Surgical Approaches to the Forearm, Wrist and Hand
High Yield Overview
Forearm, Wrist and Hand Approaches
Use the interval, protect the nerve, preserve tendon glide
Intervaltrue planes matter
Nervessmall branches count
Glidetendon function depends on handling
Approach Families
Forearm bone access
PatternHenry for volar radius, Thompson for dorsal/proximal radius, subcutaneous border for ulna.
TreatmentChosen by bone, plate position, fracture plane and nerve risk.
Wrist access
PatternVolar wrist, dorsal wrist, radial-sided and ulnar-sided windows.
TreatmentChosen by carpal target, distal radius fragment, DRUJ, scaphoid or ligament pathology.
Hand tendon access
PatternBruner, midlateral, dorsal hand and tendon-zone exposures.
TreatmentChosen to preserve skin, pulleys, tendon glide and neurovascular bundles.
Nerve decompression
PatternCarpal tunnel, cubital tunnel, radial tunnel and Guyon canal exposures.
TreatmentChosen by compressive site and branch anatomy.
Critical Must-Knows
- In the upper limb, a small cutaneous nerve or tendon pulley can determine the result.
- The Henry approach is safe only when the radial artery, superficial radial nerve, FCR plane and pronator handling are deliberate.
- The Thompson approach risks the posterior interosseous nerve; pronation moves the nerve away during proximal radius exposure.
- Hand incisions should respect creases, skin flaps, neurovascular bundles and tendon glide.
- Closure and rehabilitation are part of the approach because stiffness, adhesions and scar sensitivity can dominate outcome.
Clinical Pearls
- "For forearm fractures, approach choice follows the bone surface that needs reduction and plate placement.
- "For flexor tendon surgery, exposure must allow repair while preserving pulleys and digital neurovascular bundles.
- "For dorsal wrist work, protect extensor compartments and repair the retinaculum when needed to prevent bowstringing or tendon irritation.
- "A carpal tunnel incision should avoid the palmar cutaneous branch and recurrent motor branch territory.
Small structures, large consequences
Upper-limb approaches fail when the surgeon treats the exposure as a skin incision. Nerve branches, vessels, pulleys, extensor compartments and tendon sheaths must be protected from the start.
At a Glance: Upper-Limb Approach Choice
| Target | Common Exposure | Main Danger | Rule |
|---|---|---|---|
| Volar radius | Henry approach | Radial artery, median nerve, superficial radial nerve | Use FCR interval and protect pronator quadratus. |
| Dorsal/proximal radius | Thompson approach | Posterior interosseous nerve | Pronating the forearm helps move PIN away. |
| Ulna shaft | Subcutaneous border | Dorsal sensory ulnar nerve distally | Stay on safe border and preserve soft tissue. |
| Carpal tunnel | Volar palm | Palmar cutaneous branch and recurrent motor branch | Incision ulnar to thenar crease and controlled release. |
| Flexor tendon | Bruner or midlateral | Digital nerves and pulleys | Expose enough to repair but preserve pulley system. |
| Extensor tendon | Dorsal hand/wrist | Sagittal bands and extensor retinaculum | Repair stabilising structures and preserve tendon glide. |
Mnemonic
MAPUpper-Limb Approach
M
Mark
Landmarks, incision, previous scars and planned extension.
A
Avoid
Named nerves, vessels, skin flaps and tendon pulleys.
P
Plane
True interval, tendon window or subcutaneous border.
Memory Hook:Map the limb before opening it.
Mnemonic
GLIDEHand Exposure
G
Gentle tissue handling
Protect skin and subcutaneous flaps.
L
Locate nerves
Digital, palmar cutaneous, dorsal sensory and superficial radial branches.
I
Incision planning
Use Bruner, midlateral or dorsal lines according to target.
D
Do not sacrifice pulleys
Preserve A2 and A4 when possible.
E
Early rehabilitation plan
Closure must support tendon glide and therapy.
Memory Hook:The hand outcome depends on glide.
Overview and Indications
Forearm, wrist and hand approaches are selected by the target structure and by the functional tissue that must survive the exposure. In the forearm, the question is usually which bone surface needs reduction and fixation. In the wrist, the question is whether the target is volar, dorsal, radial, ulnar, intra-articular or ligamentous. In the hand, the question is how to reach tendon, nerve, bone or joint without creating stiffness, scar sensitivity or tendon adhesion.
Forearm
Prioritise safe intervals, plate position, radial artery and PIN safety. The radius has different safe windows depending on level.
Wrist
Prioritise carpal target, extensor compartments, palmar cutaneous branch, radial artery and DRUJ exposure.
Hand
Prioritise neurovascular bundles, pulleys, tendon glide, skin creases and rehabilitation-friendly closure.
