surgical approaches to forearm wrist hand
TRANSCRIPT
SURGICAL APPROACHES TOFOREARM ,WRIST AND HAND
DR.RAJESH
PG, MS(ORTHO)
GMC,SEC
INDICATIONS RADIAL OSTEOTOMY TUMOR / ABSCESS BIOPSY AND EXCISION ORIF OF RADIUS FXS ANTERIOR EXPOSURE OF BICIPITAL TUBEROSITY
SUPERFICIAL RADIAL NERVE COMPRESSION
SYNDROME (WARTENBERG SYNDROME)
INTERVAL DISTALLY BETWEEN
BRACHIORADIALIS AND FCR PROXIMALLY BETWEEN
BRACHIORADIALIS AND PT
VOLAR APPROACH TO RADIUS(HENRY)
POSITION PLACE SUPINE ON TABLE AND SUPINATE ARM AND PLACE ON ARMBOARD EXSANGUINATE ARM
INCISIONLONGITUDINAL INCISION
BEGIN JUST LATERAL TO BICEPS TENDON ON FLEXOR CREASE OF ELBOW
END AT RADIAL STYLOID PROCESS
SUPERFICIAL DISSECTION INCISE THE DEEP FASCIA IN LINE WITH
SKIN INCISION DEVELOP A PLANE BETWEEN BR AND
FCR DISTALLY MOVE PROXIMAL TO DEVELOP PLANE
BETWEEN PT AND BR IDENTIFY THE SUPERFICIAL RADIAL
NERVE BENEATH BR LIGATE THE BRANCHES OF THE RADIAL
ARTERY TO AID LATERAL RETRACTION OF BR
DEEP DISSECTION - PROXIMAL THIRD FOLLOW THE BICEPS TENDON TO ITS
INSERTION ON THE BICIPITAL TUBEROSITY
RADIAL TO THE INSERTION OF BICEPS TENDON INCISE THE BURSA TO GAIN ACCESS TO THE PROXIMAL PART OF RADIUS (RADIAL ARTERY WHICH RUNS ALONG THE ULNAR SIDE OF THE BICEPS TENDON)
FULLY SUPINATE THE FOREARM TO DISPLACE THE PIN RADIALLY AND BRING THE ORIGIN OF THE SUPINATOR MUSCLE INTO THE ANTERIOR ASPECT OF THE RADIUS
INCISE THE SUPINATOR MUSCLE ALONG THE LINE IF ITS BROAD INSERTION AND CONTINUE SUBPERIOSTEAL DISSECTION LATERALLY
DEEP DISSECTION - MIDDLE THIRD PRONATE THE FOREARM TO BRING THE
INSERTION OF THE PRONATOR TERES, ALONG THE RADIAL ASPECT OF THE RADIUS, INTO VIEW
DETACH THE PRONATOR INSERTION FROM BONE AND RETRACT MEDIALLY
DEEP DISSECTION - DISTAL THIRD PARTIALLY SUPINATE THE FOREARM DISSECT THE PERIOSTEUM OFF THE
LATERAL ASPECT OF THE DISTAL THIRD OF THE RADIUS, LATERAL TO THE PRONATOR QUADRATUS AND FLEXOR POLLICIS LONGUS
DANGERSPOSTERIOR INTEROSSEOUS NERVE
THE POSTERIOR INTEROSSEOUS NERVE ENTERS THE SUPINATOR MUSCLE BENEATH A FIBROUS ARCH KNOWN AS THE ARCADE OF FROHSE.
