Gamekeeper's Thumb Treatment & Management

Medical Issues/Complications

• Delayed repair of the UCL

  • Complete ruptures of the UCL require surgical intervention for repair within the first 3 weeks of the injury (preferably in the first week while the anatomic position is maintained).
  • Complete tears that are repaired after 3 weeks have an increased incidence of weakness and pain on pinch grasp. An associated increase in MCP joint arthritis is noted in the long term.
• Closed treatment of a completely torn UCL

  • A 50% failure rate is reported with complete tears that are treated with bracing and early motion. If a patient is unable to tolerate or refuses surgery, then bracing is the treatment of choice. A thumb spica splint or functional brace can be attempted, but it must be understood that full stability of the thumb may not occur.
  • Soft-tissue interposition, which is caused by the adductor aponeurosis holding the torn UCL in a displaced position, prevents healing. Surgical correction is necessary to reconstruct the UCL and allow healing.
  • ROM is limited in the thumb at the MCP joint if the joint is immobilized longer than 4 weeks.

Surgical Intervention

All complete UCL tears require operative intervention. An incision is made over the ulnar border of the MCP joint of the thumb. The adductor aponeurosis is incised longitudinally and retracted distally. The dorsal capsule is then exposed, and the proper and accessory collateral ligaments are assessed. If the joint is subluxed and if the soft-tissue repair seems insufficient to hold the reduced joint, a small-gauge Kirschner wire (ie, K-wire) can be inserted to maintain the MCP joint in position. The UCL can then be repaired. If a small piece of avulsed bone is present, remove it; a large bone fragment should be reduced and preserved.

Other Treatment

For small, nondisplaced avulsion fractures of the proximal phalanx that are found to be stable on stress testing, nonoperative treatment by a spica-type cast for 4 weeks can be completed with good results.

• Closed treatment

  • Nonoperative treatment can be considered for partial tears (grade I or grade II) of the UCL, which usually involve an isolated rupture of the proper collateral portion of the ligament. This may be treated with immobilization in a thumb spica-type cast for 4 weeks. The cast should be well-molded around the MCP joint, and the interphalangeal joint can be left free. With appropriate closed treatment, expect 90% good to excellent results.^[9]
  • Nonoperative treatment can also be considered in patients that either refuse surgery or who are too infirm to tolerate an operative procedure despite a complete UCL tear. In these patients a functional brace or well-molded spica splint can be applied,^{[9, 10]} but it must be understood by the patient that complete healing of the UCL is not expected if the tear was complete.

Rehabilitation Program

Physical Therapy

Postoperatively, the patient is immobilized in a thumb spica cast for 4 weeks. At 4 weeks, the cast and any pins that were placed may be removed. The patient is then placed in a hand-based splint that immobilizes the MCP joint for 2 weeks. The splint is removed for therapy during this 2-week period, and active motion of the MCP joint is begun. Unrestricted usage is allowed at 3 months.

Medical Issues/Complications

• Radial sensory nerve injury

  • Even when the radial sensory nerve is isolated and protected during surgery, a neuropraxia may still occur.
  • The neuropraxia usually resolves spontaneously. Only if the neuropraxia persists after 6 months to 1 year should surgical re-exploration be considered.
• Postsurgical stiffness of the MCP and interphalangeal joints is a common complication (although it is usually not a functional problem) and tends to improve with time.

Medical Issues/Complications

• Chronic instability is a long-term complication of UCL rupture.

  • The most common cause is the patient's failure to seek medical attention in a timely fashion for diagnosis and treatment.
  • The longer a complete rupture of the UCL exists, the more likely it is to progress to chronic instability, even after its repair. Success has been limited with repairing the tissues after 6 weeks from the time of injury.
• The dorsal capsule, as well as the extensor pollicis brevis and extensor pollicis longus muscles, become attenuated, adding to the dorsal instability of the MCP joint. The thumb then tends to displace volarly and to rotate into supination.

Surgical Intervention

Chronic instability is difficult to treat. Limited success has been associated with repair of gamekeeper's thumb injuries using the capsuloligamentous structures on the ulnar border of the MCP joint.

• If no degenerative changes are present at the MCP joint, consider a ligament reconstruction. A free tendon, usually the palmaris longus, can be woven through the metacarpal neck and the base of the proximal phalanx.
• If arthritis is present or if the patient is a manual laborer, consider an arthrodesis of the MCP joint. Arthrodesis does not lead to significant impairment, if motion of the interphalangeal and carpometacarpal joints is maintained.