Gamekeeper Thumb 

  • Author: Michael A Secko IV, MD; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Feb 2, 2011
 

Background

Gamekeeper's thumb was originally described by Campbell in 1955 when he reported chronic laxity of the ulnar collateral ligament (UCL) of the thumb in 24 Scottish gamekeepers. The injury occurred as gamekeepers sacrificed wounded rabbits and other small game by breaking their necks between the ground and their thumbs and index fingers.

Today, this injury is more a result of delayed treatment of an acute injury. The alternative term skier's thumb was popularized by Gerber et al and has become more synonymous with an acute injury. A significant proportion of these injuries are a result of fall or blows to the thumbs. One of the common mechanisms is a skier landing against the ski pole or ground while the thumb is abducted causing a valgus force on the thumb.

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Pathophysiology

The metacarpophalangeal (MCP) joint is a diarthrodial joint with the metacarpal head stabilized by ligamentous and musculotendinous attachments. The thumb MCP joint is capable of motion predominately in flexion and extension with a limited degree of rotation. The ulnar collateral ligament provides static stabilization of the thumb MCP joint. The UCL consists of both a proper ligament and an accessory ligament. The proper is taut in flexion, while the accessory is taut in extension.

The dynamic stabilizers are the intrinsic and extrinsic muscles of the thumb or most notably the adductor pollicis muscle. Dorsally, this muscle expands to form the adductor aponeurosis lying superficial to the UCL.

Chronic laxity of the UCL results from repetitive lateral stress applied to the abducted MCP joint, in particular, the stabilizing ligaments on the ulnar side of the thumb MCP joint. Subsequent instability of the first MCP joint can result from the chronic laxity of the UCL and moreover, lead to functional disability such as weakness of pincer grasp and arthritis.

An acute injury results from a sudden forced abduction stress at the MCP, particularly a fall against a ski pole or the ground. The distal attachment on the proximal phalanx is the most frequent site of rupture. The UCL may even avulse a small portion of the proximal phalanx at its insertion site. The rate of associated fractures in the skeletally mature varies from 23-50% of patients treated operatively.

A Stener lesion occurs when the ruptured end of the UCL retracts and becomes abnormally displaced proximal to the adductor aponeurosis and may be palpated clinically on the ulnar side of the MCP joint. Proper anatomical alignment and healing becomes impeded because the adductor aponeurosis becomes interposed between the sites of insertion on the proximal phalanx with the ruptured end. This lesion can also be associated with a fracture as well.

In the pediatric population, epiphyseal fusion of the proximal phalanx occurs in those aged 16-18 years. Ulnar collateral ligament ruptures of the thumb MCP joint in children are usually associated with epiphyseal fractures (Salter-Harris III) of the proximal phalanx.

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Epidemiology

Frequency

United States

The incidence is increased in skiers. This common injury can also be sustained while playing football or rugby. Some instances of skier's thumb injuries are reported in sports with direct ball-to-thumb impact, such as volleyball. Gripped object sports cannot be implicated as the lone risk factor since thumb injuries are not common in sports such as lacrosse, hockey, or tennis. Ulnar collateral injuries have been reported in cases of people falling on outstretched hands with the thumb without reports of gripping any handle.

Skier's thumb is the most common upper extremity injury in skiing and is second only to medial collateral ligament (MCL) injury of the knee. Reported injury rates in downhill skiing vary between 2.3 and 4.4 per 1000 skiing days. Of these, between 7% and 9.5% are injuries to the UCL.

The incidence of Stener lesion–diagnosed definitively during surgery—was first noted in 64% of patients with clinical UCL injuries. Subsequent studies report between 14% and 87% of patients.

Mortality/Morbidity

Disruption of the UCL leads to instability of the first MCP joint. This results in poor pincer grasp and opposition and can ultimately lead to degenerative arthritic changes and difficulty carrying on the activities of daily living secondary to chronic pain.

If the diagnosis is missed or the injury is not treated properly, enduring pain, weak pincer grasp, or arthritis may result.

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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.

Specialty Editor Board

Robert M McNamara, MD, FAAEM  Chair and Professor, Department of Emergency Medicine, Temple University School of Medicine

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.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Eric L Legome, MD  Chief, Department of Emergency Medicine, Kings County Hospital Center; Associate Professor, Department of Emergency Medicine, New York Medical College

Eric L 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.

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 

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

References
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  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].

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  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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