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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


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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.



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