Orthopedic Surgery for Gamekeeper's Thumb Workup

  • Author: Matthew Hannibal, MD; Chief Editor: Harris Gellman, MD   more...
 
Updated: Feb 17, 2012
 

Laboratory Studies

  • No laboratory tests are necessary for the diagnosis of gamekeeper's thumb.
  • In cases that require surgical intervention, routine preoperative laboratory workup is indicated.
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Imaging Studies

  • Standard radiographs
    • Before any manipulation of the thumb, obtain standard anteroposterior, lateral, and oblique radiographs to exclude metacarpal fractures and gamekeeper's fractures. See images below. Anteroposterior radiograph displaying a gamekeeperAnteroposterior radiograph displaying a gamekeeper's fracture. Lateral radiograph displaying a gamekeeper's fractLateral 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 radiographs (see image below): Radiographs obtained with the thumb in the flexed and extended positions and with valgus stress at the MCP joint can help the physician to determine the degree of instability of partial tears of the UCL. Radiograph displaying a stress test of a torn ulnaRadiograph displaying a stress test of a torn ulnar collateral ligament.
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Diagnostic Procedures

  • Stress testing under local anesthesia
    • 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 office setting. Often, the 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.
    • 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.
    • See images of stress testing below. Stress testing of the metacarpophalangeal joint ofStress testing of the metacarpophalangeal joint of the thumb in flexion. Stress testing of the metacarpophalangeal joint ofStress testing of the metacarpophalangeal joint of the thumb in extension.
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Contributor Information and Disclosures
Author

Matthew Hannibal, MD  Staff Physician, Carolina Orthopedic Specialists

Disclosure: Nothing to disclose.

Coauthor(s)

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.

Specialty Editor Board

Peter M Murray, MD  Professor 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 Association for Hand Surgery, American Orthopaedic Association, American Society for Reconstructive Microsurgery, American Society for Surgery of the Hand, Florida Medical Association, Orthopaedic Research Society, and Society of Military Orthopaedic Surgeons

Disclosure: Nothing to disclose.

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

Disclosure: Medscape Salary Employment

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

Disclosure: Nothing to disclose.

Dinesh Patel, MD, FACS  Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital

Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons

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

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, and Arkansas Medical Society

Disclosure: Nothing to disclose.

References

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  3. Bekler H, Gokce A, Beyzadeoglu T. Avulsion fractures from the base of phalanges of the fingers. Tech Hand Up Extrem Surg. Sep 2006;10(3):157-61. [Medline].

  4. 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. Aug 2007;35(8):1321-5. [Medline].

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  12. 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. Mar 2009;13(1):7-10. [Medline].

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  15. 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. Dec 1991;62(6):524-6. [Medline].

  16. 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]. May 1990;15(3):457-60. [Medline].

  17. 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. May-Jun 1981;9(3):171-7. [Medline].

  18. 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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