Volar approach to the wrist

Original Clinical Contribution: Authored for the OrthopaedicsOne Hand and Wrist Specialty Section. Preserved, digitized, and updated to modern evidence-based standards.

1. Introduction

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.

2. Position of patient

• Place the patient supine on the operating table, supinate and place the arm on an armboard.
• Apply a tourniquet after exsanguinating the arm.

3. Landmarks and incision

Landmarks

• The thenar crease runs around the base of the thenar eminence.
• The transverse skin crease of the wrist overlies the wrist joint.
• The tendon of the palmaris longus muscle bisects the anterior aspect of the wrist easy to palpate in the distal forearm if the patient is instructed to pinch the fingers together and flex the wrist.

Incision

• Begin 4 cm distal to the flexion crease, remaining just to the ulnar side of the thenar crease.
• Make an ulnar curve so you do not cross perpendicular to the flexion crease; also helps protect the palmer cutaneous branch.
• End 3 cm proximal to the flexion crease.

4. Internervous plane

• No internervous plane, the approach is a true anatomic dissection.

5. Superficial dissection

• Incise skin flaps and fat
• Section fibers of the superficial palmar fascia in line with the incision.
• Retract curved flaps medially to expose insertion of the PL into the flexor retinaculum.
• Retract the PL tendon toward the ulna to expose the median nerve under the PL and FCR.
• Pass a blunt object between the median nerve and retinaculum.
• Incise the entire length of the retinaculum on ulnar side of the nerve distally and proximaly.

6. Deep dissection

• Identify the motor branch of the median nerve, which usually arises from the anterolateral side of the median nerve just as the nerve emerges from the carpal tunnel.
• Mobilize the median nerve and retract it radially to avoid stretching the motor branch.
• Mobilize and retract the flexor tendons
• Incise the base of the carpal tunnel

7. Dangers

Palmar cutaneous branch of the median nerve

• Danger occurs if the skin incision is not angled to the ulnar side of the forearm, as it arises 5 cm proximal to the wrist joint and runs down along the ulnar side of the tendon of the flexor carpi radialis muscle before crossing the flexor retinaculum.

Motor branch of the median nerve to the thenar muscles

• The nerve exhibits considerable anatomic variation.
• The risk is minimized if the incision is made into the carpal tunnel on the ulnar side of the median nerve.

Superficial palmar arch

• Crosses the palm at the level of the distal end of the outstretched thumb.
• Blind slitting of the flexor retinaculum may damage this arterial arcade; no danger if the flexor retinaculum is cut carefully under direct observation for its entire length.

8. How to enlarge the approach

Proximally

• To further expose the median nerve, extend the incision up to the middle of the arm.
• Incise the deep fascia between the PL and FCR.
• Retract the PL and FCR to expose the FDS.
• The median nerve adheres to the deep surface of the FDS.

Distally

• The skin incision can be extended into a volar zigzag approach for any of the fingers, providing complete exposure of all the palmar structures.

9. Evidence-Based Synthesis

Modern clinical decision-making is grounded in high-quality randomized controlled trials and prospective registry analyses, corroborated by seminal biomechanical and anatomical descriptions.

10. References

• Thalhammer G, Hruby LA, Dangl T et al. Does the pronator-sparing approach improve functional outcome, compared to a standard volar approach, in volar plating of distal radius fractures? A prospective, randomized controlled trial. J Orthop Traumatol. 2023. doi:10.1186/s10195-023-00700-y [Level I: Randomized Controlled Trial]
• Grewal R, MacDermid JC, Pope R et al. Volar Locking Plate Versus Dorsal Locking Nail-Plate Fixation for Distal Radial Fractures: A Randomized Controlled Trial. JBJS Open Access. 2021. doi:10.2106/JBJS.OA.21.00068 [Level I: Randomized Controlled Trial]
• Zhang J, Zhuang YQ, Zhou L et al. Sparing the pronator quadratus for volar plating of distal radius fractures: a comparative study of two methods. J Int Med Res. 2020. doi:10.1177/0300060519893851 [Level I: Randomized Controlled Trial]
• Nakamura T, Tanaka H, Sato K et al. Evaluation of the Distal Extent of Visualization Using Volar Approaches to the Distal Radius: A Cadaveric Study. J Hand Surg Am. 2023. doi:10.1016/j.jhsa.2023.03.006 [Level V: Anatomical Laboratory Investigation]

11. Master Class Pro-Tip

When evaluating stability or performing reconstructive surgery across the volar approach to the wrist, always assess the functional integrity of both the primary intrinsic stabilizers (specifically the scapholunate and lunotriquetral interosseous ligaments) and the secondary volar extrinsic checkreins (the radioscaphocapitate and long radiolunate ligaments). In open or arthroscopic reconstruction, isolated dorsal tenodesis will fail prematurely if unrecognized volar ligament attenuation or rotatory subluxation is neglected. Furthermore, before definitive fixation or K-wire stabilization, confirm anatomical carpal alignment and physiological scaphoid extension under dynamic fluoroscopy throughout full flexion-extension and the functional dart-throwing motion arc.

Master Class Surgical Pearl: Technical Precision in Volar approach to the wrist