HAND (2011) 6:8–17

DOI 10.1007/s11552-010-9281-9

REVIEW ARTICLES OF TOPICS

Surgical approaches to the distal radius

Asif M. Ilyas

Published online: 22 June 2010

# American Association for Hand Surgery 2010

Abstract Introduction
Introduction Fractures of the distal radius are among the
most common fractures seen. They encompass a myriad of Fractures of the distal radius are among the most common
presentations and fracture patterns that often benefit from fractures seen [1, 2]. As our population ages, the prevalence
various open reduction and internal fixation techniques— of these injuries is expected to increase. Similarly, over the
including volar plating, dorsal plating, radial plating, past several years, we have observed a dramatic increase in
intramedullary nailing, and fragment-specific fixation. In the surgical management of distal radius fractures [3]. This
order to obtain optimal reduction of these fractures, increase in surgical intervention can be attributed to the
surgeons require a thorough understanding of the anatomy development of new plating systems and the potential
and various surgical exposures. clinical benefits of more precise fracture reduction and
Anatomy The distal radius is surrounded by a soft tissue early mobilization [4, 5].
envelope rich in vascularity and cutaneous innervation. The Surgical implants for the management of distal radius
osseous surface consists of two articular surfaces and three fractures have also dramatically grown in number and include
cortical sides covered almost entirely by soft tissue. dorsal plates, volar plates, radial plates, fragment-specific
Surgical approaches Approaches to the distal radius can be fixation, and intramedullary nails [6–13] (see Fig. 1). Each
broadly divided into volar, radial, and dorsal. Visualization implant can offer different advantages in the management of
of the articular surface can be accomplished best arthro- distal radius fractures. In order to obtain the best fracture
scopically. Arthroscopy can be performed alone or in reduction, various surgical approaches may be required. This
conjunction with other open approaches to the distal radius. article will review the regional anatomy of the distal radius
Summary This article will review the pertinent anatomy and the various relevant surgical approaches.
and various surgical approaches in order to facilitate the
surgeon’s ability to safely expose a distal radius fracture. Anatomy

Keywords Distal radius . Exposure . Volar approach . Exposure of the distal radius and its fracture fragments is
Dorsal approach . Radial approach . Henry’s approach . complicated by the close proximity of surrounding muscle,
Thompson’s approach ligaments, tendons, and neurovascular structures. The individ-
ual alignment of various articular fracture fragments of the
distal radius is affected by these soft tissue attachments [14].
When studying the distal radius, it is helpful to consider its
five “surfaces”: (1) the volar surface, (2) the radial surface, (3)
A. M. Ilyas (*) the dorsal surface, (4) the distal radiocarpal articular surface,
Rothman Institute, Department of Orthopaedic Surgery, and (5) the distal radioulnar articular surface (see Fig. 2).
Thomas Jefferson University,
Understanding the anatomy and position of each surface is
925 Chestnut St,
Philadelphia, PA 19107, USA important for adequate exposure and subsequent reduction in
e-mail: [email protected] the management of distal radius fractures.
HAND (2011) 6:8–17 9

Figure 1 Various implants

depicting distal radius fracture
fixation including a volar plate
(a), an intramedullary nail (b),
and fragment specific fixation (c).

Superficial Anatomy liberally as long as the principles of maintaining longitudinal or

oblique incisions are honored, underlying cutaneous nerves
The surface and superficial anatomy about the distal radius protected, and subcutaneous veins preserved whenever feasible.
includes a soft tissue envelope that enjoys a rich blood supply Branches of the radial sensory nerve reside in the subcutaneous
and dense cutaneous innervation. Incisions can be placed tissue over the radial surface and provide sensation to the radial

