Surgical Approaches to the Forearm, Wrist and Hand

Best for waist and distal-pole fractures. A curved incision over the FCR / scaphoid tubercle, developing the plane between the FCR and the radial artery (the radial artery is the key structure to protect). It allows correction of the humpback (flexion) deformity and volar wedge bone grafting, and it avoids the dorsal blood supply. The cost is release of the volar radioscaphocapitate / radiocarpal ligaments, which must be repaired.

Best for proximal-pole fractures and percutaneous or retrograde screw placement down the central scaphoid axis. It gives the ideal screw trajectory for the proximal pole, but it risks the dorsal ridge vessels that are the scaphoid's dominant blood supply, plus the superficial radial nerve and extensor tendons - so dissection is kept minimal (often percutaneous).

Extend when reduction, tendon retrieval, nerve identification or implant safety cannot be achieved through the current window.

Stop when the nerve is not found, tendon glide is compromised, skin viability is doubtful or image intensifier views are inadequate.

Distal radius fractures are among the most common fractures worldwide, with a bimodal distribution (young high-energy and elderly fragility). Carpal tunnel syndrome is the most common compressive neuropathy, affecting roughly 1 to 5 percent of the general adult population. Flexor tendon and digital injuries cluster in working-age men through occupational and machinery trauma.

Hand and wrist procedures are less consistently captured in national arthroplasty registries than hip and knee, but distal radius fracture management is tracked in trauma audits (for example UK trauma audit datasets), which consistently show wide variation in operative versus non-operative management of the elderly distal radius fracture.

Routine access to mini C-arm imaging, locking-plate systems, hand-therapy services, wrist arthroscopy and endoscopic carpal tunnel equipment. Wide-awake (WALANT) surgery is increasingly used to allow intraoperative tendon-glide testing.

Reliance on open release, conventional plating or non-operative management, with fewer dedicated hand-therapy services. The core principles, interval-based exposure, nerve protection and pulley preservation, remain unchanged and matter even more when revision and therapy are scarce.

Endoscopic release returns patients to work sooner with less scar pain, but randomised evidence shows a higher transient nerve-injury rate and no advantage in permanent injury or symptom relief. The debate is about morbidity and cost, not cure.

Volar locked plating dominates practice, yet meta-analysis shows it trades lower tendon-irritation risk for higher median-nerve and carpal-tunnel risk versus dorsal plating. Overall outcomes are similar, so fragment pattern and surgeon experience decide.

Historic teaching protected A2 and A4 absolutely. Contemporary evidence supports judicious venting of part of A2 or A4 to allow a bulky repair to glide, provided enough pulley is preserved to prevent bowstringing.

Wide-awake local anaesthesia no tourniquet allows intraoperative testing of tendon glide and gapping, but the zone II review found it is not superior in outcome. Its role is pragmatic rather than evidence-mandated.