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Duke Orthopaedics
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Wheeless' Textbook of Orthopaedics

Surgical Treatment of Acute Gamekeeper's Thumb


- See:
- Incision:
    - skin incision begins on mid-lateral aspect of the ulnar side of the thumb, is curved over the MP joint, and extends proximally just ulnar to the EPL tendon;
             - take care to identify branches of the superfical radial nerve at the proximal aspect of the incision;
    - identify the EPL, its extensor hood, and the adductor aponeurosis;
    - if a Stener lesion is present, it should be visible at this point, and can be seen as a mass of tissue just proximal to the adductor     aponeurosis;

- Deep Dissection:
    - longitudinal incision is made thru aponeurosis volar to edge of EPL, leaving rim of tissue on tendon to be used later for closure;
             - take care to preserve the underlying MP joint capsule;
             - alternatively, the deep dissection can procedure thru the attachment of the adductor tendon to the extensor hood;
                    - again, take care to avoid damage to the capsule;
    - the adductor tendon is retracted volarly;
    - note presence of transverse tear in the dorsal capsule and identify ligament tear;
    - dorsal capsule is reflected, which permits a clear view of joint and inside portion of the collateral ligament;

- Assessment of Ligamentous Injury:
    - in vast majority of cases (90%), ligament ruptures at its insertion into phalanx;
          - in a minority of cases, the tear occurs thru the mid-substance, which allows for direct tendon repair;
    - in some cases, the accessory collateral ligament and volar plate will also be torn and will require repair;

- Management of Palmar Subluxation:
    - prior to ligament fixation, determine whethere there is volar subluxation of MP joint;
    - if there is plamar subluxation of the MP joint, the joint should be reduced with a K wire;

- Ligament Fixation:
    - w/ distal rupture consider fixation w/ small bone anchors or w/ pull out suture;
             - ulnar collateral ligament flap is partially dissected and moblized off the metacarpal to permit advancement;
             - its essential that the bone anchors in the proximal phalanx be placed volar to the mid-axial line, in order to reproduce the normal insertion of the ligament on the volar-ulnar base of the phalanx;
             - the volar position of the bone anchor will prevent volar subluxation of the joint;
    - alteranatively the ligament can be anchored down w/ sutures tied down over a button;
    - volar ulnar edge of proximal phalanx is debrided of soft tissue;
    - drill 2 parallel holes distally and dorsally to exit on the far side of the cortext;
             - take care to avoid the N/V bundle;
    - pass a 2-0 PDS suture through the distal ligament using a short Bunnel Weave (which will allow the suture to be pulled out postoperatively);
    - sutures are pulled through the drill holes and tied over a padded button;

- Wound Closure:
    - closure should include re-approximation of the attachment of adductor tendon to the dorsal extensor hood



Acute Grade III ulnar collateral ligament ruptures. A new surgical and rehabilitation protocol.

Post-traumatic instability of the metacarpophalangeal joint of the thumb.

Instability of the metacarpophalangeal joint of the thumb.

Reconstruction of the ulnar collateral ligament in athletes.

Acute surgical repair of the skier's thumb.

Acute and late radial collateral ligament injuries of the thumb metacarpophalangeal joint.

Ulnar collateral ligament repair of the MP joint of the thumb: A study comparing two methods of repair.



Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Wednesday, October 3, 2012 7:37 pm