Dorsolateral approach to the Wrist

The dorsolateral approach to the wrist offers an excellent and safe exposure of the scaphoid bone. Its major drawback is that it endangers the superficial branch of the radial nerve, and it also may interfere with the dorsal blood supply of the scaphoid.

  • Dorsolateral approach to the wrist uses include the following:
    1. Bone grafting for scaphoid nonunion.
    2. Excision of the proximal fragment of a non-united scaphoid.
    3. Excision of the radial styloid in combination with either of the two above procedures.
    4. Open reduction and internal fixation of fractures of the scaphoid. When this approach is used for this indication, it is frequently combined with a volar approach to the scaphoid.

  • Place the patient supine on the operating table, with the arm extended on an arm board.
  • Pronate the forearm to expose the dorsoradial aspect of the wrist, and apply an exsanguinating bandage and tourniquet.

  • Landmarks:
    1. Radial styloid process.
    2. Anatomic snuff-box.
    3. First metacarpal bone.
  • Incision:

    • Make a gently curved, S-shaped incision centered over the snuff-box.
    • The cut should extend from the base of the first metacarpal to a point about 3 cm above the snuff-box.

  • There is no true internervous plane for the dorsolateral approach to the wrist.
    • The plane of dissection falls between the tendons of the extensor pollicis longus and extensor pollicis brevis muscles, both of which are supplied by the posterior interosseous nerve.
    • Because both muscles receive their nerve supply well proximal to this dissection, using this plane does not cause denervation.

  • Identify the tendons of the extensor pollicis longus muscle dorsally and the extensor pollicis brevis muscle ventrally.
  • Open the fascia between the two tendons, taking care not to cut the sensory branch of the superficial radial nerve, which lies superficial to the tendon of the extensor pollicis longus muscle.
  • Now, separate the tendons, retracting the extensor pollicis longus dorsally and toward the ulna, and the extensor pollicis brevis ventrally.
  • Identify the radial artery as it traverses the inferior margin of the wound, lying on the bone .
  • Find the tendon of the extensor carpi radialis longus muscle as it lies on the dorsal aspect of the wrist joint.
  • Mobilize it and retract it in a dorsal and ulnar direction, together with the tendon of the extensor pollicis longus muscle, to expose the dorsoradial aspect of the wrist joint.

  • Incise the capsule of the wrist joint longitudinally.
  • Reflect the capsule dorsally and in a volar direction to expose the articulation between the distal end of the radius and the proximal end of the scaphoid.
  • The radial artery retracts radially and in a volar direction with the joint capsule.
  • Place the wrist in ulnar deviation and continue stripping the capsule off the scaphoid to expose the joint completely.
  • Try to preserve as much soft-tissue attachments to the bone as possible. Modern aiming guides have substantially reduced the need for radial dissection in open reduction and internal fixation of scaphoid fractures.

  • There is no extension for the dorsolateral approach to the wrist.

  • The structures at risk during the dorsolateral approach to the wrist includes:
    1. The superficial radial nerve:
      • Because it lies directly over the tendon of the extensor pollicis longus muscle.
      • It is extremely easy to cut as the tendon is mobilized.
      • Incising the nerve may produce a troublesome neuroma.

  • Surgical Exposures in Orthopaedics book - 4th Edition
  • Campbel's Operative Orthopaedics book 12th
Dorsolateral approach to the wrist Dorsolateral approach to the wrist Dorsolateral approach to the wrist Dorsolateral approach to the wrist Dorsolateral approach to the wrist Dorsolateral approach to the wrist
Images Source:
  • Surgical Exposures in Orthopaedics 4th Edition Book.

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