COMPRESSION OF THE NERVE AT THIS POINT PRODUCES AS POSTERIOR INTEROSSEOUS NERVE ENTRAPMENT SYNDROME
STEP TO PROTECT THE PIN INCLUDE DISSECTING SUPINATOR OFF RADIUS SUBPERIOSTALLY DO NOT PLACE RETRACTORS ON POSTERIOR SURFACE OF RADIAL NECK AVOID EXCESSIVE RADIAL RETRACTION OF SUPINATOR SUPINATING THE FOREARM TO MOVE PIN AWAY FROM THE SURGICAL FIELD
SUPERFICIAL RADIAL NERVE VULNERABLE WITH MANIPULATION OF MOBILE WAD OF THREE DAMAGE TO IT CAN CAUSE A PAINFUL NEUROMA RUNS DOWN FOREARM UNDER BODY OF BRACHIORADIALIS
RADIAL ARTERY RUNS DOWN MIDDLE OF FOREARM UNDER BRACHIORADIALIS
DORSAL APPROACH TO RADIUS(THOMPSON)
ACCESS PROVIDES EXPOSURE
TO PROXIMAL 1/3 OF RADIUS
INDICATIONS ORIF OF RADIAL FRACTURES TREATMENT OF NONUNION ACCESS TO THE PIN AS IT
PASSES THROUGH THE ARCADE OF FROHSE FOR
NERVE PARALYSISRESISTANT TENNIS
ELBOW RADIAL OSTEOTOMY OSTEOMYELITIS AND BONE
TUMORS
INTERNERVOUS PLANE PROXIMALLY BETWEEN
ECRB (RADIAL NERVE) AND EDC (PIN NERVE)
DISTALLY BETWEEN ECRB (RADIAL NERVE) AND EPL (PIN
NERVE) DISTALLY APPROACH
POSITION PLACE PATIENT SUPINE
IF ARM IS ON ARM BOARD, THEN PRONATE THE FOREARM
IF ARM IS ACROSS CHEST, THE SUPINATE THE FOREARM
INCISION STRAIGHT OR GENTLY CURVED INCISION
FROM POINT( 1.5) ANTERIOR TO THE LATERAL
EPICONDYLE OF THE HUMERUS TO POINT JUST DISTAL TO LISTER'S
TUBERCLE( mid point of the wrist)
SUPERFICIAL DISSECTION PROXIMALLY DEVELOP INTERVAL
BETWEEN ECRB AND THE EDC PROXIMALLY EXPOSE PROXIMAL
THIRD OF THE RADIUS AND OVERLYING SUPINATOR
DISTALLY DEVELOP PLANE BETWEEN THE ECRB AND EPL AND EXPOSES LATERAL ASPECT OF DISTAL THIRD OF THE RADIUS
DEEP DISSECTION - PROXIMAL THIRD TWO METHODS EXIST TO PROTECT PIN
PROXIMAL TO DISTAL: DETACH ORIGIN OF ECRB AND ECRL FROM LATERAL EPICONDYLE AND IDENTIFY AND DISSECT PIN AS IT ENTERS SUPINATOR MUSCLE
DISTAL TO PROXIMAL: IDENTIFY NERVE AS IT EXITS SUPINATOR AND DISSECT IT PROXIMALLY OUT OF SUPINATOR SUBSTANCE
PRONATE ARM TO EXPOSE ANTERIOR ASPECT OF RADIUS AND MOVE PIN AWAY FROM ORIGIN OF SUPINATOR
CAN SUPINATE AFTER SUCCESSFUL IDENTIFICATION OF NERVE AND AFTER BONY EXPOSURE IS COMPLETE
DETACH SUPINATOR MUSCLE AT INSERTION ON ANTERIOR ASPECT OF RADIUS
SUBPERIOSTEALLY STRIP SUPINATOR TO EXPOSE PROXIMAL THIRD OF RADIUS
DEEP DISSECTION - MIDDLE THIRD MAKE INCISION ALONG SUPERIOR AND
INFERIOR BORDERS OF APL AND EPB AND RETRACT THEM OFF BONE TO EXPOSEMIDDLE THIRD OF RADIUS
DANGERS POSTERIOR INTEROSSEOUS