Approach choice follows plate position
For forearm fixation, the approach should match the reduction surface and intended plate position. A technically easy incision that places the plate poorly is the wrong approach.
Relevant Anatomy
Upper-limb approach anatomy is dominated by named nerves, vessels, tendon compartments and gliding surfaces.
Anatomy That Changes the Approach
| Region | Key Structures | Why It Matters |
|---|---|---|
| Volar forearm | Radial artery, FCR, FPL, median nerve, pronator quadratus | Henry approach uses the FCR region and pronator quadratus for distal radius protection. |
| Dorsal proximal radius | PIN, supinator, EDC/ECRB interval | PIN injury is the feared complication; forearm rotation changes nerve position. |
| Ulnar border | Subcutaneous ulna, ECU/FCU interval, dorsal sensory ulnar nerve distally | Ulna is accessible but soft-tissue stripping still compromises healing. |
| Volar wrist | Median nerve, palmar cutaneous branch, recurrent motor branch, superficial palmar arch | Carpal tunnel release requires controlled distal and proximal release. |
| Dorsal wrist | Extensor compartments, EPL, dorsal sensory branches | Retinacular handling affects tendon irritation and bowstringing. |
| Digits | Digital nerves and arteries, flexor sheath, A2/A4 pulleys | Poor exposure can cause neuroma, tendon adhesion or bowstringing. |
Do not use generated anatomy as proof
For this region, exact nerve and vessel anatomy is too important to infer from a decorative diagram. Use verified anatomy sources and identify structures directly in theatre.
Internervous Plane and Intervals
Common Intervals
| Approach | Interval or Window | Target | Main Risk |
|---|---|---|---|
| Henry | Between brachioradialis and FCR region; develop volar radial interval | Volar radius and distal radius | Radial artery, superficial radial nerve, median nerve if too ulnar. |
| Thompson | Between EDC and ECRB proximally; dorsal radial exposure | Proximal/middle radius | PIN in supinator. |
| Subcutaneous ulna | Between ECU and FCU along ulnar border | Ulna shaft | Dorsal sensory ulnar branch distally, soft-tissue stripping. |
| Carpal tunnel | Volar palm incision ulnar to thenar crease | Transverse carpal ligament | Palmar cutaneous branch, recurrent motor branch, superficial arch. |
| Dorsal wrist | Between extensor compartments depending target | Carpus, distal radius, DRUJ, scaphoid | EPL, extensor retinaculum, dorsal sensory branches. |
| Bruner / midlateral | Zig-zag volar or midlateral finger incision | Flexor tendon, phalanx, digital nerve | Digital neurovascular bundle and pulleys. |
PIN protection
In dorsal proximal radius exposure, pronating the forearm helps move the posterior interosseous nerve away from the operative field. Still, do not rely on rotation alone if the dissection is unsafe.
Patient Positioning
Positioning and Setup
| Setup | Best Use | Practical Checks |
|---|---|---|
| Supine, arm table | Most forearm, wrist and hand surgery | Tourniquet, hand table, image intensifier, shoulder abduction comfortable. |
| Hand table with traction | Wrist arthroscopy, carpal work | Finger traps, traction tower, portals, nerve protection. |
| Arm across chest or pronated/supinated | Dorsal radius, Thompson, ulna access | Confirm C-arm views before prepping. |
| Wide prep to elbow or arm | Tendon, nerve, revision, infection or trauma | Allows proximal/distal extension and graft harvest if needed. |
Surgical Technique
Use: volar radius, distal radius fixation, radial shaft exposure.
- Supine position with arm on hand table.
- Mark radial styloid, FCR tendon, radial artery course and planned plate position.
- Incise along FCR for distal radius or extend proximally as needed.
- Develop the interval carefully; protect radial artery and superficial radial nerve.
- Mobilise FPL and expose pronator quadratus distally.
- Elevate pronator quadratus in a controlled manner and repair if possible.
- Confirm reduction, plate position and screw length.
Pitfalls: radial artery injury, median nerve traction, superficial radial nerve irritation, excessive pronator stripping and flexor tendon irritation from prominent plate.
Structures at Risk and Complications
Complications to Prevent
| Risk | Where | Prevention |
|---|---|---|
| PIN palsy | Thompson/proximal radius | Pronate forearm, respect supinator, avoid blind proximal dissection. |
| Radial artery injury | Henry and radial wrist | Identify and mobilise deliberately; avoid blind retraction. |
| Median nerve or branch injury | Carpal tunnel and volar wrist | Know palmar cutaneous and recurrent motor branch anatomy. |
| Digital nerve injury | Finger exposures | Use full-thickness flaps and identify bundles early. |
| Tendon adhesions | Hand tendon surgery | Gentle handling, pulley preservation, repair quality and early therapy. |
| Scar sensitivity | Palm and digits | Plan incisions away from high-pressure zones when possible. |
When to extend
Extend when reduction, tendon retrieval, nerve identification or implant safety cannot be achieved through the current window.
