surface of the metacarpals, extend the incision distally and retract the extensor tendons (This type of extension is rarely used in practice).

  • The structures at risk during dorsal approach to the wrist includes:

    1. Radial nerve (superficial radial nerve):
      1. Emerges from beneath brachioradialis tendon just above the wrist joint before traveling to dorsum of the hand.
    2. Dorsal cutaneous branches:
      1. Supplied by both radial and ulnar nerves.
      2. Lies in subcutaneous fat.
      3. Its Injury may lead to painful neuromas.
    3. Radial artery:
      1. Crosses wrist joint laterally.
      2. It can be avoided by maintaining dissection below the periosteum.
    4. Interosseous ligaments:
      1. Can destabilize carpus.
      2. It can be avoid by raising flaps.
    5. Scaphoid devascularization:
      1. It can be avoid by not detaching capsular attachment on dorsal ridge of scaphoid.

  • Surgical Exposures in Orthopaedics book - 4th Edition
  • Campbel's Operative Orthopaedics book 12th
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