Gamekeeper Thumb Clinical Presentation
- Author: Michael A Secko IV, MD; Chief Editor: Rick Kulkarni, MD more...
History
Patients may complain of pain, swelling, and/or ecchymosis of the MCP joint after a fall or blow to the thumb, forcing it into a combination of hyperextension and radial (lateral) deviation. This commonly occurs while participating in sports but has been noted in patients who fall on outstretched hands and in motor vehicle accidents. The most common mechanism is a fall while holding onto a ski pole. This injury can also be seen in a football player forcibly abducting and hyperextending a thumb while holding back a rushing opponent.
Patients may also complain of weakness or worsening pain when pinching the thumb against the index finger when no acute injury is reported.
Physical
The injured thumb should be evaluated for pain, point tenderness, ecchymosis, and/or swelling, specifically on the ulnar aspect of the MCP joint.
A palpable mass on the ulnar aspect of the MCP joint may be obvious and may represent the ruptured UCL that is abnormally displaced proximally and dorsally relative to the adductor aponeurosis.
Standard radiographs should be obtained before lateral stress examination, because stress testing may cause further displacement of an avulsion fracture that was originally minimally displaced.
Valgus (lateral) stress testing can determine the integrity of the UCL. Stability of the opposite thumb should be tested as well for comparison.
Stress examination is performed while stabilizing the thumb metacarpal with one hand to prevent rotation. The thumb should be placed in 30° flexion, and a lateral (radial) stress should be applied on the joint.
A displaced avulsion fracture is a contraindication to stress testing but a nondisplaced fracture is not.
Administration of local anesthetic may be necessary to facilitate optimal examination. This can be accomplished by either a local injection of 1% lidocaine into the MCP joint or by blocking the sensory branches of the radial and median nerves at the wrist.
Laxity (angulation) of more than 35° or laxity 15° more than the uninjured side suggests a complete rupture of the proper collateral ligament. Laxity (angulation) less than 35° or comparative laxity less than 15° probably denotes an incomplete rupture.
The accessory collateral ligament may remain intact, and gross instability may not be present. Therefore, examination in extension should be performed. Reports have demonstrated that laxity of the MCP joint in extension when stressed, consistently indicates tears of the proper and accessory collateral ligaments and is more commonly associated with a Stener lesion. Laxity of more than 35° or laxity of 15° more than the uninjured side may suggest rupture of the accessory collateral ligament.
If lateral (valgus) laxity of the MCP joint exists for both the flexed and extended positions, then complete rupture of the UCL should be suspected, and greater possibility of a Stener lesion exists.
Causes
Fall onto outstretched hand causing a forced abduction and extension of the thumb
Plancher KD et al. Role of MR imaging in the management of "skier's thumb" injuries. Magn Reson Imaging Clin N Am. Feb 1999;7(1):73-84, viii. [Medline].
Hintermann B, Holzach PJ, Schütz M, Matter P. Skier's thumb--the significance of bony injuries. Am J Sports Med. Nov-Dec 1993;21(6):800-4. [Medline].
Abrahamsson SO, Sollerman C, Lundborg G, et al. Diagnosis of displaced ulnar collateral ligament of the metacarpophalangeal joint of the thumb. J Hand Surg [Am]. May 1990;15(3):457-60. [Medline].
Adams BD, Muller DL. Assessment of thumb positioning in the treatment of ulnar collateral ligament injuries. A laboratory study. Am J Sports Med. Sep-Oct 1996;24(5):672-5. [Medline].
Campbell CS. Gamekeeper's thumb. J Bone Joint Surg Br. Feb 1955;37-B(1):148-9. [Medline].
Demirel M, Turhan E, Dereboy F, Akgun R, Ozturk A. Surgical treatment of skier's thumb injuries: case report and review of the literature. Mt Sinai J Med. Sep 2006;73(5):818-21. [Medline].
Fairhurst M, Hansen L. Treatment of "Gamekeeper's Thumb" by reconstruction of the ulnar collateral ligament. J Hand Surg [Br]. Dec 2002;27(6):542-5. [Medline].
Fricker R, Hintermann B. Skier's thumb. Treatment, prevention and recommendations. Sports Med. Jan 1995;19(1):73-9. [Medline].
Jones MH, England SJ, Muwanga CL, Hildreth T. The use of ultrasound in the diagnosis of injuries of the ulnar collateral ligament of the thumb. J Hand Surg [Br]. Feb 2000;25(1):29-32. [Medline].
Musharafieh RS, Bassim YR, Atiyeh BS. Ulnar collateral ligament rupture of the first metacarpophalangeal joint: a frequently missed injury in the emergency department. J Emerg Med. Mar-Apr 1997;15(2):193-6. [Medline].
Newland CC. Gamekeeper's thumb. Orthop Clin North Am. Jan 1992;23(1):41-8. [Medline].
Peterson JJ, Bancroft LW. Injuries of the fingers and thumb in the athlete. Clin Sports Med. Jul 2006;25(3):527-42, vii-viii. [Medline].
Pichora DR, McMurtry RY, Bell MJ. Gamekeepers thumb: a prospective study of functional bracing. J Hand Surg [Am]. May 1989;14(3):567-73. [Medline].
Richard JR. Gamekeeper's thumb: ulnar collateral ligament injury. Am Fam Physician. Apr 1996;53(5):1775-81. [Medline].
Stener B. Displacement of the ruptured ulnar collateral ligament of the metacarpophalangeal joint of the thumb: clinical and anatomic study. J Bone Joint Surg [Br]. 1962;44:869-79.
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