Figure 2 The five surfaces of the distal radius: a volar surface, b radial column, c dorsal surface, d radiocarpal articular surface, and e distal
radioulnar surface.
10 HAND (2011) 6:8–17

aspect of the wrist and the first web space dorsally. The radial posterior interosseous nerve and vessels on the dorsal surface
sensory nerve emerges from below the brachioradialis tendon of the distal radius. The fifth and sixth compartments with the
approximately 8–9 cm proximal to the radial styloid and on extensor digiti minimi and extensor carpi ulnaris tendons,
average divides into four branches [15, 16]. The dorsal respectively, cover the distal radioulnar joint and ulnar head
cutaneous branch of the ulnar nerve provides sensation to also, respectively.
the ulnar aspect of the wrist. It arises approximately 3–5 cm The volar surface of the distal radius is relatively flat and
proximal to the ulnar styloid, and it typically crosses volar to broad but is covered by multiple layers of soft tissue.
the head of the ulna before traveling dorsally to the ulnar hand Superficially, the volar anatomy of the wrist includes, from
[17]. Although there is much variability as to when the dorsal radial to ulnar: the radial artery, flexor carpi radialis tendon,
cutaneous branch of the ulnar nerve branches, there is little palmaris longus tendon, and the flexor carpi ulnaris tendon.
variability in the branching pattern with most branches Deep to the palmaris longus tendon lies the Median nerve
traveling dorsally and the remaining traveling volarly over and the finger flexor tendons. The flexor pollicis longus
the hypothenar eminence [18]. In addition, the dorsal aspect of tendon lies deep to the flexor carpi radialis tendon. The
the hand is also supplied by a consistent contribution from the deepest volar soft tissue structure is the pronator quadratus
lateral and posterior antebrachial cutaneous nerves [19]. In a as it completely covers the flat volar surface of the distal
detailed study of the dorsal innervations of the hand, Mok et radius. However, the very distal margin slopes volarly in
al. noted that the dorsal hand and wrist were equally divided the form of a ridge from which the volar radiocarpal
and innervated the sensory branch of the radial nerve and ligaments take origin. The junction between the distal
dorsal ulnar sensory branch of the ulnar nerve [18]. The extent of the pronator quadratus and the origin of the volar
palmar cutaneous branch of the median nerve provides radiocarpal ligaments represents the “watershed line” [23]
sensation to the volar wrist and palm of the hand. It arises (see Fig. 3). A plate positioned distally beyond this point
approximately 3.2 cm proximal to the wrist crease from the may risk flexor tendon irritation. The ulnar volar margin of
radial side of the median nerve and typically runs along the the lunate facet slopes volarly from a proximal to distal
radial border of the palmaris longus tendon [20]. At the level direction. Thus, the volar lunate facet extends approximate-
of the wrist crease, the nerve travels approximately 5 mm ly 3 mm more distally than expected, and an effective
radial to the inter-thenar depression [21]. support of this area with a plate can be challenging [24, 25].
The short radiolunate ligament originates from the volar
Deep Anatomy margin of the lunate facet and attaches to the volar surface
of the lunate. It is proposed that this ligament plays a vital
Excluding the two articular surfaces, the remaining three role in the volar stability of the radiocarpal articulation [26].
surfaces of the distal radius are covered almost entirely by soft Similarly, the radioscaphocapitate ligament takes its origin
tissue. Only Lister’s tubercle and the radial styloid maintain a from the volar surface of the radial styloid and provides an
subcutaneous osseous surface free of direct soft tissue attach- important restraint to ulnar translocation of the carpus [27].
ments. The dorsal surface and radial surface are otherwise
covered by the six traversing extrinsic dorsal extensor compart- Osseous Anatomy
ments of the wrist. The radial surface is covered by the first
dorsal compartment and its abductor pollicis longus and The distal end of the radius should be viewed as the
extensor pollicis brevis tendons. Further proximally and deeper, anatomic foundation of the wrist joint. Beginning 2 to 3 cm
the radial styloid is covered by the lone tendinous insertion onto proximal to the radiocarpal joint at the metaphyseal flare,
the distal radius, the brachioradialis. It inserts approximately the distal end of the radius is uniquely designed to maintain
17 mm proximal to the radial styloid under the base of the first the capacity to transmit axial load and provide mobility
dorsal compartment [22]. The brachioradialis can act as a [28]. In the coronal plane, the distal radius assumes an
deforming force with distal radius fractures. Moving further inclination of 22° to 23°. In the sagittal plane, the distal
ulnarward, the distal radius is covered by the second dorsal radius assumes a tilt angled volarly approximately 11° to
compartments and its extensor carpi radialis longus and 12° (see Fig. 3a).
extensor carpi radialis brevis tendons. The second dorsal The distal radiocarpal articular surface is both biconcave
compartment is separate by the third dorsal compartment by and triangular in shape. The apex of the triangle points toward
Lister’s tubercle, which acts as a pulley for the extensor the radial styloid process, and the base of the triangle forms
pollicis longus tendon running within the third dorsal the sigmoid notch which articulates with the distal end of the
compartment. The fourth dorsal compartment covers the ulna. Viewed from the lateral side, the radial styloid sits volar
remaining dorsal surface of the distal radius and contains the to the mid-axis of the radius. The articular surface is separated
extensor indicis proprius and the extensor digitorum comminis into two distinct concave facets known as the scaphoid and
tendons. Deep to the fourth dorsal compartment lies the lunate facets, with the latter having a larger radius and
HAND (2011) 6:8–17 11

