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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_708_Библиотеки_им_академика_М_И_Перельмана
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Figure 47-2. Develop a slight plantar skin flap by incising the subcutaneous flap
in line with the skin incision.
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Figure 47-3. Incise the fibrous flexor sheath longitudinally to expose the
underlying tendons.
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Figure 47-4. If a flexor tenotomy or flexor-to-extensor transfer is to be
performed, take a blunt hook and insert it around the long flexor tendon. Putting
the hook toward you will passively flex both the proximal and distal
interphalangeal joints and allow the long flexor tendon to be divided well distal
to the site of the dissection.
Dangers
The plantar digital nerve is endangered if the skin incision is made too far
plantarly. It is also at risk if the dissection drifts too far in a plantar
direction. The guide to making a safe incision is to identify the end of the
interphalangeal creases. If the incision is made at this site—at the junction
between the smooth and wrinkled skin—the danger to the plantar digital
nerve will be diminished.
The plantar digital artery runs with the digital nerve on its inner side. It
may also be damaged if the approach moves too far in a plantar direction.
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How to Enlarge the Exposure
This exposure is designed purely for exposure of the fibrous flexor sheath
and its contents and cannot be extended usefully either proximally or
distally.
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48
Transverse Approach for Surgery
to a Hammer Toe
Position of the Patient
Landmarks and Incision
Internervous Plane
Superficial Surgical Dissection
Deep Surgical Dissection
Dangers
How to Enlarge the Approach
Introduction
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The transverse approach for surgery to hammer toe is used for surgery
to correct a fixed flexion deformity of the proximal interphalangeal
(PIP) joint of the affected toe. This approach is most often used for
treatment of an underlying deformity, such as fusion of a diseased
fixed flexed PIP joint.
In this condition, the skin overlying the dorsal aspect of the PIP
joint is often thin and inflamed. If skin breakdown or ulceration is
present, surgery should be deferred until the condition has been
improved by nonoperative techniques.
The approach has no other uses. Surgery should not be carried out
if there is any evidence of vascular insufficiency of the foot, since a
poor blood supply to the tissue may lead to slow healing or even cause
flap necrosis.
The operation can be carried out under a general anesthetic, spinal
anesthesia, or if confined to one toe, under ring block local anesthesia.
Position of the Patient
Place the patient supine on the operating table (see Fig. 1-1). If a general
anesthetic is to be used, place a tourniquet on the middle of the thigh after
exsanguination of the limb. If a local ring block is to be used, place a rubber
tourniquet at the base of the toe.
Landmarks and Incision
Palpate the head of the proximal phalanx that is prominent. The skin
overlying it is thin, red, and often inflamed.
Excise a transverse ellipse of skin centered over the PIP joint of the
affected toe. The incision should excise approximately 3 to 4 mm of skin
and extend from one side of the dorsum of the toe to the other (Fig. 48-1).
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Figure 48-1. Excise a transverse ellipse of skin centered over the proximal
interphalangeal joint of the affected toe. The incision should excise
approximately 3 to 4 mm of skin and extend from one side of the dorsum of the
toe to the other.
Internervous Plane
There is no internervous plane in this surgical approach.
Superficial Surgical Dissection
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Incise the thin subcutaneous tissue in the line of the skin incision to expose
the common extensor tendon overlying the PIP joint. Next, excise an ellipse
of the common extensor tendon in the line of the skin incision to expose the
distal end of the proximal phalanx of the affected toe (Fig. 48-2).
Deep Surgical Dissection
Using a pair of sharp bone cutters, excise the distal 5 to 6 mm of the
exposed proximal phalanx (Fig. 48-3). This will expose the distal end of the
middle phalanx. Keeping the bone cutters closely applied to the middle
phalanx, push them distally to expose the proximal end of the middle
phalanx and excise the articular surface of the middle phalanx (Fig. 48-4).
Excision of the distal end of the proximal phalanx and the proximal end
of the middle phalanx together with excision of an ellipse of skin and an
ellipse of extensor tendon will allow full correction of the flexion deformity
of the PIP joint. The flexor tendons are exposed in the base of the wound,
but should not be in danger providing the bone cutters do not extend too far
in a plantar direction.
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Figure 48-2. Incise the thin subcutaneous tissue in the line of the skin incision
to expose the common extensor tendon overlying the proximal interphalangeal
joint. Next, excise an ellipse of the common extensor tendon in the line of the
skin incision to expose the distal end of the proximal phalanx of the affected
toe.
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Figure 48-3. Using a pair of sharp bone cutters, excise the distal 5 to 6 mm of
the exposed proximal phalanx. This will expose the distal end of the middle
phalanx.
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