When to stop
Stop when the nerve is not found, tendon glide is compromised, skin viability is doubtful or image intensifier views are inadequate.
Evidence Base
Forearm exposure principles
Henry, Thompson and contemporary forearm fracture literature • Operative orthopaedic technique literature (Classic to contemporary)
Key Findings:
- Anatomical reduction and restoration of radial bow are essential in adult forearm fractures.
- Approach choice follows plate surface, fracture level and nerve risk.
- PIN safety is central during dorsal proximal radius exposure.
Finding: Technique consensus
Clinical Implication: Forearm approaches should be described with interval and nerve protection, not just incision.
Flexor tendon repair and exposure
Yang et al. and flexor tendon repair literature • Clinics / hand surgery literature (2017-2024)
Key Findings:
- Repair strength, gap resistance and tendon glide all influence rehabilitation.
- Pulley preservation and careful exposure reduce bowstringing and adhesions.
- Surgical repair and therapy protocol must be planned together.
Finding: Biomechanical and clinical evidence
Clinical Implication: A hand approach should be planned around the repair and rehabilitation, not only around access.
Carpal tunnel anatomy and safety
Hand surgery anatomical literature • Journal of Hand Surgery and anatomical reviews (Contemporary)
Key Findings:
- Incomplete release and nerve branch injury are preventable technical failures.
- Incision placement influences scar sensitivity and branch safety.
- Open and endoscopic techniques both require exact understanding of transverse carpal ligament boundaries.
Finding: Anatomy and outcomes literature
Clinical Implication: Median nerve decompression is a small approach with high anatomical precision.
Viva Scenarios
Use these scenarios to practise clinical reasoning and management decisions
CLINICAL SCENARIOStandard
Approach for radial shaft fixation
CLINICAL PROMPT
"An adult has a displaced radial shaft fracture requiring plate fixation."
PRACTICAL APPROACH
I would choose the approach according to fracture level and intended plate position. For volar radius or distal/midshaft exposure I would commonly use the Henry approach, protecting radial artery and superficial radial nerve, developing the FCR/brachioradialis region and preserving pronator quadratus distally. For proximal dorsal exposure I would consider Thompson, with deliberate PIN protection and forearm pronation.
KEY CLINICAL POINTS
Approach follows fracture level and plate surface.
Restore radial bow.
Henry protects radial artery and superficial radial nerve.
Thompson requires PIN awareness.
COMMON PITFALLS
✗Choosing approach by habit rather than plate position.
✗Ignoring PIN risk proximally.
✗Failing to restore radial bow.
FURTHER QUESTIONS
"How do you protect the PIN in Thompson approach?"
"What is your approach to the ulna?"
CLINICAL SCENARIOChallenging
Flexor tendon exposure
CLINICAL PROMPT
"A patient has a zone II flexor tendon laceration requiring repair."
PRACTICAL APPROACH
I would use an incision that gives adequate exposure while protecting digital neurovascular bundles and preserving pulley function. A Bruner or midlateral approach may be used depending wound and target. I would identify the digital nerves, open the sheath only as needed, preserve A2 and A4 pulleys where possible, retrieve tendon ends atraumatically, perform a strong low-bulk repair and coordinate protected early rehabilitation.
KEY CLINICAL POINTS
Exposure and rehabilitation are linked.
Digital nerves must be identified.
Preserve A2 and A4 pulleys where possible.
Repair should allow glide and early protected motion.
COMMON PITFALLS
✗Sacrificing pulleys unnecessarily.
✗Bulky repair that will not glide.
✗No therapy plan.
FURTHER QUESTIONS
"Which pulleys are most important?"
"What complications are you trying to prevent?"
Forearm, Wrist and Hand Approaches: Decision Sheet
Clinical summary
Forearm
- •Henry: volar radius, radial artery and superficial radial nerve awareness.
- •Thompson: dorsal/proximal radius, PIN risk.
- •Ulna: subcutaneous border, preserve soft tissue.
Wrist
- •Carpal tunnel: avoid palmar cutaneous and recurrent motor branches.
- •Dorsal wrist: respect extensor compartments and retinaculum.
- •Scaphoid/carpus: approach follows fracture plane and fixation goal.
Hand
- •Use Bruner or midlateral incisions for digital exposure.
- •Identify digital neurovascular bundles.
- •Preserve pulleys and tendon glide.
Must not miss
- •PIN palsy in dorsal proximal radius exposure.
- •Radial artery injury in volar radial exposure.
- •Incomplete carpal tunnel release.
- •Digital nerve injury and tendon adhesions.