NERVE INJURY USUALLY
FROM RETRACTION IN 25% OF PATIENTS THE NERVE
ACTUALLY TOUCHES THE DORSAL ASPECT OF THE RADIUS
PLATES PLACED HIGH ON THE DORSAL SURFACE MAY TRAP THE NERVE
PIN MUST BE IDENTIFIED WITHIN THE SUPINATOR MUSCLE
APPROACH TO ULNA
INIDICATIONS ORIF OF ULNAR SHAFT FXS ULNAR OSTEOTOMY ULNAR LENGTHENING (KIENBOCK'S
DISEASE) ULNAR SHORTENING (FOR RADIAL
MALUNION) OSTEOMYELITIS AND TUMORS OF ULNA
INTERNERVOUS PLANE BETWEEN ECU AND FCU
POSITION PLACE SUPINE ON TABLE PLACE ARM ACROSS CHEST TO
EXPOSE SUBCUTANEOUS BORDER OF ULNA
APPROACH LINEAR LONGITUDINAL INCISION OVER
SUBCUTANEOUS BORDER OF ULNA LENGTH BASED ON PROCEDURE
SUPERFICIAL DISSECTION INCISE DEEP FASCIA IN DISTAL INCISION
IN LINE WITH SKIN INCISION DIVIDE PLANE BETWEEN ECU AND FCU DISSECT DOWN TO SUBCUTANEOUS
BORDER OF ULNA ( DIVIDE FIBERS OF ECU TO REACH BONE)
DEEP DISSECTION INCISE PERIOSTEUM OVER ULNA PERFORM SUBPERIOSTEAL DISSECTION IN THE PROXIMAL FIFTH OF THE ULNA,
PART OF THE INSERTION OF THE TRICEPS WILL NEED TO BE DETACHED TO GAIN ACCESS TO THE BONE
DANGERS ULNAR NERVE
PROXIMALLY PASSES THROUGH TWO HEADS OF FCU
TRAVELS DOWN FOREARM UNDER FCU AND ON TOP OF FDP
PROTECT BY DISSECTING FCU SUBPERIOSTALLY
ULNAR ARTERY TRAVELS DOWN FOREARM WITH
ULNAR NERVE (RADIAL SIDE) PROTECT BY DISSECTING FCU
SUBPERIOSTALLY
POST APPROACH TO PROXIMAL 3RD ULNA AND RADIAL HEAD(BOYDS)
INDICATION PROXIMAL THIRD ULNA FRXS WITH RADIAL
HEAD DISLOCATION(MONTEGGIA) ISOLATED RADIAL HEAD AND NECK FRXS
INCISION INCISION GIVEN ABOUT 2.5CM ABOVE ELBOW
JOINT JUST LATERAL TO TRICEPS TENDON EXTEND OVER OLECRONON TO JN OF
PROXIMAL AND MIDDLE 3RD OF ULNA POSTERIORALY
DISSECTION DEVELOP THE INTERVAL BETWEEN THE ULNA
ON MEDIAL SIDE , ANCONEUS AND ECU LATERALLY
STRIP THE ANCONEUS SUBPERIOSTEALLY TO EXPOSE THE RADIAL HEAD
DISTAL TO RADIAL HEAD, REFLECT THE SUPINATOR SUBPERIOSTEALLY FROM ULNA
PEEL THE SUPINATOR FROM THE PROXIMAL 4TH OF RADIUS, WITH PIN INCORPORATED IN THE MUSCLE MASS
REFLECT SUPINATOR, ANCONEUS AND ECU RADIALLY TO EXPOSE LAT.BORDER OF ULNA AND PROXIMAL FOURTH OF RADIUS
DANGERS RECURRENT INTEROSSEOUS
ARTERY – DIVIDE THE ARTERY DORASL INTEROSSEOUS ARTERY
SMITH – PETERSEN MEDIAL APPROACH TO WRIST
INDICATION ARTHODESIS OF WRIST
POSITION PT SUPINE ON THE TABLE FORE ARM PRONE ON THE BOARD
INCISION CURVILINEAR INCISION CENTERED
OVER THE ULNAR STYLOID, PARALLEL TO THE ULNA PROXIMALLY , OVER 5TH M.C BASE DISTALLY
