Fractures of the base of the proximal phalanx: Palmar approach combined with palmar plating

Displaced fractures of the base of the proximal phalanx (PP) remain a challenging surgical problem. Regardless of the osteosynthesis material chosen (K-wires, screws, plates), when open reduction is required, the surgical approaches typically used are either dorsal or lateral. These approaches inevitably cause surgical trauma to the extensor apparatus which, via the intrinsic system, envelops the dorsal and lateral surfaces of PP at this level. To preserve the extensor apparatus, the authors propose a palmar approach combined with anterior plate fixation.

This is a retrospective, single-center study conducted between September 2022 and October 2025. Patients presenting with displaced fractures of the base of PP were included. The surgical approach was a palmar Bruner-type incision. The flexor apparatus was retracted laterally after subcapsular-periosteal elevation. Osteosynthesis was performed using a palmar T-plate or grid plate, 1 or 1.3 mm thick (Medartis®). The flexor apparatus was repositioned after secure pulley fixation to the periosteum. Under the supervision of the physiotherapy team, patients were instructed to achieve full immediate mobilization with syndactyly and nighttime extension splinting. Patients were reviewed with radiographic assessment at 3 weeks, 6 weeks, and 12 weeks, along with clinical evaluation: wound healing, pain (VAS), active finger mobility (TAM), and active extension deficit of the PIP joint (digital goniometer).

The study included 15 patients, 8 women and 7 men, with a mean age of 52 years (range 23-83). 19 displaced fractures of the base of PP were treated using this technique. Two patients had fractures involving the last three digits. Consolidation was achieved at 6 weeks in all cases without any displacement. At 12 weeks, pain had resolved (VAS 0), mean TAM was 256° (range 210°-280°), PIP extension was complete in 12 cases, and in 7 cases the PIP extension deficit was less than 20°. No complication were observed in any of the 19 cases, and no hardware removal was required.

The excellent mobility results are likely attributable to the palmar approach. By sparing the extensor apparatus from any trauma, adhesions are avoided. Cross-sectional examination at the base of PP reveals that the extensor apparatus envelops PP over three-quarters of its circumference. Only the palmar approach and palmar fixation truly spare the extensor apparatus. The disadvantage is the elevation of the flexor apparatus and the need to secure the A2 pulley.

Osteosynthesis of fractures of the base of PP using a palmar approach and palmar plate offers a new strategy for these surgically challenging fractures. Greater experience and longer follow-up are needed to confirm these preliminary results.