Operations

Question 1

Describe the traditional dorsal approach to the wrist, including the radially based Mayo ligament sparing capsulotomy.

Answer 1

1. Longitudinal skin incision across the wrist line with the third metacarpal.
2. Dessection down to the extensor retinaculum with care taken to preserve superficial sensory branches of radial nerve.
3. Identification of Lister’s tubercle and EPL tendon.
4. Longitudinal incision to enter third dorsal compartment and subsequent radial retraction of EPL.
5. Fourth and fifth extensor compartments elevated from radial to ulnar in subperiosteal plane.
6. Retinaculum covering Lsiter’s elevated subperiosteally from ulnar to radial until second compartment tendons exposed.
7. Self-retaining retractor placed to retract EPL + second compartment radially and 4th/5th compartments ulnarly.
8. Dorsal radiocarpal (DRC) and dorsal intercarpal (DIC) ligaments split longitudinally with apex at the triquetrum. Capsule divided off the dorsal lip of the radius to yield radially based rectangular flap. Care taken to preserve LT and SL ligaments.

** If exposure of the ulnocarpal joint / TFCC is required the DRC is divided longitudinally (as above) but a proximally based triangular flap is created by a vertical capsular extension parallel to the 6th compartment.

Question 2

Describe the dorsal approach to ulnocarpal joint and TFCC.

Answer 2

1. Longitudinal skin incision across the wrist line with the third metacarpal.
2. Dessection down to the extensor retinaculum with care taken to preserve superficial sensory branches of radial nerve.
3. Identification of Lister’s tubercle and EPL tendon.
4. Longitudinal incision to enter third dorsal compartment and subsequent radial retraction of EPL.
5. Fourth and fifth extensor compartments elevated from radial to ulnar in subperiosteal plane.
6. Retinaculum covering Lsiter’s elevated subperiosteally from ulnar to radial until second compartment tendons exposed.
7. Self-retaining retractor placed to retract EPL + second compartment radially and 4th/5th compartments ulnarly.
8. The DRC is divided longitudinally and a proximally based triangular flap is created by a vertical capsular extension parallel to the 6th compartment.

Question 3

Describe the approach for a trapeziectomy and LRTI.

Answer 3

1. Wagner incision designed at the junction of glaborous and non-glaborous skin at the base with the thumb.
2. Dessection down to the joint capsule of the 1st metacarpal and trapezium with care to preserve superficial sensory of the radial nerve.
3. Radial artery identified proximally and protected.
4. Subperiosteal dissection of joint capsule to expose trapezium.
5. Trapezium excised with sharp dissection and aid of K-wire for joystick.
6. 50% of FCR incised at musculotendinous junction and passed into CMC space with tendon passer.
7. Bone tunnel drilled in based of 1st CMC and FCR secured to itself. Remaining portion of FCR formed into anchovy and placed into defect.
8. 1st CMC stabilized with K-wire.
9. Wound closed and splint placed.
   10.