SURGICAL APPROACHES TO

THE TRAUMATIZED WRIST

Presentation can be downloaded at www.diuchirurgiemain.org

CHRISTIAN DUMONTIER, MD, PHD

CENTRE DE LA MAIN, GUADELOUPE
With the help of Duparc, Le Viet, Brunelli & Dubert

SURGICAL PRINCIPLES HAVE BEEN UNCHANGED SINCE WILLIAM HALSTED

Gentle handling of tissue
Meticulous haemostasis (the use of a
tourniquet is not an excuse)
Preservation of blood supply
Strict aseptic technique
Minimum tension on tissues
Accurate tissue apposition
Obliteration of deadspace
To conform to surgical principles one should
choose the correct surgical approach

PRINCIPLES WHEN CHOOSING A SURGICAL APPROACH

Draw before incision: project
yourself from the skin to the bones

PRINCIPLES WHEN CHOOSING A SURGICAL APPROACH

Draw before incision: project yourself from
the skin to the bones
Install the patient and yourself comfortably
Be sure you have all the instruments and
devices you need
Choose an approach that allow you:
To do what you have planned !
To extend the incision if needed:
Incision are usually in the axis of the
wrist
Rarely zig-zag incision at the wrist

No

MOST FREQUENT WRIST INJURIES

Distal radius fractures

Scaphoid fractures
Scapholunate injuries
Peri-lunate injuries
Ulnar head injuries

DISTAL RADIUS FRACTURES

K-wires (Kapandjis technique)

Locking plates: Trans-FCR
approach

K-WIRING IN DRF
Start with the radial one (the radial
column is restored first, for ideal
length of the radius)
Radial nerve (up to 25%
complications have been
reported, mostly during
removal)
1st extensor tendons
compartment
Brachioradialis

K-WIRING IN DRF
Then place the dorso-radial KWire, lateral to the EPL (radial to
Listers tubercle +++)
2nd extensor tendons
compartment
Then the dorso-ulnar one, oriented
laterally to stay into the radius
4th compartment, NIOP ?

ANTERIOR APPROACH: THE TRANS-FCR APPROACH

Close to Henrys Approach (same
skin incision)
Go through the FCR sheath to
avoid dissection and coagulation
of radial artery branches
Beware of the subcutaneous nerve
branches, i.e. the cutaneous branch
of the median nerve

ANTERIOR APPROACH: THE TRANS-FCR APPROACH

Leave the EPL muscle ulnarly (to
avoid its devascularization)
Release the pronator quadratus
(trans-muscle w/wo suture of the
fascia (Ehrardt) or laterally)
PQ repair might reduce pain in
the early postoperative period.
Open the radial most insertion of
the 1st compartment (and release
the brachioradialis)
Hberle S, Sandmann GH, Deiler S, Kraus TM, Fensky F, Torsiglieri T, Rondak IC, Biberthaler P, Stckle U, Siebenlist S.Pronator quadratus
repair after volar plating of distal radius fractures or not? Results of a prospective randomized trial. Eur J Med Res. 2015 Nov 25;20:93.
Erhard L, Bou farah C, Elkholti K, Ninou M, Rostoucher P. [Pronator quadratus repair using the Henry approach with an outward-return
running suture]. Rev Chir Orthop Reparatrice Appar Mot. 2007 Jun;93(4):381-4.

SCAPHOID FRACTURES

Anterior approach
How to place your screw in the
middle of the scaphoid ?
Posterior approach
No danger
Lateral approach
For the treatment of non-union
using Zaidenbergs vascularized
graft

PER-CUTANEOUS ANTERIOR APPROACH TO THE SCAPHOID

Fluoroscopy +++
Draw the axis of the scaphoid on
both the AP and lateral view
Incision over the STT
Enter slightly laterally to be in the
middle at the proximal pole
Make a trench in the trapezium
Pass through the trapezium (only
solution to be in the middle in both
the proximal and middle third of the
scaphoid)
Verstreken F, Meermans G. Transtrapezial approach for fixation of acute scaphoid fractures: rationale, surgical
techniques, and results: AAOS exhibit selection. J Bone Joint Surg Am. 2015;97(10):850-858.

OPEN APPROACH FOR THE FRACTURED SCAPHOID

Anterior Russe incision (either a

zig-zag incision, or a J type)
The radio-carpal artery goes
through the incision (ligate it)
Incision is radial to the FCR
Direct incision over the RSL

POSTERIOR APPROACH OF THE FRACTURED SCAPHOID

Incision medial to Lister tubercle
Release the EPL
Longitudinal capsular incision
How far distally ?

POSTERIOR APPROACH OF THE FRACTURED SCAPHOID

The screw is in the axis of the
abducted thumb with the wrist
in flexion

PERI-LUNATE INJURIES ARE TREATED THROUGH A POSTERIOR APPROACH

Small arch of Mayfield

Scapholunate
Perilunate dislocation
Greater arch of Mayfield
Trans-scapho PLD
Others including Fentons injury

Posterior approach, large incision to get access to all lesions

SKIN INCISION
Longitudinal
Over the 3/4 extensor
compartments
Incise longitudinally the extensor
retinaculum over the 4th
compartment

TO ENTER THE JOINT

If the capsule is torn
If not, prefer the Berger incision
over the ligaments
Large view
Dorsal ligaments are proprioreceptors
Solid sutures at the end

KNOWLEDGE OF THE ANATOMY IS STILL

THE BASIS OF SURGERY.
SURGICAL APPROACHES RELY ON THE
KNOWLEDGE OF BOTH THE ANATOMY AND
THE PATHOPHYSIOLOGY OF THE INJURY

CONCLUSION ?