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Orthopedic Surgery for Gamekeeper's Thumb Workup

  • Author: Matthew Hannibal, MD; Chief Editor: Harris Gellman, MD  more...
 
Updated: Nov 06, 2014
 

Imaging Studies

Standard radiography

Before any manipulation of the thumb, obtain standard anteroposterior, lateral, and oblique radiographs to exclude metacarpal fractures and gamekeeper's fractures (see the images below).

Anteroposterior radiograph displaying a gamekeeper Anteroposterior radiograph displaying a gamekeeper's fracture.
Lateral radiograph displaying a gamekeeper's fract Lateral radiograph displaying a gamekeeper's fracture.

Nondisplaced avulsion fractures that are associated with rupture of the insertion point of the ulnar collateral ligament are not contraindications to manipulation. If these fractures were not displaced at the time of injury and greatest stress, they are stable enough for the manipulation of stress testing.

Gamekeeper's fractures should not be manipulated, especially those that involve more than 30% of the joint surface and those that are malrotated and/or displaced. Such fractures are indications for surgical intervention.

The finding of 3 mm of volar subluxation of the phalanx on the metacarpal is suggestive of complete UCL rupture and instability. Radial deviation of more than 40° in extension and more than 20° in flexion also indicates instability.

Stress radiography

Radiographs obtained with the thumb in the flexed and extended positions and with valgus stress at the MCP joint (see the image below) can help the physician to determine the degree of instability of partial tears of the UCL.

Radiograph displaying a stress test of a torn ulna Radiograph displaying a stress test of a torn ulnar collateral ligament.

Ultrasonography

In a French study, Gherissi et al evaluated echography (ultrasonography) to diagnose Stener lesions in 25 gamekeeper's thumbs from March 2005 to March 2007.[1] They found that ultrasonography is useful in identifying Stener lesion in the emergency department because it is available, cheap, noninvasive, and dynamic. Ultrasonography was ultrasonographer-dependent and ultrasonogram-dependent. The author's study revealed the advantage of using ultrasonography with tissue harmonic imaging.

Magnetic resonance imaging

In a 2014 study of 43 UCL injuries, Milner et al described the use of magnetic resonance imaging (MRI) to assess the degree of UCL displacement and thereby help create a four-type classification to facilitate determination of which UCL injuries require surgical treatment.[14] They found that type 1 (partial or minimally displaced) and type 2 (< 3 mm displaced) tears typically healed by immobilization alone, whereas 90% of type 3 (>3 mm displaced) tears failed immobilization and required surgery, as did 100% of type 4 (Stener) tears.

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Diagnostic Procedures

The patient often has considerable pain in the thumb, and stressing the MCP joint leads to guarding and misleading findings on examination. The thumb is best examined under local anesthesia, which can be administered in the emergency department or in the office setting (see the images below). Often, administration of 2-3 mL of 1% lidocaine into the MCP joint of the thumb is sufficient to relieve the pain and relax the patient's guarding.

Stress testing of the metacarpophalangeal joint of Stress testing of the metacarpophalangeal joint of the thumb in flexion.
Stress testing of the metacarpophalangeal joint of Stress testing of the metacarpophalangeal joint of the thumb in extension.

If more anesthesia is required, perform a metacarpal or digital block. Some authors recommend the use of an ulnar or median nerve block to negate the effects of the intrinsic muscles. If the injection into the joint relieves the pain, no further anesthesia is necessary.

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Laboratory Studies

No laboratory tests are necessary for the diagnosis of gamekeeper's thumb. In cases where surgical intervention is required, routine preoperative laboratory workup is indicated.

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Contributor Information and Disclosures
Author

Matthew Hannibal, MD Staff Physician, Carolina Orthopedic Specialists

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Michael Yaszemski, MD, PhD Associate Professor, Departments of Orthopedic Surgery and Bioengineering, Mayo Foundation, Mayo Medical School

Disclosure: Nothing to disclose.

Chief Editor

Harris Gellman, MD Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami, Leonard M Miller School of Medicine, Clinical Professor, Surgery, Nova Southeastern School of Medicine

Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, Arkansas Medical Society

Disclosure: Nothing to disclose.

