What is a preferable incision over the wrist crease?

Preferable Incision Over the Wrist Crease

A transverse incision along the wrist crease is preferable over a longitudinal incision because it follows Langer's lines, resulting in better cosmetic outcomes, less scar contracture, and reduced postoperative complications while still providing adequate surgical exposure. 1

Anatomical Considerations for Wrist Incisions

• Transverse incisions following Langer's skin lines provide better scar characteristics and cosmetic outcomes compared to longitudinal incisions 2, 1
• Longitudinal incisions over the wrist have higher risk of scar contracture and may be cosmetically unacceptable 2
• When planning wrist incisions, careful consideration must be given to the underlying neurovascular structures to prevent iatrogenic injury 3

Specific Nerve Considerations

• In anterior wrist approaches, the palmar cutaneous branch of the median nerve (PCBMN) is most at risk of injury 3
• For dorsal approaches, the safest zone for incision is directly over or slightly radial to Lister's tubercle to avoid injury to the superficial branch of the radial nerve (SBRN) 3
• For ulnar-sided approaches, the dorsal branch of the ulnar nerve (DBUN) should be protected by making incisions on the ulnar side of the wrist around the ulnar styloid with the forearm in supination or neutral position 3

Types of Wrist Incisions

Transverse Incisions

• Universal dorsal transverse incision follows Langer's lines and can be adjusted with radial and ulnar extensions while respecting nerves and veins 1
• Transverse incisions along the wrist crease result in better cosmetic outcomes and less scar contracture 2, 1
• The "double Y sliding flap" approach with the main body along the dorsal wrist crease provides wide access to the dorsal surface of the wrist joint while maintaining good cosmetic results 4

Specialized Incisions

• The "Link incision" connects the dorsoulnar approach to the thumb metacarpophalangeal joint with the flexor carpi radialis approach, providing access to the thumb trapeziometacarpal joint, scaphotrapeziotrapezoid joint, and radial styloid 2
• For carpal tunnel release, a short transverse incision (2.5-4.0 cm) from Kaplan's line to the area distal to the transverse wrist crease provides adequate exposure while minimizing anterior wrist pain 5

Clinical Implications

• For radial-sided chronic wrist pain with normal or nonspecific radiographs, MRI is the recommended next study regardless of the surgical approach chosen 6, 7
• When planning surgical approaches to the wrist, the surgeon must consider not only cosmetic outcomes but also adequate exposure for the intended procedure 2, 1
• In emergency settings, while midline incisions provide better access, transverse incisions have been shown to have less negative impact on wound dehiscence, burst abdomen, and postoperative pain 6

Common Pitfalls and How to Avoid Them

• Longitudinal incisions crossing the wrist crease may lead to scar contracture and should be avoided when possible 2
• Failure to identify anatomical variations in nerve distribution may increase the risk of iatrogenic nerve injury 3
• When extending incisions, follow Langer's lines to achieve better scar characteristics 2, 1
• For vascular access procedures at the wrist, a radial-cephalic primary arteriovenous fistula is preferred, with careful consideration of the incision to preserve more proximal vessels for future access placement 6