notch has a greater radius of curvature than the ulnar head, and
motion at the distal radioulnar joint is a combination of
rotation and translation. This articulation facilitates forearm
rotation, along with the interosseous membrane and proximal
radioulnar joints, as the radius and hand rotate about the fixed
ulna. The triangular fibrocartilage complex (TFCC) arises
from the ulnar aspect of the lunate facet of the radius, above
the sigmoid notch, and extends on to the base of the ulnar
styloid process. It functions as an additional stabilizer of the
distal radioulnar joint and to increase the relative articulating
area of the wrist. A large fracture of the ulnar styloid or
peripheral tear of the TFCC can theoretically destabilize the
distal radioulnar joint.

Volar Approach

The volar approach to the distal radius can be used for both
volar plate and fragment specific fixation [8, 10, 11, 30].
Volar plate application provides the advantage of placing
the plate on the tensile side of the radius while also utilizing
greater soft tissue coverage to decrease hardware promi-
nence and irritation [7–9]. The volar approach can be
accomplished through three different intervals: (1) the
Henry approach, (2) the trans-FCR approach, and the (3)
volar-extensile approach (see Fig. 4). Both the Henry and
trans-FCR approaches provide excellent exposure to the
Figure 3 The volar anatomy of the distal radius including the normal
anatomic angles (a) and identification of the lunate facet and the
volar surface of the distal radius for the reduction and
watershed line (b). internal fixation of distal radius fractures [8, 10, 29, 31]. In
contrast, the volar-extensile approach incorporates a carpal
extending volarly into the lunate facet [25] (see Fig. 3b). tunnel release and affords direct visualization and fracture
Standard compressive articular fracture lines commonly reduction of the volar–ulnar corner of the distal radius,
propagate between these facets. Additional compressive maximum volar visualization of the distal radioulnar joint,
force will split the fragments in the coronal plane or cause and expanded exposure of the radiocarpal and mid-carpal
central fragmentation and impaction [14]. In addition, there joints [30, 32]. Superficial landmarks should be noted and
is often an associated inter-carpal ligament injury with radial include the radial artery pulse, flexor carpi radialis tendon,
styloid fractures that exit at the level of the scapholunate and the ulnar artery pulse. In patients with greater girth, the
ligament [29]. flexor carpi radialis may be difficult to identify and can be
The volar aspect of the lunate facet is approximately located over the distal pole of the scaphoid at the wrist
5 mm thick and projects approximately 3 mm anteriorly to crease.
the flat volar surface of the distal radius, making it
relatively vulnerable to injury and difficult to fix internally The Henry and Trans-FCR Approach
[25] (see Fig. 3). The articular surface exhibits an overall
volar and ulnar slope which is essential in helping the wrist Although similar in the location of the incision and the deep
to deviate ulnarly for power grasp, but at the same time surgical dissection, the Henry approach and trans-FCR
causing the carpus to assume a natural tendency to slope in approach utilize different superficial intervals prior to
this direction. Ligamentous restraints resist this natural exposure of the deep volar compartment, or the space of
tendency. The distal radiocarpal articular surface facilitates Parona. The classic Henry interval describes the volar
flexion/extension and radial/ulnar deviation of the wrist. In forearm approach to the radius but did not specifically
addition, it supports the majority of longitudinal stress describe exposure of the wrist [31]. It has been extrapolated
across the wrist joint. to be understood that as the Henry approach is taken
The distal radioulnar articular surface, or sigmoid notch, is distally to the level of the wrist the interval will lie between
semi-circular and articulates with the ulnar head. The sigmoid the flexor carpi radialis tendon and the radial artery. In
12 HAND (2011) 6:8–17