SUPERFICIAL DISSECTON WHILE INCISING SKIN AND
SUBCNTANEOUS TISSUE AVOID INJURY TO DORSAL BRANCH OF ULNAR.N
INCISE THE FASCIA
DEEP DISSECTION OPEN THE CAPSULE
LONGITUDINALLY DO NOT INJURE THE TFC
ATTACHED TO THE ULNAR STYLOID 2.5CM OF ULNA RESECTED
OBLIQUELY(PROXIMAL TO STYLOID PROCESS)
RADIO CARPEL JOINT EXPOSED BY REFLECTION OF CAPSULE AND LIGAMENTS FROM CARPUS AND RADIUS
DANGERS DORSAL BRANCH OF ULNAR.N WHICH WINDS AROUND THE WRIST
JUST DISTAL TO ULNAR HEAD
COMPARTMENT SYNDROME
THE FOREARM CONTAINS MUSCLE COMPARTMENTS CONSTRAINED BYSTRONG FASCIA
MOST COMMONLY AFFECTED IS ANT COMPARTMENT
ALL THE THREE COMPARTMENTE SHOULD BE RELEASED
LONGITUDINAL INCISION EXT FROM LAT SIDE OF ELBOW CREASE TO RADIAL STYLOID PROCESS
SPLIT THE FASCIA OVER THE FCR AND PL AND THEN FASCIA OVER THE FDS
POSTERIOR COMPARTMENT DECOPRESSION DONE BYLONGITUDINAL INCISION FROM LAT HUMERAL EPICONDYL TO LISTERS TUBERCLE
INCISE THE FASCIA OVER THE LINE OF SKIN INCISION
EXTENSILE INCISION ANT INCISION CAN BE
EXTENDED DISTALLY TO WRIST CREASE AND HAND (TO RELEASE CARPAL TUNNEL AND DEEP PALMAR FASCIA
PROXIMALLY TO THE ANT LAT APPROACH TO HUMERUS
FCR APPROACH TO DISTAL RADIUS
INDICATIONS ORIF OF FXS AND DISLOCATIONS OF DISTAL
RADIUS AND CARPUS
POSITION PLACE SUPINE ON TABLE SUPINATE ARM AND PLACE ON
ARMBOARD EXSANGUINATE ARM (IF USING
TOURNIQUET)
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 DISSECTION
EXTEND INCISION UP MIDDLE OF ARM INCISE DEEP FASCIA BETWEEN PL AND FCR RETRACT PL AND FCR TO EXPOSE FDS
INDICATIONS TO FURTHER EXPOSE MEDIAN NERVE OR
RADIUS 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
DORSAL APPROACH TO WRIST
INDICATIONSWRIST FUSIONSYNOVECTOMY AND REPAIR OF
EXTENSOR TENDONSEXCISION OF LOWER END OF RADIUSPROXIMAL ROW CARPECTOMY
ORIF OF DISTAL RADIUS FX (DISPLACED INTRA-ARTICULAR DORSAL LIP FXS)
CARPAL FX AND DISLOCATIONS
DANGERSRADIAL ARTERYRADIAL NERVE (SUPERFICIAL RADIAL
NERVE)POSTERIOR INTEROSSEOUS NERVE
POSITION PT SUPINE ON TABLE PRONATE FOREARM AND
PLACE ON ARMBOARD EXSANGUINATE ARM
INCISION MAKE ~ 8 CM INCISION MIDLINE
(HALFWAY BETWEEN RADIAL AND ULNAR STYLOID)
CAN EXTEND PROXIMALLY OR DISTALLY AS NEEDED
DANGERS RADIAL ARTERY PALMAR CUTANEOUS
BRANCH OF MEDIAN NERVE ARISES 5 CM PROXIMAL TO WRIST
JOINT RUNS ULNAR TO FCR 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
DEEP SURGICAL DISSECTION DISSECTION DEPENDS ON THE PROCEDURE TO
BE CARRIED OUT
SYNOVECTOMY INCISE THE EXT RETINACULAM OVER SECOND
