eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics

Gamekeeper Thumb: Follow-up

Author: Michael A Secko IV, MD, Clinical Assistant Instructor, Staff Physician, Clinical Assistant Instructor, Department of Emergency Medicine, Kings County Hospital, State University of New York Downstate Medical Center
Coauthor(s): Mark A Silverberg, MD, FACEP, MMB, Assistant Professor, Assistant Residency Director, Department of Emergency Medicine, State University of New York Downstate College of Medicine; Consulting Staff, Department of Emergency Medicine, Staten Island University Hospital, Kings County Hospital, University Hospital, State University of New York Downstate at Brooklyn; Joseph Kim, MD, Chairman, Department of Emergency Medicine, Western Medical Center; Clinical Instructor, University of California at Irvine
Contributor Information and Disclosures

Updated: Apr 9, 2008

Follow-up

Further Outpatient Care

  • Conservative management with a functional brace
    • Once the cast or splint has been removed, a period of active MCP flexion exercises should be followed with gradual return to activities.
    • Patients should be advised to avoid heavy gripping or grasping until the grip strength has returned to normal.
  • Surgical management
    • Patients should be placed in a short arm thumb spica cast for 4 weeks.
    • The thumb spica cast and pins (if any were placed) are removed after 4 weeks.
    • For the ensuing 2 weeks, a splint that immobilizes the MCP is applied and removed for therapy of the MCP.
    • Next is active range of motion of the MCP joint and unrestricted usage is allowed at about 3 months postoperatively.
  • Follow-up care should be arranged with an orthopedic or a hand surgeon.
  • Surgery may be necessary in patients who do not respond to conservative therapy initially.

Inpatient & Outpatient Medications

  • A course of NSAIDs is recommended.
  • A brief course of narcotics may be needed to alleviate the acute phase of pain and swelling.

Complications

  • Chronic instability is a major complication of UCL rupture. An unstable MCP joint can lead to degenerative joint changes and cause weakness of power grasp as well as decreased dexterity of fine pincher-type movements.
  • The most common cause is failure to seek medical attention in a timely fashion or a missed diagnosis.
  • Risk factors for chronic instability include the following:
    • Larger tears
    • Those left untreated or have delayed treatment more than 6 weeks
    • Return to play/activities too prematurely
    • May even occur after adequate repair
  • Stiffness of the metacarpal and interphalangeal joint may be seen, especially following cast removal. Most improve with time and range of motion exercises.
  • Transient neurapraxia of the branch of the superficial radial nerve may be a complication after undergoing surgery.

Prognosis

  • Most authors agree that early diagnosis is the most important factor that determines the functional outcome.
  • Partial ligament tears: Nonsurgical conservative management usually yields thumbs with normal range of motion.
  • Complete ligament tears
    • Early referral/consultation is indicated, especially if some degree of uncertainty exists about whether a complete UCL tear is present.
    • The failure rate is about 50% using conservative treatment with functional bracing and early motion exercises.
    • Early surgical intervention—within 3 weeks of injury—has led to good results in the treatment of gamekeeper's/skier's thumb injury. The prognosis may be worse if surgical intervention has been delayed. The anatomy may be too distorted by 6 weeks to permit direct repair; however, studies have reported good results obtainable with late repair or reconstruction.

Patient Education

  • Changes in pole design, such as the strapless pole, have not been associated with a decrease in the incidence of gamekeeper's/skier's thumb injuries. If skiers are trained to discard their pole or poles during a fall, the risk might be reduced.

Miscellaneous

Medicolegal Pitfalls

  • Failure to diagnose this ligamentous injury
  • Failure to properly treat this ligamentous injury
  • Failure to make timely referral to orthopedist or hand surgeon
  • Failure to incorporate stress testing with a normal radiograph
  • Stress testing with a displaced bone fragment
 


More on Gamekeeper Thumb

Overview: Gamekeeper Thumb
Differential Diagnoses & Workup: Gamekeeper Thumb
Treatment & Medication: Gamekeeper Thumb
Follow-up: Gamekeeper Thumb
References
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References

  1. 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].

  2. 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].

  3. 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].

  4. 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].

  5. Campbell CS. Gamekeeper's thumb. J Bone Joint Surg Br. Feb 1955;37-B(1):148-9. [Medline].

  6. 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].

  7. 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].

  8. Fricker R, Hintermann B. Skier's thumb. Treatment, prevention and recommendations. Sports Med. Jan 1995;19(1):73-9. [Medline].

  9. 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].

  10. 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].

  11. Newland CC. Gamekeeper's thumb. Orthop Clin North Am. Jan 1992;23(1):41-8. [Medline].

  12. 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].

  13. 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].

  14. Richard JR. Gamekeeper's thumb: ulnar collateral ligament injury. Am Fam Physician. Apr 1996;53(5):1775-81. [Medline].

  15. 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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Further Reading

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Keywords

skier thumb, skier's thumb, injury to ulnar collateral ligament, UCL, hyperabduction of thumb, gamekeeper's thumb

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Contributor Information and Disclosures

Author

Michael A Secko IV, MD, Clinical Assistant Instructor, Staff Physician, Clinical Assistant Instructor, Department of Emergency Medicine, Kings County Hospital, State University of New York Downstate Medical Center
Disclosure: Nothing to disclose.

Coauthor(s)

Mark A Silverberg, MD, FACEP, MMB, Assistant Professor, Assistant Residency Director, Department of Emergency Medicine, State University of New York Downstate College of Medicine; Consulting Staff, Department of Emergency Medicine, Staten Island University Hospital, Kings County Hospital, University Hospital, State University of New York Downstate at Brooklyn
Mark A Silverberg, MD, FACEP, MMB is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Joseph Kim, MD, Chairman, Department of Emergency Medicine, Western Medical Center; Clinical Instructor, University of California at Irvine
Disclosure: Nothing to disclose.

Medical Editor

Robert M McNamara, MD, FAAEM, Professor of Emergency Medicine, Temple University; Chief, Department of Internal Medicine, Section of Emergency Medicine, Temple University Hospital
Robert M McNamara, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American Medical Association, Pennsylvania Medical Society, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Eric Legome, MD, Residency Director, Assistant Professor of Emergency Medicine, Department of Emergency Medicine New York University, New York University Hospital, Bellevue Hospital Center, Manhattan VA
Eric Legome, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

 
 
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