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Surgical Treatment of Gamekeeper’s Thumb


- See: Anesthetic Options

- 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 EPL tendon;
    - take care to identify branches of the superfical radial nerve at the proximal aspect of the incision;

- Adductor Aponeurosis:
    - identify the adductor aponeurosis (superficial expansion of adductor pollicis), which is continguous with the extensor mechanism which 
           overlies the EPL;
    - 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;
    - 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;

- Joint Capsule and Collateral Ligaments:
    - note presence of transverse tear in the dorsal capsule and identify ligament tear;
    - dorsal capsule is reflected, which permits a clear view of joint & inside portion of the collateral ligament;
    - in a minority of cases, the tear occurs thru the mid-substance, which allows for direct tendon repair;
    - in vast majority of cases (90%), ligament ruptures at its insertion into phalanx;
    - prior to ligament fixation, some surgeons will hold the joint reduced with a K wire;
    - in addition to inspection of proper collateral ligament, it is also important to visualize the accessory ligament and volar plate;

- MP joint subluxation:
    - if volar MPJ subluxation is present, it should be reduced and held with a K wire at this time;

- Surgical 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;
           - the normal insertion site is at the proximal-ulnar base of the proximal 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 thru the drill holes and tied over a padded button;
    - closure should include re-approximation of the attachment of adductor tendon to the dorsal extensor hood


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Ulnar collateral ligament repair of the metacarpo-phalangeal joint of the thumb: a study comparing two methods of repair.