Wrist - Volar Approach

Modern Study Review (AI-Generated)

High-Yield Summary

The volar (palmar) approach to the wrist is the gold standard for open carpal tunnel release, distal radius fracture fixation, and addressing volar wrist pathology. It offers direct, wide exposure of the carpal tunnel and volar wrist structures with excellent visualization while minimizing soft tissue trauma. Although endoscopic techniques are increasingly used for select cases, the open volar approach remains indispensable for complex fractures and procedures requiring rigid fixation or extensive soft tissue management.

Applied Anatomy & Intervals

Internervous Interval

No true internervous plane exists. Dissection proceeds carefully between tendons and neurovascular structures, with meticulous retraction to avoid injury.

Anatomic Landmarks

Ulnar side of the thenar crease (incision start point)
Palmaris longus (PL) tendon (key for dissection and retraction)
Flexor carpi radialis (FCR) tendon (palmar cutaneous branch of median nerve lies ulnar to this)
Flexor retinaculum (transverse carpal ligament)

Patient Positioning & Setup

Table Type: Standard operating table with arm board
Patient Position: Supine, arm abducted on arm board, wrist supinated
Specialized Equipment:
Pneumatic tourniquet on upper arm for bloodless field
Hand table or padded arm support
C-arm fluoroscopy positioned for AP and lateral views if fracture fixation is planned

Surgical Technique (The “Vital Steps”)

Incision & Superficial Dissection

Longitudinal or slightly curved incision on the ulnar side of the thenar crease, extending distally toward the wrist flexion crease.
Stay ulnar to the PL tendon to protect the palmar cutaneous branch of the median nerve.
Elevate skin flaps carefully, identifying and preserving the palmar cutaneous branch, which typically runs along the ulnar side of the FCR tendon.

Deep Dissection & Exposure

Incise the superficial palmar fascia in line with the skin incision.
Identify and isolate the PL tendon; retract it ulnarly to expose deeper structures.
Locate the median nerve between the PL and FCR tendons.
Incise the flexor retinaculum on the ulnar side of the median nerve to avoid injury to the motor branch.
Retract the median nerve radially and tendons as needed to expose the carpal tunnel and volar wrist structures.
Proceed with the intended procedure (e.g., carpal tunnel release, distal radius fixation).

The “Danger Zone”

Structure	Location / Risk Area	Protection Strategy
Palmar cutaneous branch of median nerve	Arises ~5 cm proximal to wrist; runs ulnar to FCR tendon	Stay ulnar to PL tendon; careful skin flap elevation
Motor branch of median nerve	Variable origin from anterolateral median nerve distal to carpal tunnel	Incise flexor retinaculum on ulnar side of median nerve; avoid deep dissection here
Superficial palmar arch	Crosses palm at distal end of outstretched thumb	Avoid blind or overly distal flexor retinaculum incisions

Post-Operative Pearl

Encourage early active finger and wrist mobilization to prevent stiffness. Avoid forceful wrist extension or heavy gripping for 2–3 weeks to protect the healing flexor retinaculum and median nerve.

Classic Clinical Notes