Gamekeeper Thumb Treatment & Management

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

Prehospital Care

Ice should be applied acutely. Splinting may avoid painful motion associated with travel to the hospital.

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Emergency Department Care

Gamekeeper's thumb injuries may or may not require surgical intervention. This decision is typically made by an appropriate specialist such as a hand/orthopedic surgeon. The emergency medicine physician should immobilize all suspected injuries in a thumb spica splint and have the patient follow up within 1 week.

Injuries that are not fixed surgically require application of a well-molded functional brace (short arm thumb spica or a smaller, glove-type thumb spica) for 4-6 weeks, with the MCP joint typically flexed to about 20-30°. These include the following:

  • Partial tears of the UCL
  • Nondisplaced avulsion fractures

Gamekeeper's thumb injuries that require surgical exploration to identify a Stener lesion and restore proper anatomical alignment include the following:

  • Complete tears
  • Displaced avulsion fractures
  • Large (>25%) articular surface fracture of the proximal phalanx
  • Volar subluxation of the proximal phalanx

Classification, examination, and treatment of skier's thumb (adapted from Hinterman et al[2] )

  • Type I: Nondisplaced fracture, stable in flexion (< 35° angulation); conservative management with 4-6 weeks in plaster cast (short arm thumb spica, or small glove-type thumb spica cast)
  • Type II: Displaced fracture; treat surgically
  • Type III: No fracture, stable in flexion (< 35° angulation); conservative management in cast for 4-6 weeks
  • Type IV: No fracture, unstable in flexion (>35° angulation); treat surgically
  • Type V: Avulsion fracture of volar plate, stable in flexion; conservative management in cast for 4-6 weeks
  • Type VI: Fragmentation of volar ulnar portion of proximal phalanx with associated injury of the UCL; treat surgically

In regards to all the different types of surgical repairs, success rates are comparable with all of the most commonly used operative techniques.

  • Pediatric gamekeeper's thumb: If fragment (Salter-Harris III) is displaced by less than 2 mm, nonsurgical management is indicated. For fragments displaced greater than 2 mm, surgery is the best option. Salter-Harris type I and II fractures associated with UCL instability may heal well with casting alone.
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Consultations

An orthopedic or hand surgeon should be notified if the injury requires operative management to ensure timely repair.

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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

  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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