Authors of section

Authors

Fiesky Nuñez, Renato Fricker, Matej Kastelec, Terry Axelrod

Executive Editor

Chris Colton

Open all credits

Midaxial approach to the proximal phalanx

1. Indications for the midaxial approach

The midaxial approach is indicated for oblique, spiral, comminuted, or transverse fractures, of the diaphysis and metaphysis.

It is also indicated for proximal metaphyseal fractures, when a resection is to be performed.

Midaxial approach to the proximal phalanx

2. Planning the incision

To plan the line of the incision, fully flex the finger, as shown, and mark the ends of the joint skin creases with dots.

Midaxial approach to the proximal phalanx

Extend the finger and connect the dots in a line.
The resulting line is safe for a skin incision. The digital artery and digital nerve will lie palmar to this line.

Midaxial approach to the proximal phalanx

3. Skin incision

For proximal fractures, make a skin incision from B to C. For further exposure the incision can be extended to A.

Midaxial approach to the proximal phalanx

For middle phalangeal fractures, incise from A to B.

Midaxial approach to the proximal phalanx

4. Nerve identification

Identify and protect the dorsal branches of the radial, ulnar, and median nerves.

Midaxial approach to the proximal phalanx

5. Retraction of the oblique fibers of the lateral band

Retract the oblique fibers of the lateral band using two retractors.

Midaxial approach to the proximal phalanx

Try to preserve the periosteum, which should be elevated only immediately adjacent to the fracture line, in order to avoid scar formation, tendon adhesion and fragment devascularization.

Midaxial approach to the proximal phalanx

6. Alternative: Resection of the oblique fibers of the lateral band (Burton and Eaton)

It is occasionally necessary, for the visualization of very proximal fractures, to resect unilaterally oblique fibers of the lateral band.
This resection also avoids impingement with the planned implant and intrinsic tendon adhesions.

Midaxial approach to the proximal phalanx

7. Palmar access

Generally, avoid penetration of the flexor tendon sheaths.
In case of tendon laceration, however, the midaxial approach can be used in order to perform tendon repair.

Midaxial approach to the proximal phalanx