Surgical Approaches
9.1 General Remarks
To avoid risks and complications due to incisions, these should be made on the flexor side of the hand or finger, usually in a zigzag (Bruner) but sometimes in an L or S shape. By contrast, straight incisions are possible on the extensor aspect of the hand; however, these should pass laterally to the joints. Straight incisions should not be made directly over the extensor tendons, so as to avoid adhesions due to scarring.
Scars on the sensitive fingertips and edges of the hand interfere with hand function. Whenever possible, the radial side of the index, middle and ring fingertips and the ulnar side of the little fingertip should be spared.
Structures that run longitudinally, nerves, and vessels must be noted particularly. Veins that run longitudinally must be preserved, whereas transversely running veins may be ligated if necessary.
If deeper structures have to be divided to obtain adequate vision, they must be divided in a way that they can be repaired by suture. This applies particularly to extensor tendons, ligaments, and joint capsule.
Note
Scars in the region of tendon sutures and internal fixation material tend to form considerable adhesions, which in turn leads to major delay in restoration of function due to scar retraction.
9.2 Palmar Approach to the Distal Phalanx, Distal Interphalangeal Joint, and Distal Middle Phalanx
Incise the skin in zigzag fashion according to Bruner ( ▶ Fig. 9.1a).
Expose and incise laterally the A5 annular pulley and C3 cruciate pulley to expose the insertion of the deep flexor tendon ( ▶ Fig. 9.1b).
Practical Tip
Preserve the vessels and nerves on the radial and ulnar sides and, if possible, the A4 annular pulley.
Reflect the divided annular pulleys laterally; retract the distal deep flexor tendon with a blunt retractor to expose the palmar plate ( ▶ Fig. 9.1c).
To obtain access to the joint, divide the palmar plate gradually as far as needed ( ▶ Fig. 9.1c).
Fig. 9.1 Palmar approach to the proximal distal phalanx, distal interphalangeal joint, and distal middle phalanx. (a) Skin incision. (b) The skin and subcutaneous tissue are elevated together from the extensor sheath and retracted with retaining sutures. The radial/ulnar neurovascular bundles (not shown) are protected and the tendon sheath is incised laterally. (c) Retaining sutures are placed in the divided A5 pulley, the deep flexor tendon is retracted laterally, and the palmar plate is exposed.
9.3 Dorsal Approach to the Distal Phalanx, Distal Interphalangeal Joint, and Distal Middle Phalanx
Perform the skin incision over the dorsal joint crease, preferably in Y, H, or S shape ( ▶ Fig. 9.2a).
Retract the skin flaps by fine retaining sutures and expose the insertion of the extensor tendon on the distal phalanx ( ▶ Fig. 9.2b).
Expose the distal interphalangeal joint by oblique / lazy S-shaped division of the distal extensor tendon ( ▶ Fig. 9.2c).
Caution
Protect the nail matrix to avoid deformity of the nail.
Fig. 9.2 Dorsal approach to the proximal distal phalanx, distal interphalangeal joint, and distal middle phalanx. (a) Skin incisions; the Y-shaped incision is preferable. (b) The skin flaps are retracted with retaining sutures. The exposed extensor tendon is divided distally with a longitudinal, lazy S-shaped incision. (c) Exposure of the distal interphalangeal joint.
9.4 Palmar Approach to the Middle Phalanx, Proximal Interphalangeal Joint, and Proximal Phalanx
Make a zigzag (Bruner) incision on the palmar surface of the finger; reflect the rounded tips of the skin flaps ulnarly or radially at the level of the joint creases ( ▶ Fig. 9.3a).
Expose the flexor tendon sheaths; protect the radial and ulnar neurovascular bundles, which are covered by the Grayson ligaments ( ▶ Fig. 9.3b).
Depending on the approach, incise the tendon sheath laterally close to the insertion, dividing the annular pulleys longitudinally ( ▶ Fig. 9.3c).
Practical Tip
Preserve enough tissue for subsequent repair of the annular pulleys.
Expose the palmar side of the finger by retracting the flexor tendon.
To look into the joint, the palmar plate can be divided laterally; subsequent repair must be possible ( ▶ Fig. 9.3d).
Complete exposure of the finger joints is possible only when the lateral ligaments have been detached, preferably distally ( ▶ Fig. 9.3e).
Following hyperextension, the head of the proximal part of the joint can be dislocated fully ( ▶ Fig. 9.3f).
