- Palmar to the DIP joint
The palmar approach is indicated for avulsion fractures of the palmar base of the distal phalanx by the insertion of the profundus tendon.
The volar plate lies immediately deep to profundus flexor tendon. Division
of the volar plate should be avoided.
Identify and protect the digital nerve and artery.
Make a carefully planned palmar angled skin incision (Bruner zigzag), using
the flexor skin crease as a guide, as illustrated.
The apex of the angle should be at the distal flexor crease, level with the DIP joint.
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 tendons and the C3 and A5 pulleys are now visible.
Make a blunt dissection of the pulp.
Divide the A5 and C3 pulleys laterally near their bony attachments, leaving
enough for later reattachment (at least 2 mm).
Do not cut the A4 pulley, as it is essential for active finger flexion.
Elevation of the pulley flap
Elevate the pulley flap and retract it with a fine suture to expose the flexor tendon, the palmar aspect of the DIP joint and the distal phalanx.
Reattach the A5 and C3 pulleys, using fine mattress sutures, prior to skin closure.