Dorsal Approach to the Wrist and Carpus

What it exposes. The dorsal approach is the workhorse extensile exposure of the radiocarpal and midcarpal joints. From a single incision it gives simultaneous access to the distal radial articular surface, the scapholunate interval, the lunate, the proximal pole and dorsal ridge of the scaphoid, and the midcarpal joint. The dorsal surface of the carpus is subcutaneous, and the extensor tendons can be mobilised and retracted to expose almost the entire joint.

Why dorsal. It is the single most versatile exposure for degenerative and post-traumatic wrist reconstruction. It allows direct inspection and staging of the cartilage surfaces (the deciding factor in choosing between proximal row carpectomy and four-corner fusion), and the terminal PIN in the floor of the fourth compartment can be resected for denervation through the same incision. The volar (Henry) approach, by contrast, exposes the distal radius and the volar ligaments but gives poor access to the proximal row and midcarpal joint. Primary indications: - Proximal row carpectomy for scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) wrists in selected stages

• Four-corner (limited intercarpal) fusion with scaphoid excision for SLAC and SNAC arthritis
• Total wrist arthrodesis (fusion) for painful pancarpal arthritis, failed salvage, or rheumatoid destruction
• Total wrist arthroplasty for low-demand inflammatory or osteoarthritis in selected patients
• Dorsal fixation of scaphoid fractures, especially proximal-pole and displaced waist fractures
• Excision of a dorsal wrist ganglion, which arises from the scapholunate joint
• Open reduction and internal fixation of carpal fractures and fracture-dislocations (transscaphoid perilunate injury, lunate fracture)
• Wrist denervation by posterior interosseous nerve neurectomy, alone or combined with another procedure
• Revascularisation or bone grafting for Kienbock disease of the lunate or Preiser disease of the scaphoid Contraindications: - Active infection or breached dorsal skin (use an alternative or delay)
• Significant dorsal scarring from previous surgery or burn (plan the incision to avoid skin necrosis)
• When the pathology is purely volar (volar lunate dislocation, volar distal radius fracture), a volar approach is more appropriate
• When an arthroscopic procedure would suffice (many scaphoid fractures, early SLAC assessment, ganglia), arthroscopy avoids opening the joint Alternative and complementary approaches: the volar (Henry) approach for volar pathology and volar plating; arthroscopic radiocarpal and midcarpal assessment for staging SLAC/SNAC and minimally invasive scaphoid fixation or ganglion excision; a lateral (radial) approach for limited radial-sided access; and combined dorsal and volar approaches for complex carpal reconstruction or circumferential wrist fusion. Position & landmarks. The patient is supine with the affected arm abducted onto a radiolucent hand table and a well-padded upper-arm tourniquet in place. The arm is exsanguinated and the tourniquet inflated to around 250 mmHg (or about 100 mmHg above systolic pressure). The surgeon sits at the head (cephalad end) of the table looking distally along the limb, the standard hand-surgery position for dorsal wrist work; the forearm is flexed to 90 degrees at the elbow so the dorsal wrist faces the surgeon, or pronated flat on the table. Palpable landmarks to mark are Lister's tubercle (the dorsal tubercle of the radius, the single most important landmark), the radial and ulnar styloids, the palpable radiocarpal joint line just distal to Lister's tubercle, and the base of the third metacarpal (the distal extent of the incision). Soft-tissue landmarks are the extensor tendon contours centrally, the anatomical snuffbox radially (containing the radial artery and radial sensory branches), and the dorsal veins with the cephalic tributaries in the subcutaneous plane.

Work down through the layers centred on Lister's tubercle, opening the third-fourth compartment interval, protecting the cutaneous nerves and the terminal PIN, then making a ligament-sparing capsulotomy to deliver the radiocarpal and midcarpal joints. The dissection navigates the six dorsal extensor compartments, which must be known in order, radial to ulnar. All are supplied by the radial nerve, with the wrist and finger extensors receiving motor supply through the posterior interosseous nerve.

Structures at risk, by layer

Extensile options. Extend proximally along the dorsum of the forearm to expose the distal third of the radius, the extensor compartments, the PIN proximally and the interosseous membrane (useful for dorsal plating of distal radius fractures and proximal PIN exploration). Extend distally onto the dorsum of the hand to expose the carpometacarpal joints and metacarpal bases (for carpometacarpal fracture-dislocation and limited carpometacarpal fusion). The dorsal approach cannot be carried across onto the volar wrist: purely volar pathology such as a volar lunate dislocation or volar distal radius fracture requires a separate volar exposure. Retinacular closure — the key decision.

Complications.

Post-operative care. Splint and elevate the limb and perform a neurovascular check documenting digital sensation and capillary refill, watching the dorsal sensory nerve distribution. For reconstructions that permit motion (proximal row carpectomy, four-corner fusion once stable), begin early protected motion under hand therapy. For total wrist fusion, immobilise until radiographic union, typically 6 to 10 weeks, then progress to strengthening once the construct or soft tissues have healed.

• Proximal row carpectomy for SLAC and SNAC wrists in selected stages, excising the scaphoid, lunate and triquetrum so the capitate head articulates with the lunate fossa of the radius.
• Four-corner (limited intercarpal) fusion with scaphoid excision for SLAC and SNAC arthritis, decorticating and fusing the lunate, capitate, hamate and triquetrum.
• Total wrist arthrodesis for painful pancarpal arthritis or failed salvage, applying a precontoured dorsal fusion plate from the third metacarpal to the radial diaphysis with bone graft.
• Total wrist arthroplasty for low-demand inflammatory or osteoarthritis in selected patients.
• Dorsal scaphoid fixation, placing a headless compression screw along the central scaphoid axis (ideal for proximal-pole fractures).
• Dorsal ganglion excision, tracing the stalk to the scapholunate joint and excising a cuff of capsule.
• Posterior interosseous nerve neurectomy for wrist denervation, alone or combined with another procedure.
• Revascularisation or bone grafting for Kienbock disease of the lunate or Preiser disease of the scaphoid.

The dorsal approach to the wrist is a fundamental hand-surgery exposure taught and practised worldwide across all examination systems. The reconstructive procedures performed through it share convergent international principles, while surgical detail varies with implant availability and surgeon preference.

Procedure-selection principles: - Proximal row carpectomy suits early-to-moderate SLAC/SNAC with a preserved capitate head and lunate fossa

• Four-corner fusion is preferred when the capitate head or lunate fossa is degraded, accepting nonunion and hardware risk
• Total wrist fusion is the definitive salvage for pancarpal arthritis or failed reconstruction, prioritising pain relief over motion Global practice variation. In high-resource settings, precontoured dorsal wrist-fusion plates, circular four-corner fusion plates and variable-pitch headless screws are standard, and arthroscopy is used to stage arthritis before open reconstruction. In resource-limited settings the same reconstructive goals are met with K-wire fixation, tension-band wiring or locally contoured plates, and arthroscopic staging is less often available. Consent (globally applicable): discuss dorsal sensory nerve injury and possible painful neuroma, extensor tendon irritation or rupture (especially over dorsal hardware), stiffness, infection, and for fusions nonunion and the loss of wrist motion.