- See:
- Finger Tip Injuries
- Brunner Type Incisions:
- The zig-zag volar-digital incision for flexor tendon surgery.
- Midaxial Incision:
- indications: septic arthritis of IP joints and MP joint of thumb;
- site for placing midaxial incision is performed by flexing finger & marking the point at each joint where the flexion crease ends;
- points are connected which identifies the midaxial line;
- begin the incision on midlateral aspect of finger at level of proximal finger crease and carry it distally to PIP joint just dorsal to flexor skin crease;
- since flexor since creases extend slightly over half way around finger nail, incision is made slightly posterolateral;
- continue incision in central portion of each finger segment;
- fat is more plentiful centrally than it is over joint, & allows greater safety margin;
- since fat is scanty over PIP joint, and be careful not to enter it by mistake;
- immediately after incising the fat, carry the dissection volarward deep to the nueorvascular bundle and expose the tendon sheath;
- digital nerve and artery lie approximately 2 mm volar to the margin of incision, so it is best to preserve thickness of fat on volar flap;
- note that the common digital nerve divides at the palmar aspect of the proximal phalanx;
- develop the dorsal flap a little to aid in closure of the incision;
- on radial sides of index and middle finger & ular side of little finger is a dorsal branch of the digital nerve that should be preserved when possible;
- dissection of Cleland's ligament;
- after skin incision, first structure encountered is Cleland's ligament;
- this contains fibers that run in volar to dorsal direction & connect thiner fascial layers surrounding digital nerve and artery with skin;
- Cleland's ligament can be isolated from adjacent fat at the level of PIP joint to allow it to be resutured during closure;
- resuturing of ligament may prevent hyperextension deformities at PIP jont;
- once Cleland's ligament is divided, further dissection will expose side of phalanx, & margin of the flexor sheath;
joint inspection:
- enter the joint between the volar plate and the accessory colateral ligament
Variations in digital nerve anatomy.
The digital palmar oblique incision.
A modified midlateral incision for volar approach to the digit.