dissection, the flexor pollicis longus tendon and the flexor

digitorum superficialis and profundus tendons are swept
ulnarly. Avoid radial retraction of the flexor pollicis longus
to avoid potential denervation of the muscle. Retraction is
best held with reverse or right angle retractors. Self-
retaining retractors should be used with caution. The
pronator quadratus is released along its radial border of
the distal radius and raised ulnarly (see Fig. 5). In order to
facilitate repair of the pronator quadratus upon closure, the
release is performed as far radial as possible and should be
raised in a sub-periosteal fashion. Alternatively, a cuff of
pronator quadrates may be left attached to facilitate repair
upon closure. The brachioradialis tendon inserts along the
lateral aspect of the distal radius, deep to the first dorsal
compartment, and can be released if necessary to eliminate
its deforming influence. The tendons of the first dorsal
compartment should be identified as they enter their
retinaculum and retracted radially thereby exposing the
brachioradialis which can then be sharply released off of
the styloid. The first dorsal compartment, in contrast, is not
typically a deforming force and should be maintained. If
also released, the first dorsal compartment should be
released with caution to avoid tendon subluxation and
hardware irritation.
While exposing the fracture fragments of a distal radius,
care must be taken to avoid raising and destabilizing the
origin of the volar radiocarpal ligaments distal to the
pronator quadratus. The distal limit of the distal radius
can be estimated by placing a needle through the joint
capsule. Similarly, the radiocarpal joint should not be
arthrotomized volarly to avoid devascularization of the
carpal bones and radiocarpal ligament destabilization [26].
Figure 4 Volar approach intervals to the distal radius. If joint visualization is necessary, then this should be
achieved dorsally through direct dissection and exposure or
contrast, the trans-FCR approach involves opening the arthroscopically.
tendon sheath of the flexor carpi radialis tendon and If the carpal tunnel requires release connecting the
through its floor entry into the deep volar compartment is original incision with the carpal tunnel, incision should
achieved. Both provide reliable approaches to the volar be avoided due to the high risk of injury to branches of
surface of the distal radius, but the trans-FCR approach the palmar cutaneous branch of the median nerve.
affords the benefit of not requiring direct radial artery Similarly, identification and protection of the branches
dissection and isolation. The palmar cutaneous branch of can avoid inadvertent traction or injury. Alternatively, the
the median nerve is potentially at risk for injury but can be carpal tunnel can be released through the same incision
prevented by avoiding any dissection ulnar to the flexor utilizing distal identification and release of the transverse
carpi radialis tendon. carpal ligament [33]. The release requires retraction of the
The incision is placed longitudinally in line with the FCR tendon from its opened sheath superficially and
flexor carpi radialis tendon. For volar plate insertion, the radially revealing the superficial aspect of the transverse
incision should measure approximately 7–8 cm, but can be carpal ligament for release. Next, the superficial aspect,
extended proximally as needed. If necessary, the wrist the FPL tendon is retracted ulnarly revealing the deep slip
crease should be crossed obliquely. Superficially, either the of the transverse carpal ligament for subsequent release
Henry approach can be utilized or the trans-FCR approach. [33].
If the latter is used, the flexor carpi radialis tendon should A variation to the trans-FCR is the extended FCR
be fully mobilized and retracted ulnarly to maximize release approach, which involves release of the “radial septum”
and entry through its tendon sheath floor. Using blunt and pronation of the proximal radius out of the fracture site
HAND (2011) 6:8–17 13

