The palmar approach is indicated for avulsion fractures of the palmar base of the distal phalanx by the insertion of the profundus tendon.
2. Surgical anatomy
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.
3. Skin incision
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.
4. Blunt dissection
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.
5. 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.
6. Wound closure
Reattach the A5 and C3 pulleys, using fine mattress sutures, prior to skin closure.