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Gamekeeper Thumb Treatment & Management

  • Author: Michael A Secko, IV, MD; Chief Editor: Trevor John Mills, MD, MPH  more...
 
Updated: Apr 18, 2016
 

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[7] )

  • 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.

In an evaluation of 43 cases of UCL injury by MRI to measure the degree of ligament displacement, it was found that partial and minimally displaced UCL tears and tears displaced less than 3 mm typically healed by immobilization alone. For tears displaced more than 3 mm, immobilization failed in 90% of cases and required surgery, along with all cases with a Stener lesion.[3]

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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, Department of Emergency Medicine, Kings County Hospital, State University of New York Downstate Medical Center

Disclosure: Nothing to disclose.

Coauthor(s)

Joseph Kim, MD Chairman, Department of Emergency Medicine, Western Medical Center; Clinical Instructor, University of California, Irvine, School of Medicine

Disclosure: Nothing to disclose.

Mark A Silverberg, MD, MMB, FACEP Assistant Professor, Associate 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 Medical Center

Mark A Silverberg, MD, MMB, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Council of Emergency Medicine Residency Directors, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Eric L Legome, MD Chief, Department of Emergency Medicine, Kings County Hospital Center; Professor Clinical, Department of Emergency Medicine, State University of New York Downstate College of Medicine

Eric L Legome, MD is a member of the following medical societies: Alpha Omega Alpha, Council of Emergency Medicine Residency Directors, American Academy of Emergency Medicine, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Trevor John Mills, MD, MPH Chief of Emergency Medicine, Veterans Affairs Northern California Health Care System; Professor of Emergency Medicine, Department of Emergency Medicine, University of California, Davis, School of Medicine

Trevor John Mills, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Additional Contributors

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, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

References
  1. Gagliardi JA, Agarwal A. Gamekeeper's Thumb (Skier's Thumb). Applied Radiology. 2012. 41(7-8):29c-29d. [Full Text].

  2. Dominguez Gonzalez JJ, Zorrilla Ribot P, Perez Riverol EN, Martinez Rodriguez AS. Simultaneous Bilateral Functional Radiography in Ulnar Collateral Ligament Lesion of the Thumb: An Original Technique. Am J Orthop (Belle Mead NJ). 2015 Aug. 44 (8):359-62. [Medline].

  3. Milner CS, Manon-Matos Y, Thirkannad SM. Gamekeeper's thumb--a treatment-oriented magnetic resonance imaging classification. J Hand Surg Am. 2015 Jan. 40 (1):90-5. [Medline].

  4. Plancher KD et al. Role of MR imaging in the management of "skier's thumb" injuries. Magn Reson Imaging Clin N Am. 1999 Feb. 7(1):73-84, viii. [Medline].

  5. Melville DM, Jacobson JA, Fessell DP. Ultrasound of the thumb ulnar collateral ligament: technique and pathology. AJR Am J Roentgenol. 2014 Feb. 202 (2):W168. [Medline].

  6. 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]. 2000 Feb. 25(1):29-32. [Medline].

  7. Hintermann B, Holzach PJ, Schütz M, Matter P. Skier's thumb--the significance of bony injuries. Am J Sports Med. 1993 Nov-Dec. 21(6):800-4. [Medline].

  8. 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]. 1990 May. 15(3):457-60. [Medline].

  9. Adams BD, Muller DL. Assessment of thumb positioning in the treatment of ulnar collateral ligament injuries. A laboratory study. Am J Sports Med. 1996 Sep-Oct. 24(5):672-5. [Medline].

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

  11. 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. 2006 Sep. 73(5):818-21. [Medline].

  12. Fairhurst M, Hansen L. Treatment of "Gamekeeper's Thumb" by reconstruction of the ulnar collateral ligament. J Hand Surg [Br]. 2002 Dec. 27(6):542-5. [Medline].

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

  14. 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. 1997 Mar-Apr. 15(2):193-6. [Medline].

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

  16. Peterson JJ, Bancroft LW. Injuries of the fingers and thumb in the athlete. Clin Sports Med. 2006 Jul. 25(3):527-42, vii-viii. [Medline].

  17. Pichora DR, McMurtry RY, Bell MJ. Gamekeepers thumb: a prospective study of functional bracing. J Hand Surg [Am]. 1989 May. 14(3):567-73. [Medline].

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

  19. 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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Lateral radiograph displaying a gamekeeper's fracture.
 
 
 
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