EXT COMPARTMENT(ECRB&ECRL) SEQUENTIALLY DEROOF ALL THE
COMPARTMENTS FROM RETENACULAM PLACE THE RETINACULAM BETWEEN THE EXT
TENDONS AND DISTAL ENDS OF RADIUS & ULNA TO PROVIDE PROTECTION FOR TENDONS
FULL EXPOSURE OF WRIST JOINT INCISE RETINACULAM OVER 4TH
COMPARTMENT(EXT COMM & EXT INDI) MOBILZE AND RETRACT THE TENDONS ULNAR
AND RADIAL DIRECTION TO EXPOSE UNDERLYING RADIUS AND CAPSULE
INCISE CAPSULE LONGITUDINALLY AND DISSECT THE DORSAL RADIOCARPAL LIGAMENT TO EXPOSE DISTAL END OF RADIUS AND CARPAL BONES
TENDONS OF ECRL AND ECRB MUSCLES ATTACHED TO BASES OF 2ND &3RD MCS AND LIE IN A TUNNEL ,RETRACTED LATERALLY
VOLAR APPROACH TO WRIST
INDICATIONS DECOMPRESSION OF MEDIAN NERVE FLEXOR TENDON SYNOVECTOMY CARPAL TUNNEL TUMOR EXCISION CARPAL TUNNEL NERVE AND TENDON
REPAIR DRAINAGE OF SEPSIS TRACKING UP FROM
THE MID-PALMER SPACE ORIF OF FXS AND DISLOCATIONS OF
DISTAL RADIUS AND CARPUS ESPECIALLY VOLAR LIP INTRA-
ARTICULAR FXS
SUPINATE ARM AND PLACE ON ARMBOARD
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 DONT CROSS PERPENDICULAR TO FLEXION CREASE
ALSO HELPS PROTECT PALMER CUTANEOUS BRANCH
END 3 CM PROXIMAL TO FLEXION CREASE
SUPERFICIAL DISSECTION INCISE SKIN FLAPS SECTION FIBERS OF SUPERFICIAL PALMAR
FASCIA IN LINE WITH INCISION RETRACT CURVED FLAPS MEDIALLY TO
EXPOSE INSERTION OF PL INTO FLEXOR RETINACULUM
RETRACT PL TENDON TOWARD ULNA TO EXPOSE MEDIAN NERVE UNDER PL AND FCR
PASS A BLUNT OBJECT BETWEEN MEDIAN NERVE AND RETINACULUM.
INCISE ENTIRE LENGTH OF RETINACULUM ON ULNAR SIDE OF NERVE
PROXIMAL EXTENSION INDICATIONS
TO FURTHER EXPOSE MEDIAN NERVE
DISSECTION EXTEND INCISION UP MIDDLE OF
ARM INCISE DEEP FASCIA BETWEEN PL
AND FCR RETRACT PL AND FCR TO EXPOSE
FDS MEDIAN NERVE ADHERES TO DEEP
SURFACE OF FDS
DEEP DISSECTION AND ACCESS TO VOLAR WRIST JOINT IDENTIFY MOTOR BRANCH OF MEDIAN
NERVE (WHERE MEDIAN NERVE EMERGES FROM CARPAL TUNNEL
MOBILIZE MEDIAN NERVE AND RETRACT RADIALLY (SO DONT STRETCH MOTOR BRANCH)
MOBILIZE AND RETRACT FLEXOR TENDONS
DANGERS PALMER CUTANEOUS BRANCH OF MEDIAN
NERVE ARISES 5 CM PROXIMAL TO WRIST JOINT RUNS ULNAR TO FCR GREATEST THREAT WHEN YOU DONT
CURVE YOUR INCISION ULNAR
MOTOR BRANCH OF MEDIAN NERVE SIGNIFICANT ANATOMIC VARIATION RISK TO NERVE MINIMIZE IF INCISION
THROUGH RETINACULUM MADE ULNAR TO MEDIAN NERVE
SUPERFICIAL PALMER ARCH
INDICATIONS ULNAR N DECOMPRESSION IN GUYONS
CANAL EXPLORATION OF NRVE IN CASE OF