Fig. 9.3 Palmar approach to the middle phalanx, the proximal interphalangeal joint, and the proximal phalanx. (a) Zigzag skin incision (Bruner) for surgical exposure of the flexor side of the middle finger. (b) Exposure of the tendon sheath, preserving the radial and ulnar neurovascular bundles. A1 to A5: annular pulleys; C1 to C3: cruciate pulleys. (c) Palmar exposure of the proximal interphalangeal joint: lateral division of the A3 annular pulley and C1 cruciate pulley, retaining sutures, and exposure of the insertion of the superficial flexor tendon. The A2 annular pulley should be preserved if possible, while the C2 cruciate pulley can be divided if necessary.
(d) The deep flexor tendon is retracted laterally, the palmar plate is detached (proximally or distally), and the proximal interphalangeal joint is exposed. (e) For full exposure of the proximal interphalangeal joint, the collateral ligament is detached on one side (preferably the ulnar side). (f) A proximal interphalangeal joint opened by maximum hyperextension and joint dislocation (simplified illustration).
9.5 Dorsal Approach to the Middle and Proximal Phalanx, Proximal Interphalangeal Joint, and Metacarpophalangeal Joint
Make an S-shaped skin incision, curving around the joints ( ▶ Fig. 9.4a).
Practical Tip
Avoid the radial side of the index finger and ulnar side of the little finger.
Expose the dorsal extensor apparatus, the dorsal aponeurosis, protecting the dorsal sensory nerves ( ▶ Fig. 9.4b).
Access to the middle phalanx shaft ( ▶ Fig. 9.4c) is obtained by longitudinal splitting along the center of the distal extensor tendon and triangular lamina (1); an alternative is to divide the transverse retinacular ligament of Landsmeer to expose the middle phalanx by dorsal retraction of the lateral slip (2).
The approach to the shaft of the proximal phalanx ( ▶ Fig. 9.4c) is obtained by longitudinal splitting along the central slip of the extensor tendon (3); an alternative is to make an incision parallel to the central slip or through the oblique fibers between the central and lateral slips (4); another possibility is to divide the transverse retinacular ligament of Landsmeer, if necessary. The lateral slip of the extensor tendon is retracted dorsally; the oblique fibers of the proximal extensor tendon must then be partially divided longitudinally (5).
An extended dorsal approach to the proximal interphalangeal joint according to Chamay is obtained by elevation of the central slip of the extensor tendon as a distally based, V-shaped flap ( ▶ Fig. 9.4d).
Practical Tip
Avoid a detachment of the extensor central slip on the dorsal base of the middle phalanx.
The approach to the metacarpophalangeal joint is as follows:
By midline splitting of the extensor tendon or parallel to the central slip, preferably dorsoulnar ( ▶ Fig. 9.4e).
In extended position—possible only from the radial side of the index finger and ulnar side of the little finger—between the collateral ligament and accessory collateral ligament ( ▶ Fig. 9.4f).
In flexed position—by incision of the dorsal capsule parallel to the collateral ligament ( ▶ Fig. 9.4g).
Fig. 9.4 Dorsal approach to the middle and proximal phalanx and to the proximal interphalangeal and metacarpophalangeal joints. (a) Skin incisions. (b) Exposure of the extensor tendon and dorsal aponeurosis. (c) Approach to the shaft of the middle phalanx. 1: central incision through the extensor tendon and triangular lamina; 2: parallel incision along the border of the lateral slip with longitudinal division of the transverse retinacular ligament of Landsmeer. Approach to the shaft of the proximal phalanx. 3: The central slip is split down the middle. 4: A laterally displaced incision is made parallel to the central slip or through the oblique fibers between the central slip and lateral slip. 5: The lateral slip is moved dorsally and, if necessary, the transverse retinacular ligament of Landsmeer and oblique fibers of the proximal extensor apparatus are divided.
(d) Extended approach to the proximal interphalangeal joint (Chamay). A distally based, V-shaped tendon flap is created by an incision of the central slip. (e) Approach to the proximal interphalangeal joint. 1: Longitudinal splitting of the extensor digitorum tendon. 2: Parallel to the central slip, a dorsoulnar incision is made through the oblique fibers between the central and the lateral slips of the extensor tendon.
(f) Approach in extension, between the collateral and accessory collateral ligaments. (g) Approach in flexion, by incision of the dorsal capsule parallel to the collateral ligament.
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