ORIF Distal Radius with Carpal Tunnel Release
55 year old native woman with displaced volar Barton’s fracture. Ped-struck. Reduced her wrist in emerg. Booked for ORIF; overnight developed worsening symptoms of numbness in her hand globally – we arranged for carpal tunnel release as well.
Positioning: Supine, Boyse table
Regular prep and drape, with the arm out on the table. The tough part is to ensure that you get enough proximal exposure to put the plate on. Make the incision straight just ulnar to FCR. He does not continue the incision across the transverse crease of the wrist. Cauterize the little veins that come into view in the subcutaneous tissue. Find the tendon sheath of FCR and incise along the radial aspect of it. If you go too radial you’ll incise the radial artery. Mobilize the tendon ulnarly. Incise the undersurface of the tendon sheath. All of the muscles – FPL and FDP are then mobilized ulnarly until you reach pronator quadratus. This is incised along its radial border and peeled subperiosteally ulnarly. This should get you into the fracture hematoma and fracture. Subperiosteal dissection distally gets you into the capsular attachments. Proximal dissection is required to get the plate on.
Bend a bit of spring into the plate, then use it to buttress the distal fragment back on. Secure the shaft, then put a cancellous screw into the distal fragment.
We then made a separate incision for the carpal tunnel. If you carry the regular incision distally you’ll bag the palmer branch of the median nerve. So the options are to make a separate incision, staying ulnar to palmaris longus, or doing the whole procedure through one long incision that is fairly ulnar, and making it longer proximally so as to mobilize everything radially enough to do the ORIF through the tendon sheath of FCR.