TRAUMA
POSITION PLACE THE HAND ON BOARD IN SUPINATED
INCISIONMAKE 5CMS CURVED INCISION OVER RADIAL BORDER OF HYPOTHENAR EMINENCE AND CROSSING WRIST JOINT OBLIQUELY ON TO THE FOREARM
VOLAR APPROACH TO ULNAR NERVE
SUPERFICIAL DISSECTION DEEPEN THE INCISION IDENTIFY FCU TENDON MOBILIZE AND RETRACT FCU
TENDON ULNARWARDS NERVE AND ARTERY EXPOSED
DEEP SURGICAL DISSECTION TRACE THE NERVE AND ARTERY
DISTALLY INCISING OVERLYING FIBROUS
TISSUE AND VOLAR CARPAL LIGAMENT
TAKE CARE TO PROTECT NERVE AND ARTERY
GUYON CANAL IS DECOMPRESSED
DANGERS ULNAR NERVE IS VULNERABLE DURING
TWO PHASES OF DISSECTION WHEN THE FASCIA ON THE RADIAL SIDE
OF THE FCU TENDON IS INCISED WHEN THE VOLAR CARPEL LIGAMENT IS
INCISED
EXTENSILE MEASURES PROXIMAL EXTENSION
INCISE SKIN LONGITUDINALLY UP TO THE MIDDLE OF THE FOREARM
INCISE THE DEEP FASCIA IDENTIFY THE RADIAL BORDER OF
FCU TENDON DEVELOP A PLANE BETWEEN FCU
AND FDS RETRACT FCU TOWARDS THE ULNA
TO REVEAL ULNAR NERVE THIS INCISION CAN EXPOSE ULNAR N
UPTO ELBOW JOINT
VOLAR APROACH TO SCAPHOID
ADVANTAGES AVOID DAMAGING THE DORSAL
BLOOD SUPPLY TO THE SUPERFECIAL RADIAL NERVE
DISADVANTAGE THREAT TO RADIAL ARTERY
INDICATIONS BONE GRAFTING FOR NON UNION
SCAPHOID EXCISION OF PROXIMAL 1/3 OF
SCAPHOID EXCISION OF RADIAL STYLOID ORIF OF FRACTURES OF
SCAPHOID
POSITION SUPINATED HAND ON BOARD
WHILE PT IS IN SUPINATION
LANDMARKS TUBEROSITY OF SCAPHOID - JUST
DISTAL TO SKIN CREASC FCR OVER THE SCAPHOID
INCISION 3 CM CURVILINEAR INCISION OVER THE
RADIALASPECT OF WRISTFROM TUBEROSITY OF SCAPHOID TO RADIAL TO FCR
SUPERFICIAL DISSECTION INCISE DEEP FASCIA IDENTIFY RADIAL. A, AND RETRACT
LATERALLY IDENTIFY FCR TENDON AND INCISE RETINACULUM OVER FCR, RETRACT
MEDIALLY
DEEP DISSECTION INCISE CAPSULE OVER SCAPHOID EXPOSES DISTAL 2/3 RD OF BONE(NON
ARTICULAR) TO GAIN BEST VIEW OF PROXIMAL 1/3/RD
BONE - PLACE THE WRIST IN MARKED DORSIFLEXION
DANGERS RADIAL ARTERY
DORSOLATERAL APPROACH TO SCAPHOID
ADVANTAGE EXCELLENT EXPOSURE OF SCAPHOID
BONE
DISADVANTAGES ENDANGERS THE SUP.RADIAL.N MAY INTERFERE WITH THE DORSAL
BLOOD SUPLY
INDICATIONS BONE GRAFTING FOR NON UNION EXCISION OF PROXIMAL NON UNITED
BONE EXCISION OF RADIAL STYLOID ORIF OF SCAPHOID
POSITION PT SUPINE ON TABLE ARM EXTENDED FORE ARM PRONATED
LANDMARKS RADIAL STYLOID PROCESS ANATOMICAL SNUFF – BOX
INCISION GENTLY CURVED, S-SHAPED INCISION
CENTERED OVER SNUFF-BOX, FROM BASE OF 1ST M.C TO 3CM ABOVE THE SNUFF-BOX
