What is the recommended incision approach when operating over the volar aspect of the wrist?

Recommended Incision Approach for Operating Over the Volar Aspect of the Wrist

For operations over the volar aspect of the wrist, a transverse incision is recommended as it has less negative impact on wound healing, reduces the risk of dehiscence, and results in less postoperative pain compared to midline or longitudinal approaches. 1

Anatomical Considerations

• The volar radiocarpal joint is located approximately 7 mm proximal to the proximal wrist flexion crease and 16 mm proximal to the distal wrist flexion crease, making these creases reliable superficial landmarks for surgical planning 2
• When planning the incision, consider that the wrist flexion creases are consistently distal to the volar radiocarpal joint in all patients 2
• Structures at risk during volar wrist approaches include the median nerve, palmar cutaneous branch of the median nerve, and ulnar neurovascular bundle 3

Recommended Incision Technique

• For most volar wrist procedures, place the transverse incision at the distal wrist crease with possible extension proximally up to the proximal wrist crease 3
• Follow Langer's lines to minimize scarring and optimize wound healing 4
• For vascular access procedures at the wrist, the incision should preserve more proximal vessels for potential future access placement 1

Surgical Approach Options

Transverse Approach

• Provides better cosmetic results with less risk of hypertrophic scarring 5
• Results in faster functional recovery (average 6 days vs. 15 days for longitudinal approaches) 5
• Allows earlier return to work (average 10 days vs. 23 days for longitudinal approaches) 5
• Reduces the risk of wound dehiscence and postoperative pain 1

Volar Central Portal Approach (for arthroscopic procedures)

• Single incision that allows access to both radiocarpal and midcarpal joints 3
• Centers on the lunate through the Poirier space 3
• Protects volar structures at risk by using tendons as natural retractors 3
• Median distances from the volar central radiocarpal portal to key structures:
  • Median nerve: 10.5 mm
  • Palmar cutaneous branch of median nerve: 18.5 mm
  • Ulnar neurovascular bundle: 7.0 mm 3

Specific Clinical Scenarios

• For vascular access procedures (e.g., arteriovenous fistula creation), a carefully placed incision at the wrist should preserve more proximal vessels for future access placement 1
• For ganglion cyst excision on the volar aspect, arthroscopic resection through dorsal ports is preferred for radiocarpal ganglia due to less postoperative morbidity and better cosmetic results 5
• For tendon transfers involving the volar aspect of the wrist, a volar transverse incision at the mid-forearm provides adequate exposure while minimizing complications 6

Common Pitfalls and How to Avoid Them

• Avoid longitudinal incisions that cross wrist creases as they may lead to hypertrophic scarring and contracture 4, 5
• Be aware of the proximity of neurovascular structures when making volar incisions - the median nerve and ulnar neurovascular bundle are particularly at risk 3
• When performing arthroscopic procedures, consider that a volar approach has less risk of complications for radiocarpal pathology, but open approaches may be more appropriate for midcarpal pathology 5
• Avoid placing incisions directly over the radiocarpal joint, as this area is approximately 7-16 mm proximal to the wrist flexion creases 2