Additional Contributors

Peter M Murray, MD Professor and Chair, Department of Orthopedic Surgery, Mayo Clinic College of Medicine; Director of Education, Mayo Foundation for Medical Education and Research, Jacksonville; Consultant, Department of Orthopedic Surgery, Mayo Clinic, Jacksonville; Consulting Staff, Nemours Children's Clinic and Wolfson's Children's Hospital

Peter M Murray, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Reconstructive Microsurgery, Orthopaedic Research Society, Society of Military Orthopaedic Surgeons, American Association for Hand Surgery, American Society for Surgery of the Hand, Florida Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

Daniel Roger, MD Director of Hand Surgery, Wyckoff Heights Medical Center; Former Assistant Professor, Department of Orthopedics, Catholic Medical Center of Brooklyn and Queens, New York Medical College

Daniel Roger, MD is a member of the following medical societies: Medical Society of the State of New York

Disclosure: Nothing to disclose.

References
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  2. Bruens ML, Dobbelaar P, Koes BW, Coert JH. [Arm injuries due to sport climbing]. Ned Tijdschr Geneeskd. 2008 Aug 16. 152(33):1813-9. [Medline].

  3. Johnson JW, Culp RW. Acute ulnar collateral ligament injury in the athlete. Hand Clin. 2009 Aug. 25(3):437-42. [Medline].

  4. Chuter GS, Muwanga CL, Irwin LR. Ulnar collateral ligament injuries of the thumb: 10 years of surgical experience. Injury. 2009 Jun. 40(6):652-6. [Medline].

  5. Rettig A, Rettig L, Welsch M. Anatomic reconstruction of thumb metacarpophalangeal joint ulnar collateral ligament using an interference screw docking technique. Tech Hand Up Extrem Surg. 2009 Mar. 13(1):7-10. [Medline].

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  9. Baskies MA, Tuckman D, Paksima N, Posner MA. A new technique for reconstruction of the ulnar collateral ligament of the thumb. Am J Sports Med. 2007 Aug. 35(8):1321-5. [Medline].

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  12. Shinohara T, Horii E, Majima M, et al. Sonographic diagnosis of acute injuries of the ulnar collateral ligament of the metacarpophalangeal joint of the thumb. J Clin Ultrasound. 2007 Feb. 35(2):73-7. [Medline].

  13. Heyman P. Injuries to the ulnar collateral ligament of the thumb metacarpophalangeal joint. J Am Acad Orthop Surg. 1997 Jul. 5(4):224-9. [Medline].

  14. Milner CS, Manon-Matos Y, Thirkannad SM. Gamekeeper's Thumb-A Treatment-Oriented MRI Classification. J Hand Surg Am. 2014 Oct 6. [Medline].

  15. Pichora DR, McMurtry RY, Bell MJ. Gamekeepers thumb: a prospective study of functional bracing. J Hand Surg [Am]. 1989 May. 14(3):567-73. [Medline].

  16. Sollerman C, Abrahamsson SO, Lundborg G, Adalbert K. Functional splinting versus plaster cast for ruptures of the ulnar collateral ligament of the thumb. A prospective randomized study of 63 cases. Acta Orthop Scand. 1991 Dec. 62(6):524-6. [Medline].

  17. Abrahamsson SO, Sollerman C, Lundborg G, Larsson J, Egund N. Diagnosis of displaced ulnar collateral ligament of the metacarpophalangeal joint of the thumb. J Hand Surg [Am]. 1990 May. 15(3):457-60. [Medline].

  18. Gerber C, Senn E, Matter P. Skier's thumb. Surgical treatment of recent injuries to the ulnar collateral ligament of the thumb's metacarpophalangeal joint. Am J Sports Med. 1981 May-Jun. 9(3):171-7. [Medline].

  19. Stener B. Displacement of the ruptured ulnar collateral ligament of the metacarpo-phalangeal joint of the thumb. J Bone Joint Surg [Br]. July 1962. 44:869-79. [Full Text].

 
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Anteroposterior radiograph displaying a gamekeeper's fracture.
Lateral radiograph displaying a gamekeeper's fracture.
Radiograph displaying a stress test of a torn ulnar collateral ligament.
Stress testing of the metacarpophalangeal joint of the thumb in flexion.
Stress testing of the metacarpophalangeal joint of the thumb in extension.
Anterior view of a hand in a thumb spica splint.
Lateral view of a hand in a thumb spica splint.
 
 
 
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