Russe Approach

RUSSE APPROACH

USES

This specialized approach is used for fractures of the scaphoid.

ADVANTAGES

This approach provides the best visualization of the scaphoid with the least risk to the blood supply.

DISADVANTAGES

If there is more pathology requiring repair besides the scaphoid fracture, it is difficult to extend this approach into the palm without disrupting the thenar muscles.

STRUCTURES AT RISK

Proximal to the wrist crease, the radial artery is at risk on the radial side of the incision. The palmar cutaneous branch of the median nerve is at risk on the ulnar side.

TECHNIQUE

The incision starts on the radial side of the wrist and is approximately 3 cm proximal to the wrist flexor crease, just to the ulnar side of the radial pulse, over the flexor carpi radialis tendon. The incision curves across the wrist flexor crease in a slightly dorsal radial fashion. When the flexor carpi radialis tendon is identified, the radial artery is to its radial side. The sheath of the flexor carpi radialis is opened longitudinally. The deep surface of the sheath is longitudinally opened. This artery is retracted radially. The other tendinous structures along with the median nerve are retracted ulnarward, exposing the wrist capsule. The pronator quadratus is seen in the depth of the incision with its muscle fibers running transversely. The incision is carried through the wrist capsule, which exposes the scaphoid.

TRICKS

The main trick to this approach is to identify the flexor carpi radialis tendon and to work around it. Typically, this tendon is retracted in a radial fashion. Everything else goes laterally as you go through the wrist capsule.

HOW TO TELL IF YOU ARE LOST

This approach is based on the key landmark of the flexor carpi radialis (FCR) tendon. If you do not see the tendon, which is an easily identifiable structure, you are lost to one side or the other. If you are deep to the subcutaneous tissue and do not see any tendons, you are typically too far radial. If you go through the flexor retinaculum and see multiple tendons, you are too far ulnarward. This approach should not be carried deep until the FCR tendon is identified.

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