Volar Approach to the Wrist

The uses of the volar approach to the wrist include:

  1. Decompression of median nerve.
  2. Flexor tendon synovectomy.
  3. Carpal tunnel tumor excision.
  4. Carpal tunnel nerve and tendon repair.
  5. Drainage of sepsis tracking up from the mid-palmar space.
  6. Open reduction and internal fixation (ORIF) of fractures and dislocations of the distal radius and carpus.
    • Especially volar lip fractures of the radius.

  • Place the patient supine on an operating table
  • Supinate the arm and place it on arm board with palm facing up.

  • Landmark:
    1. Thenar crease.
    2. Transverse skin crease .
    3. Tendon of the palmaris longus muscle .
  • Incision:
    • Make incision just ulnar to the thenar crease in hand and ulnar to palmaris longus in wrist:
      • Begin 4cm distal to flexion crease.
      • Make ulnar curve so you don’t cross perpendicular to flexion crease.
        • also helps protect palmar cutaneous branch.
      • End 3 cm proximal to flexion crease.

    • There is No true internervous plane for the volar approach to the wrist.
    • No muscles are transected:
      • Abductor pollicis brevis and palmaris brevis fibers that cross the midline can occasionally be dissected.
    • True anatomic dissection:
      • Major nerves identified, dissected out and preserved.
      • Plane of dissection between median nerve and flexor carpi radialis tendon.

  • Incise skin flaps,
  • Incise fat,
  • Section fibers of superficial palmar fascia in line with incision,
  • Retract curved flaps medially to expose insertion of palmaris longus into flexor retinaculum,
  • Retract palmaris longus tendon toward ulna to expose median nerve between palmaris longus and flexor carpi radialis tendon,
  • Pass a blunt object between median nerve and flexor retinaculum.
  • Incise entire length of retinaculum / transverse carpal ligament on ulnar side of the nerve.

  • Identify motor branch of the median nerve (anterolateral side of the median nerve as it emerges from carpal tunnel).
  • If require access to volar aspect of wrist joint:
    • Mobilize median nerve and retract radially (so you don’t stretch motor branch).
    • Mobilize and retract flexor tendons.
    • Incise base of carpal tunnel longitudinally.
  • The most convenient approach for access to the volar aspect of the distal radius is the distal portion of the volar approach to the radius .

  • Proximal Extension:
    • The volar approach to the wrist can be extended to expose the median nerve.
    • To accomplish this:
      • extend the skin incision proximally, running it up the middle of the anterior surface of the forearm.
      • Incise the deep fascia of the forearm between the palmaris longus and flexor carpi radialis muscles.
      • Retract the flexor carpi radialis in a radial direction and the palmaris longus in an ulnar direction, exposing the muscle belly of the flexor digitorum superficialis muscle in the distal two thirds of the forearm.
      • The median nerve adheres to the deep surface of the flexor digitorum superficialis, held there by fascia.
      • Thus, if the flexor digitorum superficialis is reflected, the nerve goes with it.
  • Distal Extension:
    • The volar approach to the wrist can be extended into a volar zigzag approach for any of the fingers, providing complete exposure of all the palmar structures (Volar Approach to the Flexor Tendons).

  • The structures at risk during the volar approach to the wrist include:
    1. Palmar cutaneous branch of median nerve:
      • Arises 5 cm proximal to wrist joint.
      • Runs ulnar to flexor carpi radialis tendon before crossing flexor retinaculum.
      • Greatest risk if the skin incision is not angled to the ulnar side of the forearm .
    2. Motor branch of median nerve:
      • Significant anatomic variation.
      • Risk to nerve minimized if incision through retinaculum made ulnar to median nerve.
    3. Superficial palmar arch:
      • Crosses palm at level of distal end of outstretched thumb.
      • In danger if flexor retinaculum blindly cut (can go too far distally)
      • Avoid injury if retinaculum is cut under direct observation for its entire length.

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

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