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Development of a customized three-dimensional printed paediatric hand retractor for patient-precise dimensions and enhanced surgical autonomy

commenced, but the patient wore a customized palmar splint designed to apply pressure over the reconstructed pulley for 5 weeks. Six months following pulley reconstruction, he had a much-improved range of motion and could nearly make a full fist with a TAM of 254 (Figure 2). His function and grip strength was also much improved. In a cadaveric study, Manske and Lesker (1983) demonstrated that the transverse fibres of the palmar aponeurosis are anchored on the sides of the flexor synovial sheath by vertical intertendinous septae proximal to the A1 pulley, forming an additional pulley called the ‘PA pulley’. As a functioning pulley unit, the A2 pulley was found to be the most important, followed closely by the A1 pulley, with the PA pulley being the least critical of the three. The functional loss associated with absence of any one of these three pulleys was minimal, and the absence of either the A1 or A2 pulley was insignificant, as long as the aponeurosis transverse fibres were present. However, where all three were cut, there was a reduction in the total ROM of 12.4%. They recommended that the aponeurosis transverse fibres or PA pulley should be preserved whenever technically possible, particularly if either (or both) the A1 and A2 pulleys are divided. Phillips and Mass (1996) confirmed these observations in further cadaveric studies and recommended that perhaps the palmar aponeurosis pulley should be considered similar in importance to the other pulleys. In numerous clinical scenarios, for example primary repair and secondary flexor tendon reconstruction surgery, it is often necessary to gain access to the flexor tendons in the palm by dividing the A1 pulley. Our case report illustrated the importance of preserving either the PA (A0) or A1 pulley and not dividing both routinely.