INTERNERVOUS PLANE TWO TENDONS(EPL AND EPB) ARE BOTH
SUPLIED BY PIN, WELL PROXIMAL TO WRIST -> NO INTERNERVOUS PLANE
SUPERFICIAL DISSECTION IDENTIFY EPL AND EPB TENDONS INCISE FASCIA IN BETWEEN AND NOT TO
DAMAGER THE SUPERFECIAL.RADIAL.N RETRACT TENDONS-IDENTIFY RADIAL
ARTERY OVER THE SCAPHOID
DEEP DISSECTION INCISE CAPSULE LONGITUDINALLY EXPOSE THE PROXIMAL END OF SCAPHOID
AND DISTAL END OF RADIUS PLACE THE WRIST IN ULNAR DEVIATION
AND STRIP THE CAPSULE OFF THE RADIUS
DANGERS SUPERFICIAL RADIAL.N – LIES OVER THE
TENDON OF EPL
VOLAR APPROACH TO FLEXOR TENDONS
ADVANTAGES BEST POSSIBLE EXPOSURE TO FLEXORS
TENDONS WITH SHEATHS EXPOSURE OF NEURO VASCULAR BUNDLE SKIN INCISION MAY BE EXTENDED INTO
PALM AND WRIST- ESPRCIALLY IN CASE OF TRAUMA
SKIN LACERATIONS INCORPORATED IN TO THE INCISION
DISADVANTAGES SURGERY ON PHALANGES IS NOT SELDOM
NECESSARY IN THIS APPROACH MAY LEAD TO ADHESIONS WITH IN THE
FLEXOR SHEATHS
INDICATIONS EXPLORATION AND REPAIR OF FLEXOR
TENDONS AND NEUROVASULAR BUNDLE FOR DRAINAGE OF PUS FROM FLEXOR
SHEATHS EXCISION OF TUMOURS EXCISION OF PALMAR FASCIA IN
DUPUYTREN’S CONTRACTURES
POSITION ADJUST THE HEIGHT OF THE TABLE TO
MAKE SURGEON COMFORTABLE IN SITTING
GOOD LIGHTING IG ESSENTIAL
LANDMARKS DISTAL PHALANGEAL CREASE –
PROXIMAL TO DIP PROXIMAL PHALANGEAL CREASE -
PROXIMAL TO PIP PALMAR DIGITAL CREASE – DISTAL TO
MCP JOINT
INCISION MAKE METHYLENE BLUE OUT LINE ON
PROPOSED INCISION THE ANGLES OF ZIGZAG SHOULD BE IN
900 TO EACH OTHER (LESS THAN 900 MAY POSE SKIN NECROSIS)
THE ANGLE SHOULD NOT BE TOO FAR IN DORSAL DIRECTION
SUPERFICIAL DISSECTION ELEVATE THE FLAPS WITH SKIN HOOKS
ALONG WITH SUBCUTANEOUS TISSUE DO NOT MOBILIZE FLAPS UNTIL THE
FLEXOR SHEATHS REACHED
DEEP DISSECTION FLEXOR TENDONS LIE WITHIN THE
FLEXOR SHEATH ALONG WITH DOUBLE SYNOVIAL LAYER
NEUROVASCULAR BUNDLE IS DISSECTED FROM VOLAR SUBCUTANEOUS FAT WITH A SMALL PAIR OF SCISSORS – FOR NEUROVASCULAR BUNDLE REPAIR
IMPORTANT TO PRESERVE THE A2 AND A4 PULLEYS
DANGERS DIGITAL VESSELS AND NERVES SKIN FLAPS SHOULD NOT BE CUT AT TOO
ACUTE ANGLES
DORSO LATERAL APPROACH TO FLEXOR SHEATHS
INDICATIONS OPEN REDUCTION AND STABILIZATION
OF PHALANGEAL FRXS EXPOSURE OF FIBROUS FLEXOR
SHEATHS EXPOSURE OF THE NEUROVASCULAR
BUNDLE
POSITION PT SUPINE ON TABLE ARM STRECHED OUT ON ARMBOARD EXANGUINATION AND TORNIQUE ARE
ESSENTIAL
LANDMARKS PROXIMAL AND DISTAL
INTERPHALANGEAL CREASES
