Volar carpal exposure carpal tunnel approach

Carpal Tunnel Master And Beyond

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There are essentially two types of volar carpal exposures, one that divides the transverse carpal ligament and one that uses a modified Henry approach. The volar carpal exposure is most commonly used to reduce difficult carpal dislocations (perilunar) and for repair or reconstruction of the palmar wrist capsule and the palmar carpal ligaments. Volar approaches are also useful for reduction and fixation of palmar fragments of difficult distal radius fractures. The volar approach is often used in combination with a dorsal approach in the management of the Mayfield type of carpal injuries [19-21].

Dorsal Approach Distal Radius

Fig. 9. (A) The ligament-sparing dorsal capsulotomy can be created using the radiotriquetral and scaphotriquetral ligaments, as shown in this clinical case (lines drawn with marking pen). To gain access to the radial aspect of the wrist, the capsule between the radius and scaphoid can be divided as well. (B) The ligament-sparing dorsal capsulotomy involves identification of the dorsal radiocarpal and dorsal intercarpal ligaments, followed by a fiber-splitting approach that bisects the ligaments (lines). To facilitate radial exposure, the radial origin of the dorsal radiocarpal ligament can be elevated toward the radial styloid and the capsule between the radius and scaphoid can be divided. (Copyright 2006 Mayo Clinics, reproduced with permission of the Mayo Foundation.)

Fig. 9. (A) The ligament-sparing dorsal capsulotomy can be created using the radiotriquetral and scaphotriquetral ligaments, as shown in this clinical case (lines drawn with marking pen). To gain access to the radial aspect of the wrist, the capsule between the radius and scaphoid can be divided as well. (B) The ligament-sparing dorsal capsulotomy involves identification of the dorsal radiocarpal and dorsal intercarpal ligaments, followed by a fiber-splitting approach that bisects the ligaments (lines). To facilitate radial exposure, the radial origin of the dorsal radiocarpal ligament can be elevated toward the radial styloid and the capsule between the radius and scaphoid can be divided. (Copyright 2006 Mayo Clinics, reproduced with permission of the Mayo Foundation.)

Skin incision and subcutaneous tissue

There are many variations of the carpal tunnel approach; however, they are essentially all an extended open carpal tunnel release. One such incision follows the curve of the thenar muscles to the level of the wrist crease, and then extends proximally via a zigzag incision (Fig. 13A). The distal extent of the incision is Kaplan's cardinal line, and the proximal extent is determined by the surgeon. To minimize the chance of damage to the palmar cutaneous branch of the median nerve and its ulnar branches, the incision should be aligned between the long/ring finger web space [22] or 5 mm ulnar to the interthenar depression, which is the deepest point between the thenar and hypothenar eminences [23]. To avoid damaging the branches of the palmar cutaneous branch of the ulnar nerve, the palmar incision should not be sited any more ulnar than the longitudinal axis of the ring finger when extended [24]. At the level of the distal wrist crease, the incision should be zigzagged, starting in an ulnar direction, into the distal forearm as needed. Care should be taken in designing the zigzag incision to avoid damaging the palmar cutaneous branch of the median nerve in the distal forearm [25] on the radial side, and the ulnar neurovascular bundle on the ulnar side. The superficial palmar fascia, with its longitudinal fibers, and the antebrachial fascia should then be incised in a longitudinal fashion (Fig. 13B).

Retinaculum

After identifying the median nerve proximally, which is radial and deep to the palmaris longus tendon, the flexor retinaculum is identified. The flexor retinaculum has thick transverse crisscross fibers, and is divided on the ulnar aspect of the carpal canal just radial to the hook of the hamate (Fig. 13C). The contents of the carpal canal can be looped in a Penrose drain and retracted radially or ulnarly to expose the volar wrist capsule and the pronator quadratus muscle (Fig. 13D).

Kienbocks Disease Surgery

Fig. 10. (A) On completion of the dorsal capsulotomy, the scaphoid, lunate, and portions of the capitate and triquetrum are immediately visible. (Copyright 2006 Mayo Clinics, reproduced with permission of the Mayo Foundation.) (B) Appropriate retractions of the capsule and palmar flexion of the wrist will maximize the full exposure potential of this capsulotomy.

Fig. 10. (A) On completion of the dorsal capsulotomy, the scaphoid, lunate, and portions of the capitate and triquetrum are immediately visible. (Copyright 2006 Mayo Clinics, reproduced with permission of the Mayo Foundation.) (B) Appropriate retractions of the capsule and palmar flexion of the wrist will maximize the full exposure potential of this capsulotomy.

Capsule

Here again, the palmar wrist capsule contains important capsular ligaments [4-6]. To avoid potential postoperative problems associated with ulnar translation of the carpus, efforts should be made to minimize ligament disruption. This can be accomplished by leaving the long radiolunate ligament intact. This ligament tethers the trique-trum to the radius with the palmar lunotriquetral ligament [6]. Thus, the interligamentous sulcus or the space of Poirier is the first place to begin the capsulotomy using a fiber-splitting approach. If additional exposure is required on the radial side, a subperiosteal elevation of the radial origin of the radioscaphocapitate ligament or the long radiolunate ligament (but preferably not both), can be performed continuing from the incision in the space of Poirier. Typically, this approach is used to repair the injured space of Poirer in perilunate fracture dislocations (Fig. 14).

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