AOTrauma Webinar:  Why Do Patients Get Infection?

May 30, 2017 14:00 CET

Main Presenter: Olivier Borens, MD (Switzerland)
Chat Moderator: Stephen Kates, MD (USA)

Surgical site infections after trauma are debilitating and costly. They are feared by the surgeon and the patient alike. The incidence of this complication can be decreased by proper preoperative, intraoperative, and postoperative management.
The goal of this webinar is to present easy-to-use tools and strategies that will lead to a decrease in the incidence of infection.

More information and registration...

Infection

Executive Editor: Chris Colton

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

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Glossary

Dorsal to the PIP joint
Dorsal approaches to the PIP joint enlarge

Indications

The dorsal approach to the proximal interphalangeal (PIP) joint is indicated for intraarticular fractures.
It is also useful for coronal plane fractures of the condyles of the proximal phalanx.
Central slip avulsion fractures from the dorsal base of the middle phalanx are an ideal indication for this approach.


Dorsal approaches to the PIP joint enlarge

Skin incision

Make a straight midline dorsal incision over the PIP joint.
With this incision, vascularity and venous drainage are well preserved. Early postoperative motion will prevent scarring between skin, tendon and bone.
The disadvantage of this incision is that any skin and tendon scarring will be in the same line.


Dorsal approaches to the PIP joint enlarge

Alternative: curved skin incision

Alternatively, make a curved skin incision over the PIP joint. The convexity of the incision is planned so that the scar does not involve the radial border of the index, or the ulnar border of the little finger. The fracture configuration and implant placement must be given priority when planning the incision.

The advantage of the curved incision is that the skin and tendon scarring are not in line.
The disadvantage is reduced vascularity at the apex of the curve, with a risk of necrosis and delayed skin healing.


Dorsal approaches to the PIP joint enlarge

Nerve identification

Blunt dissection extends the approach into the thin subcutaneous tissue, taking care to identify and protect the dorsal sensory branches of the radial, ulnar, and median nerves.


Dorsal approaches to the PIP joint enlarge

Vein identification

The dorsal venous system of the fingers has longitudinal and transverse branches. Be careful to preserve the longitudinal branches. The transverse branches may be ligated, or cauterized with a bipolar cautery, for better exposure, but preserve as many dorsal veins as possible to avoid possible congestion and swelling.


Dorsal approaches to the PIP joint enlarge

Skin retraction

Retract and elevate the skin and the subcutaneous tissue as a single layer. The extensor apparatus is fully exposed and intact.


Dorsal approaches to the PIP joint enlarge

Alternative procedures

Alternative 1: Approach between the central and lateral extensor slips

Alternative 2: Central midline extensor splitting

Alternative 3: Approach lateral to the lateral band of the extensor apparatus

Alternative 4: Elevation of the central slip as a distally-based, V-shaped flap (Chamay approach)


Dorsal approaches to the PIP joint enlarge

Recommended approach:

Between lateral and central extensor tendon slips
Make an incision in the tendon, between the central slip and the lateral band.


Dorsal approaches to the PIP joint enlarge

Retraction of the slips exposes the dorsal capsule of the PIP joint.


Dorsal approaches to the PIP joint enlarge

Capsulotomy

Perform a vertical capsulotomy in order to expose the joint.

Caution
Avoid detachment of the extensor central slip and of the collateral ligaments.


Dorsal approaches to the PIP joint enlarge

Flex for better exposure

Flexing the PIP joint allows the lateral band to move in a palmar direction to give a better exposure of the joint.


Dorsal approaches to the PIP joint enlarge

Alternative 2: Split down the middle

Make a straight incision and perform a longitudinal midline tenotomy.
Do not disinsert the central slip.
The disadvantage of this approach is the possibility of developing a boutonnière deformity or lack of extension.


Dorsal approaches to the PIP joint enlarge

Alternative 3: Lift the central extensor slip as a V-shaped flap (Chamay approach)

Raise the central extensor slip as a distally-based, V-shaped flap, leaving it attached to the base of the middle phalanx.
Perform a transverse, dorsal capsulotomy.
Flexing the joint causes the lateral band to slip in a palmar direction, exposing the whole joint.


Dorsal approaches to the PIP joint enlarge

Alternative 4: Lateral to the lateral extensor band

Incise gently lateral to the lateral band.
Divide the TRL, using a dental pick inserted between it and the collateral ligament, to avoid accidentally cutting the collateral ligament.

A longitudinal capsulotomy allows the joint to be inspected.


Dorsal approaches to the PIP joint enlarge

Note

Limited reach
This dorsolateral approach does not allow access to the opposite condyle which in some situations is necessary, notably in irreducible bicondylar fractures.


Dorsal approaches to the PIP joint enlarge

Wound closure

Regardless of the approach chosen, all tendon incisions ...


Dorsal approaches to the PIP joint enlarge

... need to be sutured prior to wound closure.

v1.0 2008-11-08