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Surgical approaches to  forearm wrist hand
Surgical approaches to  forearm wrist hand
Surgical approaches to  forearm wrist hand
Surgical approaches to  forearm wrist hand
Surgical approaches to  forearm wrist hand
Surgical approaches to  forearm wrist hand
Surgical approaches to  forearm wrist hand
Surgical approaches to  forearm wrist hand
Surgical approaches to  forearm wrist hand
Surgical approaches to  forearm wrist hand
Surgical approaches to  forearm wrist hand
Surgical approaches to  forearm wrist hand
Surgical approaches to  forearm wrist hand
Surgical approaches to  forearm wrist hand
Surgical approaches to  forearm wrist hand
Surgical approaches to  forearm wrist hand
Surgical approaches to  forearm wrist hand
Surgical approaches to  forearm wrist hand
Surgical approaches to  forearm wrist hand
Surgical approaches to  forearm wrist hand
Surgical approaches to  forearm wrist hand
Surgical approaches to  forearm wrist hand
Surgical approaches to  forearm wrist hand
Surgical approaches to  forearm wrist hand
Surgical approaches to  forearm wrist hand
Surgical approaches to  forearm wrist hand
Surgical approaches to  forearm wrist hand
Surgical approaches to  forearm wrist hand
Surgical approaches to  forearm wrist hand
Surgical approaches to  forearm wrist hand
Surgical approaches to  forearm wrist hand
Surgical approaches to  forearm wrist hand
Surgical approaches to  forearm wrist hand
Surgical approaches to  forearm wrist hand
Surgical approaches to  forearm wrist hand
Surgical approaches to  forearm wrist hand
Surgical approaches to  forearm wrist hand
Surgical approaches to  forearm wrist hand
Surgical approaches to  forearm wrist hand
Surgical approaches to  forearm wrist hand
Surgical approaches to  forearm wrist hand
Surgical approaches to  forearm wrist hand
Surgical approaches to  forearm wrist hand
Surgical approaches to  forearm wrist hand
Surgical approaches to  forearm wrist hand
Surgical approaches to  forearm wrist hand
Surgical approaches to  forearm wrist hand
Surgical approaches to  forearm wrist hand
Surgical approaches to  forearm wrist hand
Surgical approaches to  forearm wrist hand
Surgical approaches to  forearm wrist hand
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Surgical approaches to forearm wrist hand

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  • 1. SURGICAL APPROACHES TO FOREARM ,WRIST AND HAND DR.RAJESH PG, MS(ORTHO) GMC,SEC
  • 2.  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)
  • 3.  POSITION  PLACE SUPINE ON TABLE AND SUPINATE  ARM AND PLACE ON ARMBOARD  EXSANGUINATE ARM  INCISION LONGITUDINAL INCISION  BEGIN JUST LATERAL TO BICEPS TENDON ON FLEXOR CREASE OF ELBOW  END AT RADIAL STYLOID PROCESS
  • 4.  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
  • 5.  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
  • 6.  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
  • 7. DANGERS  POSTERIOR 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
  • 8. 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 PARALYSIS  RESISTANT TENNIS ELBOW  RADIAL OSTEOTOMY  OSTEOMYELITIS AND BONE TUMORS
  • 9.  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)
  • 10.  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
  • 11.  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
  • 12.  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
  • 13. 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
  • 14.  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
  • 15.  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
  • 16. 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
  • 17.  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
  • 18. 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
  • 19.  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
  • 20. 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
  • 21.  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
  • 22. 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
  • 23.  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
  • 24.  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
  • 25. DORSAL APPROACH TO WRIST INDICATIONS  WRIST FUSION  SYNOVECTOMY AND REPAIR OF EXTENSOR TENDONS  EXCISION OF LOWER END OF RADIUS  PROXIMAL ROW CARPECTOMY  ORIF OF DISTAL RADIUS FX (DISPLACED INTRA-ARTICULAR DORSAL LIP FXS)  CARPAL FX AND DISLOCATIONS  DANGERS  RADIAL ARTERY  RADIAL NERVE (SUPERFICIAL RADIAL NERVE)  POSTERIOR INTEROSSEOUS NERVE
  • 26.  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
  • 27.  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
  • 28.  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
  • 29.  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
  • 30. 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
  • 31.  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
  • 32.  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
  • 33.  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
  • 34.  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
  • 35.  INDICATIONS  ULNAR N DECOMPRESSION IN GUYONS CANAL  EXPLORATION OF NRVE IN CASE OF TRAUMA  POSITION PLACE THE HAND ON BOARD IN SUPINATED INCISION MAKE 5CMS CURVED INCISION OVER RADIAL BORDER OF HYPOTHENAR EMINENCE AND CROSSING WRIST JOINT OBLIQUELY ON TO THE FOREARM VOLAR APPROACH TO ULNAR NERVE
  • 36.  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
  • 37.  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
  • 38. 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
  • 39.  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
  • 40. 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
  • 41.  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
  • 42. 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
  • 43.  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
  • 44.  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
  • 45. 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
  • 46.  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
  • 47. 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
  • 48. 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
  • 49. 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
  • 50. 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
  • 51. THANK YOU

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