HAND
Approaches
Finger – midaxial, Bruners
Hand – transverse incisions for A-1 pully releases, Dupuytren’s
-approach to 1st CMC
-approach to 2nd metacarpal for ex-fix
Anatomy
Fingertip
Nail bed (germinal matrix, sterile matrix)
Nail plate
Eponychium
Hyponychium
Pulp
Distal Interphalangeal Joint
Collateral ligament
Accessory collateral ligament
Extensor tendon insertion
Flexor tendon
Palmar plate
Proximal Interphalangeal Joint
Palmar plate + checkreins
Central band
Lateral bands
Collateral ligament
Accessory collateral ligament
Deccusation of FDS
FDP
Metacarpophalangeal Joint
Collateral ligament
Accessory collateral ligament
Palmar plate with attachment of deep transverse metacarpal ligament
Lumbrical
Interossei
Sagittal band
Digit
Pullys
Fibrous tendon sheath
Digital artery and nerve (nerve volar to artery)
Grayson’s ligaments
Cleland’s ligaments
Lateral digital sheet
Palm
Palmaris longus
Palmar aponeurosis
Pretendinous bands
Central bands
Spiral bands
Palmer digital artery and nerve
Natatory ligament
1st CMC Joint
1st and 2nd metacarpals
Trapezium
Trapezoid
Palmar oblique ligament
Ulnar collateral ligament
FCR insertion
Carpal tunnel/transverse carpal ligament
APL insertion
Dorsal: 1st dorsal interosseous muscle, radial artery
WRIST
Approaches
Carpal tunnel release, can be extended to palmar approach to lunate
Scaphoid – volar (note the radial artery including superficial palmar branch and the tendon of FCR) and dorsal (note dorsal carpal branch of radial artery)
Dorsal approach to wrist
Volar approach to distal radius
Approach to 1st dorsal compartment
Anatomy
Ligaments:
VolarRadioscaphocapitate
Radioscapholunate
Long and short radiolunate
Ulnocarpal group
Dorsal
Radiolunate
Radiotriquetral
Intercarpal
Scapholunate
Lunotriquetral
Dorsal intercarpal
TFCC - consists of articular disc (triangular fibrocartilage), meniscus homologue (lunocarpal), ulnocarpal ligament, dorsal & volar radioulnar ligament, and ECU sheath
Carpal Tunnel:
Median nerve, thenar motor branch, palmar cutaneous brance
Palmaris longus
Palmaris brevis
Hook of the hamate
Guyon’s Tunnel
1st common digital nerve
Superficial palmar arch
Flexor carpi radialis
Flexor pollicis longus
Guyon’s Tunnel
Pisiform
Hook of the hamate
Pisohamate ligament
FCU
Transverse carpal ligament
Palmar carpal ligament
Ulnar artery and nerve, superficial and deep branches
FOREARM
Approaches
Anterior approach to radius (Henry)
Posterior approach to radius
Ulnar approach
Mid-shaft radial apptoach for ex-fix
ELBOW
Approaches
Posterior approach + olecranon osteotomy – fixation of distal humeral comminuted fractures
Lateral column exposure – anterior-posterior capsular release
Kocher – radial head, lateral collateral ligament
Posterior-medial approach – ORIF medial column, ankylosis release
Medial exposure of the coronoid – coronoid fracture
Medial approach – exposure of ulnar nerve, ORiF coronoid, medial humerus
Anterolateral approach – ORIF capitellum or proximal radius
Anatomy
Basilic vein and medial antebrachial cutaneous nerve
Lateral antebrachial cutaneous nerve - biceps and brachialis
Radial nerve - brachialis and brachioradialis
Superficial radial nerve - brachioradialis
Posterior interosseous nerve – supinator, Arcade of Frohse, biceps insertion
Radial artery – median nerve, biceps tendon, brachialis, pronator teres
Median nerve – radial artery, biceps tendon, bicipital aponeurosis, brachioradialis, pronator teres, FDS, FDP, ulnar artery
Ulnar nerve – 2 heads of FCU
Anterior interosseous nerve – FDP, FPL
Biceps tendon insertion – radial artery, radial nerve, PIN
Kocher approach – ECU, acnoneus, radial collateral ligament, lateral ulnar collateral ligament, annular ligament, PIN
Structures of Nerve Compression
Median Nerve :
2 heads of pronator teres (humeral and ulnar heads), tendinous arch of FDS, bicipital aponerosis, ligament of Struthers (bridge between medial epicondyle and supracondylar process)
Anterior Interosseous Nerve:
Ulnar head of the pronator teres, tendinous arch of FDS
Ulnar Nerve:
Arcade of Struthers
Medial epicondyle
Osbourne’s Fascia
FCU
PIN:
ECRB
Arcade of Frohse
Leash of Henry (recurrent radial vessels)
The Humerus
Approaches
Posterior (triceps splitting)
Modified posterior approach (Gerwin et al)
Anterolateral approach