Authors of section

Authors

Aida Garcia, Fabio A Suarez

Executive Editor

Simon Lambert

Open all credits

Volar approach to the metacarpophalangeal joint

1. General considerations

Indications

This approach is used for the surgical treatment of fracture-dislocations of the metacarpophalangeal (MCP) joint.

Volar approach to the metacarpophalangeal joint of the 2nd ray

AO teaching video

Palmar approach to metacarpophalangeal joint of the finger

2. Surgical anatomy

Tendinous anatomy

The tendons of the flexor digitorum superficialis and profundus are closely applied to the volar plate and volar capsule of the MCP joints.

Tendinous anatomy of the metacarpals and proximal phalanges

Nerve identification

In the thin subcutaneous tissue, identify and protect the collateral neurovascular bundles of the ulnar and median nerves.

Volar nerve anatomy of the hand

Sometimes the digital nerve is dislocated volarly with the metacarpal head. Take care to identify the nerve during the approach.

Digital nerve dislocation of the level of the metacarpal head
Note: Identify and carefully dissect the neurovascular bundles to protect them.

Intraoperative photo showing a volar approach to the 2nd metacarpal head with displacement of the digital nerve after a metacarpophalangeal joint dislocation

Approach to the 2nd metacarpal head with volar dislocation of the digital nerve

3. Skin incision

Make a Z-shaped incision over the MCP joint with the apex either radially or ulnarly at the level of the skin crease.

In case of multiple neighboring incisions, the apexes should point in the same direction to avoid ischemia and necrosis of the intervening skin flaps.

Skin incisions for volar approach to the metacarpophalangeal heads

Extension of the incision

According to the dislocation complexity or soft-tissue interposition, the incision can be extended proximally in a Z-shape respecting the natural skin creases. This helps to avoid contracture of the skin.

Extended skin incisions for volar approach to the metacarpophalangeal heads

4. Exposure of the retinaculum and A1 pulley

The skin flaps are retracted to expose the distal part of the flexor retinaculum and A1 pulley.

Be aware of overretraction to avoid damage to the nerves.

Exposure of the retinaculum and A1 pulley during a volar approach to the metacarpophalangeal joint of the 2nd ray

5. Exposure of the joint

Identify and protect the digital nerves.

The flexor digitorum superficialis and profundus are sharply dissected from the volar plate and capsule and retracted to expose the volar aspect of the joint. Usually, in a dislocation, the volar joint capsule is ruptured and may be interposed in the joint space.

Exposure of the joint during a volar approach to the metacarpophalangeal joint of the 2nd ray

6. Wound closure

The joint capsule is repaired with fine sutures. The flexor tendon is repositioned. The skin is closed in a standard manner.

The A1 pulley does not need repair, as this may lead to contracture of the tendon sheath with restriction of flexor tendon excursion.

Joint capsule and skin closure after a volar approach to the metacarpophalangeal joint
Go to diagnosis