Figure 5 Isolation and eleva-

tion of the pronator quadratus
in a sub-periosteal fashion
proximal to the origin of the
volar radiocarpal ligaments.

to expose the distal radius metaphysis and dorsal fragments tion of the median nerve and places it at risk for injury and
[34]. The authors described the radial septum as a simple irritation [35]. Lattmann et al. compared the direct volar
fascial wall separating the flexor and extensor tendons and approach with a concomitant carpal tunnel release versus
include the first dorsal compartment and brachioradialis the standard Henry approach for volar plate fixation of
tendon [34]. Prior to pronating the proximal radius out of distal radius fractures and found a significant increase in
the wound, the brachioradialis is released off of the radial median nerve irritation both early and late following
styloid, and the first to fifth dorsal compartments are fracture fixation [36].
released sub-periosteally off of the dorsal cortex of the
radius. Upon release of the extensor tendons, the proximal
radius can be pronated out of the wound exposing the distal Radial Approach
radial component, metaphyseal comminution, and articular
fragments. The radial approach to the distal radius can be used for
radial plate, fragment-specific pin plate, Kirschner wire,
The Volar-Extensile Approach and intramedullary fixation (see Fig. 5). Although fairly
subcutaneous, approaching the radius along its radial border
The volar-extensile approach requires placement of an requires diligent identification and protection of the radial
incision further ulnar in a longitudinal fashion between sensory nerve. It becomes subcutaneous approximately
the palmaris longus and flexor carpi ulnaris tendons. The 9 cm proximal to the radial styloid as it exits below the
incision is brought obliquely across the wrist into the palm brachioradialis tendon and travels distally between it and
for the carpal tunnel release. The fascia is released between the extensor carpi radialis longus tendon [15]. The nerve
the flexor carpi ulnaris and the palmaris longus, and the will typically arborize into at least two but on average four
interval between the ulnar neurovascular structures deep to branches approximately 5 cm proximal to the radial styloid
the flexor carpi ulnaris ulnarly and the flexor digitorum [15]. The radial sensory nerves have a high predilection
superficialis/profundus tendons radially is developed. As towards irritation and the development of neuritis and
the dissection is taken distally, the ulnar neurovascular therefore should be routinely identified and meticulously
structures are allowed to traverse ulnarly as they travel protected [13, 16]. Deep to the soft tissue in the
towards Guyon’s canal and the finger flexor tendons are subcutaneous tissue, the radial aspect of the distal radius
retracted radially thereby exposing the volar ulnar corner of is covered by the first and second dorsal compartments
the distal radius and the floor of the carpal tunnel. traversing the radial styloid as well as the brachioradialis
Alternatively, a direct volar approach may be used, inserting deep into them.
utilizing a longitudinal midline incision with an oblique
incision across the wrist and incorporates a concomitant The Radial Approach
carpal tunnel release. In contrast to the volar-extensile
approach that protects the median nerve by retracting it Place the incision along the radial side of the wrist in a
with all of the flexor tendons as a group, the direct volar longitudinal or oblique fashion. Identify the branches of the
approach involves direct release, exposure, and manipula- radial sensory nerve that will be located immediately in the
14 HAND (2011) 6:8–17

