Gamekeeper’s Thumb Approach to the Thumb Metacarpophalangeal Joint

GAMEKEEPER’S THUMB APPROACH TO THE THUMB METACARPOPHALANGEAL JOINT

USES

Most commonly used to address tears of the ulnar collateral ligament of the thumb, this approach can be used to address many pathologies at the thumb metacarpophalangeal joint (MPJ). This includes some intraarticular fractures, joint exploration for loose bodies, chondral injuries, or release of intraarticular adhesions. Complex dislocations of the thumb MPJ can be addressed through a dorsal approach as well, although the pathology is volar. It can also be used for reconstructive procedures, including MPJ fusion or arthroplasty.

ADVANTAGES

This approach provides good exposure of the dorso-ulnar MPJ. It can be extended proximally or distally to expose the extensor mechanism of the thumb or to address bone injury or pathology of the proximal phalanx. When addressing complex dislocations of the MPJ, this approach is sometimes preferred to the volar approach, because of the reduced risk of injury to the volar digital nerves.

DISADVANTAGES

It can be difficult to visualize the radial side of the MPJ through this approach, depending on the extent of capsular and ligamentous disruption.

STRUCTURES AT RISK

The main structure at risk in this approach is the dorsal sensory branches of the superficial radial nerve.

TECHNIQUE

A curvilinear incision is made along the dorso-ulnar aspect of the thumb MPJ. Immediately on completing the skin incision, blunt dissection is used through the subcutaneous tissue layer to prevent injury to the superficial dorsal sensory branches. The adductor aponeurosis is identified and divided longitudinally in a line parallel to the extensor tendon. Below this lies the capsule of the MPJ. The ulnar collateral ligament (UCL) is the distinct band of fibers running in a dorsal to volar direction from proximal to distal. An alternate skin incision is the lazy-S incision. The proximal portion of the skin incision is the same as described. At the level of the MPJ, the incision curves volarly, allowing better access to the volar plate.

TRICKS

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