Volar Approach to the Flexor Tendons

VOLAR APPROACH TO THE FLEXOR TENDONS

USES

The volar approach to the flexor tendons, described by Brunner, is a versatile approach for tendon exploration, repair reconstruction, and tenolysis. It is useful for exploration and repair of the neurovascular bundles to the digits, for treatment of soft tissue infections, and for biopsy of tumors on the volar side of the finger.

ADVANTAGES

This approach provides excellent exposure of the tendon with the flexor tendon sheath and excellent exposure of the neurovascular bundle. It is extremely extensile. It can be extended into the palm and incorporated into a carpal tunnel release, and further extended up the forearm into the antecubital fossa.

DISADVANTAGES

There are very few disadvantages to this approach. It does leave a palmar scar, but this generally heals with good cosmesis. If the flaps are not created well, flap necrosis can result with skin loss and risks of increased scarring about the flexor tendons and resultant stiffness.

STRUCTURES AT RISK

The structures at greatest risk are the neurovascular bundles. Carrying the limbs of the incision too far dorsally puts the digital nerves and arteries at higher risk of injury. Avoid longitudinal incisions across the major flexion creases. As the scar matures and contracts, it can cause a flexion contracture across that flexion crease. Keep skin flaps thick and try to maintain an angle of 60 to 90 degrees between the limbs of the incision to reduce the risk of flap necrosis.

TECHNIQUE

The skin incision is a zigzag pattern designed along the length of the finger. The main goals of the skin incision are to avoid a longitudinal incision across a major skin crease and to create angles of the zigzag incision to approximate 90 degrees.

Create large flaps containing the skin and subcutaneous tissue, using blunt dissection and spreading in a longitudinal direction. The flaps can be retracted with sutures, and the entire flexor tendon sheath can be exposed. The pulleys overlying the tendon should be carefully identified.

The neurovascular bundles He immediately to the sides of the flexor tendon sheath, below the very thin diaphanous fibers of Grayson’s ligament. Graysons’s ligament can be longitudinally divided to expose the neurovascular bundle.

Although this is not a good approach to the phalanges, bone can be reached by carefully dissecting between the flexor tendon sheath and the neurovascular bundle. The tendon sheath is retracted, exposing the underlying bone.

TRICKS

When incorporating traumatic wounds into this incision, a more acute angle may be necessary. If you are unable to create a zigzag pattern without creating a skin angle more acute than 60 degrees, then make a longitudinal extension of the traumatic wound to the level of the skin crease, and extend the incision diagonally across the crease.

When raising flaps, use the scissors to bluntly dissect, by spreading in a longitudinal direction. This reduces the chance of injury to the digital nerve and artery. If you are having difficulty finding the nerve, sometimes you can see small white granules in the fatty tissue. These are pacinian corpuscles, and they He very close to the nerve.

HOW TO TELL IF YOU ARE LOST

If you are in too superficial a position, you will be in fat. There are many transverse crossing veins in this layer, which should not be confused with the digital vessels because of their transverse orientation. Longitudinal spreading directly over the tendon will eventually get you down to the level of the sheath. If you stay in the midline, there is minimal risk of injury to the neurovascular bundle.

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