Alternative Methods of Management

Alternatives include a longitudinal incision through the extensor tendon or a volar approach. The tendon-splitting approach is advocated by some to allow for earlier motion. This is a valid argument, although we have not had any extensor tendon subluxation from sagittal band rupture with only 1 week of postoperative immobilization.

A volar approach can be used for open reduction of a complex dorsal MP dislocation. For the index finger, the skin is incised at the thenar crease over the index metacarpal. The radial digital neurovascular bundle is usually tented up by the metacarpal head and is easily injured. The structures surrounding the metacarpal head are then serially divided starting with a longitudinal incision through the volar plate. Because the volar plate is trapped dorsal to the metacarpal head, dividing the proximal margin may be difficult. Next, the natatory ligament is divided followed by the superficial transverse metacarpal ligament. The primary argument for using the volar approach is that division of these volar structures is necessary for reduction of the joint. In my experience, only the volar plate need be divided to allow for reduction.

There are several advantages to the dorsal approach. It is virtually impossible to damage the digital neurovascular bundles. The volar plate can easily be visualized and divided because it is trapped dorsal to the metacarpal. Osteochondral fractures of the metacarpal head are more easily exposed and treated because they are frequently on the dorsal aspect of the metacarpal head. One disadvantage of the dorsal approach is the need to go through the extensor mechanism to expose the joint.

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