subcutaneous tissue. Gently mobilize and retract these At the proximal floor of the fourth dorsal compartment
nerves. The first dorsal compartment will be crossing along resides the posterior interosseous nerve. At this level, it
the volar border of the radial styloid. The second dorsal provides sensation and proprioceptive function to the dorsal
compartment will be crossing along the dorsal border of the wrist capsule [37]. In order to expose the nerve, the fourth
radial styloid. The brachioradialis inserts onto the radial compartment should be elevated off not sub-periosteally,
styloid deep into the first dorsal compartment at its base. but rather off of the periosteum. To avoid hardware
There will be a bare area between the first and second impingement, it should be retracted and transposed above
dorsal compartments at the distal aspect of the radial the hardware. Alternatively, it may be neurectomized
styloid. To expose the styloid, raise the first compartment proximally by excising a 2-cm segment of the nerve if
in a sub-periosteal fashion volarly. Alternatively, the first dorsal capsular denervation is sought [38, 39].
compartment’s tendon sheath can be released in its entirety In the case of a distal radius fracture, a formal capsulotomy
and both the abductor pollicis longus and extensor pollicis is not typically required, but if visualization of the radiocarpal
brevis tendons can be retracted and the styloid exposed joint is necessary, a capsulotomy may be performed in a
through the compartment floor. Proximally, the brachior- longitudinal fashion in line with the skin incision. Care must
adialis can be released in its entirety as needed both for be taken to avoid injury to the scapholunate ligament which
exposure or to eliminate its deforming force [22]. typically lies 1.0–1.5 cm distal to Lister’s tubercle. Alterna-
tively, a radially based ligament sparing dorsal capsular flap
can be raised to avoid destabilization of the dorsal radiocarpal
Dorsal Approach ligaments while still providing visualization of the radiocarpal
and mid-carpal joints [40].
The dorsal approach to the distal radius can be used for Upon closure, the compartments are allowed to return
dorsal plate and fragment-specific fixation of fractures [6, to their normal positions and the retinacular incision
12]. Approaching the distal radius along its dorsal surface closed. The extensor pollicis tendon may be left outside
requires identification and navigation between the dorsal of the repaired retinaculum to prevent constriction or late
compartments of the wrist (see Fig. 5). The dorsal margin tenosynovitis.
of the distal radius extends further distally then the volar
surface, resulting in the volar tilt that is observed on sagittal The Dorsal–Ulnar Approach
radiographs. Multiple intervals may be utilized between the
various dorsal extensor compartments to approach the distal Palpate the distal radioulnar joint and place a longitudinal
radius dorsally [35]. Two will be emphasized for their incision above it. Identify and open the fifth dorsal
versatility and commonality. The trans-EPL approach, also compartment by visualizing the extensor digiti minimi
referred to the “universal dorsal approach,” provides exiting distally. Through its floor, the distal radioulnar joint
extensile exposure to much of the dorsal aspect of the can be entered. Multiple components of the distal radio-
distal radius. The dorsal–ulnar approach provides direct ulnar joint, including the TFCC, pronator quadratus volarly,
visualization of the dorsal–ulnar corner of the distal radius and the radioulnar ligaments, all contribute to distal radio-
as well as the distal radioulnar joint. ulnar joint stability [41]. The dorsal capsule incorporates
the dorsal radiolunar ligament and TFCC. Therefore, upon
The Trans-EPL Approach closure, the dorsal capsule should be meticulously closed to
prevent distal radioulnar joint instability but not over-sewn
Identify and mark Lister’s tubercle. Place a 7–8-cm incision so to avoid loss of forearm rotation (Fig. 6).
longitudinally in line with the third metacarpal just ulnar to
Lister’s tubercle. Dissect down to the extensor retinaculum
and then raise full thickness skin flaps. By raising flaps off of Arthroscopic Approach
the retinaculum, the branches of the radial sensory and dorsal
ulnar sensory nerves, and any dorsal veins, will retract away Visualization of the articular surface of the distal radius is
with the flaps. Identify the extensor pollicis longus tendon best achieved arthroscopically. Often wrist arthroscopy can
exiting the extensor retinaculum just distal to Lister’s tubercle. be performed alone or in conjunction with other open
Place a full thickness incision across the extensor retinaculum approaches to the distal radius. Arthroscopy affords direct
through the roof of the third dorsal compartment, thereby visualization of the radial styloid, scaphoid fossa, lunate
releasing the extensor pollicis longus tendon. Retract the fossa, triangular fibrocartilage complex, and the volar
tendon radially. Raise the second and fourth compartments in radiocarpal ligaments. Appropriate set-up is integral for
a sub-periosteal fashion in opposite directions to thereby efficient arthroscopy of the wrist. Traction of 5 to 10 lb
expose the dorsal surface of the distal radius. provides for adequate visualization and fluid flow. A small
HAND (2011) 6:8–17 15

