Volar exposure of the schaphoid specific

Reverse Carpal Tunnel Syndrome

Natural Carpal Tunnel Syndrome Treatment

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The volar approach to the scaphoid was popularized by Russe after his description of scaphoid fracture nonunion repair [26-28]. This approach is primarily indicated for the open reduction and fixation of scaphoid waist or distal pole fractures. The advantages of this approach include preservation of the vascularity of the scaphoid by avoiding the dorsal distal blood supply, and an easier ability to correct apex dorsal angulations (humpback deformity) of scaphoid waist non-unions or malunions [29]; however, one problem with the approach is the potential of carpal instability as a result of the required

Humpback Deformity

Fig. 13. (A) Design of the extended carpal tunnel skin incision for exposure of the volar carpus (zigzag line). Care must be taken in its location and design to preserve the palmar cutaneous branch of the median nerve and its ulnar branches, the palmar cutaneous branch of the ulnar nerve, and the ulnar neurovascular bundle. (B) Once through the skin and subcutaneous tissue, the superficial palmar fascia will be encountered in the hand and in the forearm, the thin antebra-chial fascia. These fibers can be split or incised in a longitudinal manner until the transverse fibers of the flexor retinac-ulum are identified (dashed lines). (C) After incising the flexor retinaculum (dashed line), the retinacular flaps can be held open with self-retaining retractors to expose the contents of the carpal tunnel. (D) Gentle retraction of the flexor tendons and the median nerve will allow exposure of the volar capsule of the wrist joint. In cases of perilunate fracture dislocations, a transverse rent in the Space of Poirier can be identified, as illustrated here (A-D copyright 2006 Mayo Clinics, reproduced with permission of the Mayo Foundation.)

Fig. 13. (A) Design of the extended carpal tunnel skin incision for exposure of the volar carpus (zigzag line). Care must be taken in its location and design to preserve the palmar cutaneous branch of the median nerve and its ulnar branches, the palmar cutaneous branch of the ulnar nerve, and the ulnar neurovascular bundle. (B) Once through the skin and subcutaneous tissue, the superficial palmar fascia will be encountered in the hand and in the forearm, the thin antebra-chial fascia. These fibers can be split or incised in a longitudinal manner until the transverse fibers of the flexor retinac-ulum are identified (dashed lines). (C) After incising the flexor retinaculum (dashed line), the retinacular flaps can be held open with self-retaining retractors to expose the contents of the carpal tunnel. (D) Gentle retraction of the flexor tendons and the median nerve will allow exposure of the volar capsule of the wrist joint. In cases of perilunate fracture dislocations, a transverse rent in the Space of Poirier can be identified, as illustrated here (A-D copyright 2006 Mayo Clinics, reproduced with permission of the Mayo Foundation.)

division of the radiocarpal ligaments (radiosca-phocapitate and long radiolunate ligaments) [30].

Skin incision and subcutaneous tissue

A longitudinal incision, over the FCR tendon is carried proximally for 1.5 to 2 cm from scaphoid tuberosity. The distal incision angles toward and is in line with the thumb metacarpal (Fig. 15A). Care must be taken not to cross the ul-nar border of the FCR because the palmar cutaneous branch of the median nerve lies there.

Deeper dissection

The FCR tendon sheath is then divided longitudinally, and the tendon is mobilized as far as the scaphoid tuberosity distally and retracted ulnarward. In the distal portion of the wound, it will be necessary to ligate and divide the superficial branch of the radial artery, which at times can be quite sizeable (Fig. 15B,C). The deep tendon sheath of the FCR tendon is divided longitudinally, together with the pericapsular fat underlying it. Division of the pericapsular fat will reveal the palmar wrist capsule, which in this region contains the capsular ligaments of the radioscaphocapitate and the long radiolunate ligament (Fig. 15D). The long radiolunate and radioscaphocapitate ligaments are sharply divided (Fig. 15E), exposing the scaphoid waist (Fig. 15F).

Closure

The radioscaphocapitate and long radiolunate ligaments must be repaired stoutly with sutures if one is to avoid potential carpal stability problems [30].

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