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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

Reconstruction of the ulnar collateral ligament in athletes.

Acute surgical repair of the skier's thumb.

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

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