eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics
Gamekeeper Thumb: Treatment & Medication
Updated: Apr 9, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Prehospital Care
Ice should be applied acutely. Splinting may avoid painful motion associated with travel to the hospital.
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 al2 )
- 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.
Consultations
An orthopedic or hand surgeon should be notified if the injury requires operative management to ensure timely repair.
Medication
Nonsteroidal anti-inflammatory (NSAIDs) that reduce pain and swelling are the treatment of choice.
A brief course of narcotics may be warranted to alleviate the acute phase of pain and swelling.
Analgesics
Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating properties, which are beneficial for patients who have sustained trauma or injuries.
Ibuprofen (Ibuprin, Advil, Motrin)
Usually DOC for treatment of mild to moderate pain, if no contraindications exist. Inhibits inflammatory reactions and pain probably by decreasing the activity of the enzyme cyclooxygenase, which results in prostaglandin synthesis.
Adult
400 mg PO q4-6h, 600 mg q6h, or 800 mg q8h while symptoms persist; not to exceed 3.2 g/d
Pediatric
<6 months: Not established
6 months to 12 years: 20-40 mg/kg/d PO divided tid/qid
>12 years: Administer as in adults
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy
Acetaminophen (Tylenol, Panadol, Aspirin-free Anacin)
DOC for treating mild pain in patients with documented hypersensitivity to aspirin or NSAIDs, those with upper GI disease, or who take oral anticoagulants.
Adult
325-1000 mg PO q4-6h; not to exceed 4 g/d
Pediatric
<12 years: 10-15 mg/kg/dose PO q4-6h; not to exceed 2.6 g/d
>12 years: 325-650 mg PO q4h; not to exceed 5 doses/d
Rifampin can reduce analgesic effects of acetaminophen; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity
Documented hypersensitivity; known G-6-P deficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Hepatotoxicity possible in chronic alcoholics following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; acetaminophen is contained in many OTC products and combined use with these products may result in cumulative acetaminophen doses exceeding recommended maximum dose
Naproxen (Anaprox, Naprelan, Naprosyn)
Used for relief of mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing activity of the enzyme cyclooxygenase, which results in prostaglandin synthesis.
Adult
500 mg PO followed by 250 mg q6-8h; not to exceed 1.25 g/d; may increase to 1.5 g/d for limited periods
Pediatric
<2 years: Not established
>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug
Ketoprofen (Oruvail, Orudis, Actron)
Used to relieve mild to moderate pain and inflammation. Initially administer small dosages to patients with a small body size, elderly patients, and those with renal or liver disease. Doses higher than 75 mg do not increase therapeutic effects. Administer high doses with caution, and closely observe patients for response.
Adult
25-50 mg PO q6-8h; not to exceed 300 mg/d
Pediatric
<3 months: Not established
3 months to 12 years: 0.1-1 mg/kg PO q6-8h
>12 years: 25-50 mg PO q6-8h; not to exceed 300 mg/d
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy
Acetaminophen and codeine (Tylenol #3)
Drug combination indicated for treatment of mild to moderate pain.
Adult
Based on codeine content: 30-60 mg/dose PO q4-6h or 1-2 tab q4h; not to exceed 12 tab/d
Pediatric
0.5-1 mg/kg/dose based on codeine PO q4-6h; 10-15 mg/kg/dose based on acetaminophen content; not to exceed 2.6 g/d of acetaminophen
Toxicity increases with CNS depressants or tricyclic antidepressants
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in patients dependent on opiates because this substitution may result in acute opiate withdrawal symptoms; caution in severe renal or hepatic dysfunction
Oxycodone and acetaminophen (Percocet, Roxicet, Tylox)
Drug combination indicated to relieve moderate to severe pain; DOC for aspirin-hypersensitive patients.
Adult
1-2 tab or cap PO q4-6h
Pediatric
0.05-0.15 mg/kg/dose PO oxycodone; not to exceed 5 mg/dose of oxycodone q4-6h
Phenothiazines may decrease analgesic effects of this medication; toxicity increases with coadministration of either CNS depressants or tricyclic antidepressants
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Duration of action may increase in elderly patients; be aware of total daily dose of acetaminophen patient is receiving; do not exceed 4000 mg/d of acetaminophen; higher doses may cause liver toxicity
Hydrocodone bitartrate and acetaminophen (Vicodin)
Drug combination indicated to relieve moderate to severe pain.
Adult
1-2 tab or cap PO q4-6h
Pediatric
<12 years: 10-15 mg/kg/dose acetaminophen PO q4-6h; not to exceed 2.6 g/d of acetaminophen or 5 mg of hydrocodone bitartrate/dose
>12 years: 750 mg acetaminophen PO q4h; not to exceed 5 doses/d acetaminophen or 10 mg of hydrocodone bitartrate/dose
Coadministration with phenothiazines may decrease analgesic effects; toxicity increases with CNS depressants or tricyclic antidepressants
Documented hypersensitivity; high altitude cerebral edema (HACE) or elevated intracranial pressure (ICP)
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Tablets contain metabisulfite, which may cause hypersensitivity; caution in patients dependent on opiates since this substitution may result in acute opiate withdrawal symptoms; caution in severe renal or hepatic dysfunction
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
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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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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.
Further Reading
Keywords
skier thumb, skier's thumb, injury to ulnar collateral ligament, UCL, hyperabduction of thumb, gamekeeper's thumb
