Executive Editor: Chris Colton

Authors: Fiesky Nuñez, Renato Fricker, Matej Kastelec, Terry Axelrod

Proximal phalanx

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Glossary

Palmar to PIP joint
Palmar approach to the PIP joint enlarge

Indications

The palmar approach is indicated mainly for volar plate avulsion fractures of the base of the middle phalanx, for fracture dislocations of the proximal interphalangeal (PIP) joint, or for comminuted, impacted fractures of the base of the middle phalanx.
An exception to this rule is a dorsal central slip avulsion fracture of the base of the middle phalanx, with palmar dislocation, that can not be approached via a palmar exposure, and the dorsal route becomes the first choice.
The palmar approach is also indicated for volar plate arthroplasty.


Palmar approach to the PIP joint enlarge

Surgical anatomy

When approaching the PIP joint, take care to preserve the digital arteries and nerve.
The flexor tendon pulleys are either transverse (A) or cruciform (C). They are numbered sequentially from proximal to distal, as illustrated.


Palmar approach to the PIP joint enlarge

Vincular arteries

The vincular arteries are delicate, but essential to the vascularity of the flexor tendons. They must be preserved whenever possible, lest the vascularity of the tendon be compromised.


Palmar approach to the PIP joint enlarge

Skin incision

Make a carefully planned palmar, angled skin incision (Bruner zigzag), using the flexor skin creases as a guide, as illustrated.
The apex of the angle should be at the end of the intermediate flexor crease, level with the PIP joint.


Palmar approach to the PIP joint enlarge

Elevate the flap

The angled skin flap is elevated by blunt dissection in the thin subcutaneous tissue, and the apex retracted using a fine stitch. Identify and gently mobilize the digital arteries and nerves.
The flexor sheath with the C1, C2, and A3 pulleys are now visible.


Palmar approach to the PIP joint enlarge

Division of the pulleys

Incise the C1, A3, and C2 pulleys laterally, near their bony attachments, leaving enough (at least 2 mm) for later reattachment, and elevate them with sutures.
Do not cut the A2 or A4 pulleys, as these are essential for the biomechanics of active flexion of the finger.


Palmar approach to the PIP joint enlarge

This clinical photo gives a good view of the flexor tendons after the pulleys have been divided.


Palmar approach to the PIP joint enlarge

Exposure of the palmar capsule

Retract the flexor tendons, using a latex loop (such as a Penrose drain).


Palmar approach to the PIP joint enlarge

The palmar capsule is now visible. 


Palmar approach to the PIP joint enlarge

Exposure of the volar plate

Extension of the PIP joint now exposes the distal edge of the volar plate, which often bears a fracture fragment. The fracture fragment can be elevated together with the volar plate and retracted proximally.


Palmar approach to the PIP joint enlarge

In the event that the volar plate is attached to small palmar fragments not suitable for fixation, and a volar plate arthroplasty is indicated, detach the volar plate distally using a transverse incision.


Palmar approach to the PIP joint enlarge

Indications for ‘shotgun’ hyperextension exposure

If there is comminution, or impaction of fragments, at the base of the middle phalanx that need to be reduced, both collateral ligaments need to be divided.


Palmar approach to the PIP joint enlarge

This will enable full opening of the PIP joint by hyperextension (Eaton), thereby exposing fully the base of the middle phalanx.


Palmar approach to the PIP joint enlarge

Detach the ligaments

The distal and palmar attachments of the collateral ligaments should be detached bilaterally, and retracted dorsally.


Palmar approach to the PIP joint enlarge

Hyperextend the finger

After detachment of the collateral ligaments, the finger can be fully hyperextended (as in breaking open a shotgun).


Palmar approach to the PIP joint enlarge

This will give a complete view of the whole joint surface of the middle phalanx and both condyles of the proximal phalanx.


Palmar approach to the PIP joint enlarge

Wound closure

Volar plate
Reattach the volar plate and any small attached fracture fragment, using either a pullout suture, or at least two anchor sutures.


Palmar approach to the PIP joint enlarge

Pulleys
It is mandatory to repair the A3 pulley. If possible, also reattach the C1 and C2 pulleys.

v1.0 2008-11-08