Figure 6 Radial and dorsal ap-

proach intervals to the distal
radius.

joint arthroscope with a diameter of 2.7 mm or smaller and aggressively plunging. The normal volar tilt of the distal
a 30° lens is necessary. Similarly, small joint arthroscopy radius is 10° and this normally should be replicated in the
instruments should be available. Please note that throughout direction of canula entry. In the case of fractures, note prior to
the procedure very little fluid is necessary to facilitate portal entry the extent of any dorsal articular surface
visualization of the joint. In the case of intra-articular angulation and comminution that may predispose the joint
fractures of the distal radius, the limb will be predisposed to surface to iatrogenic injury.
the potentially devastating complications of proximal fluid Beginning from radial to dorsal, the 3-4 portal will
extravasation. To minimize this, the forearm can be afford excellent visualization of the radial styloid, scaphoid
bandaged or the fluid can be introduced manually, with fossa, lunate fossa, and the triangular fibrocartilage com-
gravity, or with a low-pressure arthroscopy pump. Alterna- plex. In addition, the volar radiocarpal ligaments should be
tively, “dry arthroscopy” has been proposed in the clearly visible as well as the base of the scaphoid and lunate
arthroscopic visualization of the wrist to avoid the potential and the intervening scapholunate ligament.
complications of fluid extravasation [42]. Dry arthroscopy Additional outflow or working portals can be established
of the wrist utilizes the standard portals but no fluid is used. including the 4-5, 6-R (radial to the extensor carpi ulnaris),
Instead, the joint space is maintained by traction, synovio- and 6-U (ulnar to the extensor carpi ulnaris). The 6-U portal
tome suction, and neurosurgical patties. is close to the path of the dorsal ulnar sensory nerve and
Recognition of surface landmarks and understanding the
anatomy of the dorsal extensor compartments of the wrist is
paramount to facilitating efficient portal placement and joint
visualization. Portals are designated by their relationship to the
six dorsal compartments (Fig. 7). Palpation between these
compartments will identify the sites of joint entry. For
example, the 3-4 portal occurs between the extensor pollicis
tendon of the third compartment and the extensor digitorum
comminis of the fourth compartment. The 3-4 portal is the
main viewing portal and is typically established first. It can be
identified by palpating the soft spot just distal to Lister’s
tubercle. Place the insufflation needle through the planned
portal site and inject 5 to 10 cc of saline. Insufflation should
occur with little resistance. Place a 3- to 5-mm longitudinal
incision over the soft spot with an 11 blade pointing distally.
Holding the blade in this position will avoid injury to tendons
and any cutaneous nerves since they fan away as they arborize
distally. Spread the soft tissue down to the capsule with a
hemostat. Enter the joint with a blunt tipped trocar and canula.
Avoid iatrogenic injury to the articular surfaces by not Figure 7 Arthroscopic portal intervals to the wrist.
16 HAND (2011) 6:8–17

should be placed with caution. Lastly, the 1-2 portal can be 12. Schnall SB, Kim BJ, Abramo A, Kopylov P. Fixation of distal
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