INCISION MAKE A LONGITIDINAL INCISION OVER
LATERAL ASPECT OF FINGER STARTING AT DORSAL POINT OF
PROXIMAL SKIN CREASE TO DORSAL POINT OF DISTAL SKIN CREASE
INTERNERVOUS PLANE NO INTERNERVOUS PLANE AS THERE IS
NO INTERMUSCULAR PLANE DEVELOPED
SUPERFICIAL DISSECTION DEVELOP A VOLAR SKIN FLAP BY
INCISING THE SUBCUTANEOUS FAT NEUROVASCULAR BUNDLE LIE IN THE
VOLAR FLAP NOT TO INCISE JOINTS
DEEP DISSECTION INCISE FIBROUS FLEXOR SHEATH
LONGITUDINALL TO EXPOSE UNDERLYING TENDON
DANGERS PALMAR DIGITAL NERVE
TOO FAR VOLAR INCISION MAY ENDANGER THE PALMAR NERVE
VOLAR DIGITAL.A
DRAINAGE OF MIDPALMAR SPACE
INCISION MAKE A TRANSVERSE INCISION JUST
PROXIMAL TO THE DISTAL PALMAR CREASE OVER THE SWELLING
SURGICAL DISSECTION INCISE THE SKIN CAREFULLY , IT CROSSES
THE PATHS OF DIGITAL NERVE OPEN THE PALMAR FASCIA BY BLUNT
DISSECTION IDENTIFY LONG FLEXOR TENDON OF RING
FINGER ENTER THE PALMAR SPACE BY BLUNT
DISSECTION ON THE RADIAL SIDE OF TENDON
DANGERS DIGITAL NERVES AND VESSELS IMMEDIATELY
UNDER THE PALMAR APONEUROSIS PALMAR APONEUROSIS SHOULD NOT BE
INCISED
DRAINAGE OF THENAR SPACE
INCISION MAKE 4CMS CURVED INCISON ON ULNAR
SIDE OF THENAR CREASE
SURGICAL DISSECTION DEEPEN DISSECTION IN LINE WITH THE
SKIN INCISION PRESERVE THE DIGITAL NERVES TO THE
INDEX FINGER IDENTIFY FLEXOR TENDON OF INDEX
FINGER DEEP TO THE TENDON IS THENAR SPACE
OPEN BY BLUNT DISSECTION
DANGERS MOTOR BRANCH TO THENAR MUSCLE MAY BE ENCOUNTERED AT THE
PROXIMAL BORDER OF INCISION
DRAINAGE OF PARONYCHIA INTRODUCTION
INFEECTION OF NAIL FOLD M.C. INFECTION OF HAND CAUSED BY STAPH.AUREUS PUS DISTENDS THE CUTICLE AND
SOME TIMES NAIL BED
INCISION SHORT LONGITUDINAL INCISION ON
ONE OR BOTH SIDES OF NAIL BED
DISSECTION RAISE THE SKIN FLAP AT BASE OF
NAIL EVACUATE PUS BETWEEN NAIL
&CUTICLE EXCISE HALF OF NAIL IF NAIL BED
IS INVOLVED OCCASINALLY A NICK MAY SUFFICE
DRAINAGE TO FELON IT IS THE PULP SPACE INFECTION REQUIRES
SURGICAL INTERVENTION CAUSES BY A PENETRATING INJURY
IT IS OF 2 TYPES SUPERFICIAL INFECTION – POINT OUT
AT VOLAR SKIN DEEP INFECTION – MORE LIKELY TO
CAUSE OSTEO. MYELTIS OF PHALANX IF THE ABSCESS IS POINTED ON VOLAR PULP –
GIVE INCISE ON LAT.SIDE OF VOLAR SURFACE AND ENTER THE CAVITY AND DRAIN
IF NOT POSSIBLE(SURGICAL DRAINAGE REQ) INCISION
STRAIGH LAT.INCISION OVER DISTAL PHALIX OF FINGER
TIP OF FINGER TO 1CM DISTAL D.I.P JOINT OFF THE SEPTA FROM BONE WITH DEEP
DISSECTION CAREFULLY OPEN ALL LOCULS WOUND KEPT OPEN
THANK YOU