Gamekeeper's Thumb Treatment & Management

  • Author: Matthew Hannibal, MD; Chief Editor: Craig C Young, MD  more...
 
Updated: Mar 20, 2015
 

Acute Phase

Medical Issues/Complications

See the list below:

  • 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.
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Recovery Phase

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

See the list below:

  • 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.
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Maintenance Phase

Medical Issues/Complications

See the list below:

  • 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.
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Contributor Information and Disclosures
Author

Matthew Hannibal, MD Staff Physician, Carolina Orthopedic Specialists

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.

Chief Editor

Craig C Young, MD Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical Director of Sports Medicine, Medical College of Wisconsin

Craig C Young, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, Phi Beta Kappa

Disclosure: Nothing to disclose.

Additional Contributors

Gerard A Malanga, MD Founder and Partner, New Jersey Sports Medicine, LLC and New Jersey Regenerative Institute; Director of Research, Atlantic Health; Clinical Professor, Department of Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey-New Jersey Medical School; Fellow, American College of Sports Medicine

Gerard A Malanga, MD is a member of the following medical societies: Alpha Omega Alpha, American Institute of Ultrasound in Medicine, North American Spine Society, International Spine Intervention Society, American Academy of Physical Medicine and Rehabilitation, American College of Sports Medicine

Disclosure: Received honoraria from Cephalon for speaking and teaching; Received honoraria from Endo for speaking and teaching; Received honoraria from Genzyme for speaking and teaching; Received honoraria from Prostakan for speaking and teaching; Received consulting fee from Pfizer for speaking and teaching.

Acknowledgements

Daniel Roger, MD Director of Hand Surgery, Wyckoff Heights Medical Center; Former Assistant Professor, Department of Orthopedics, Catholic Medical Center of Brooklyn and Queens, New York Medical College

Daniel Roger, MD is a member of the following medical societies: Medical Society of the State of New York

Disclosure: Nothing to disclose.

References
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  3. Scalcione LR, Pathria MN, Chung CB. The Athlete's Hand: Ligament and Tendon Injury. Semin Musculoskelet Radiol. 2012 Sep. 16(4):338-50. [Medline].

  4. Bekler H, Gokce A, Beyzadeoglu T. Avulsion fractures from the base of phalanges of the fingers. Tech Hand Up Extrem Surg. 2006 Sep. 10(3):157-61. [Medline].

  5. Malik AK, Morris T, Chou D, Sorene E, Taylor E. Clinical testing of ulnar collateral ligament injuries of the thumb. J Hand Surg Eur Vol. 2009 Jun. 34(3):363-6. [Medline].

  6. Shinohara T, Horii E, Majima M, et al. Sonographic diagnosis of acute injuries of the ulnar collateral ligament of the metacarpophalangeal joint of the thumb. J Clin Ultrasound. 2007 Feb. 35(2):73-7. [Medline].

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  10. Sollerman C, Abrahamsson SO, Lundborg G, Adalbert K. Functional splinting versus plaster cast for ruptures of the ulnar collateral ligament of the thumb. A prospective randomized study of 63 cases. Acta Orthop Scand. 1991 Dec. 62(6):524-6. [Medline].

  11. Maheshwari R, Sharma H, Duncan RD. Metacarpophalangeal joint dislocation of the thumb in children. J Bone Joint Surg Br. 2007 Feb. 89(2):227-9. [Medline].

  12. Abrahamsson SO, Sollerman C, Lundborg G, Larsson J, Egund N. Diagnosis of displaced ulnar collateral ligament of the metacarpophalangeal joint of the thumb. J Hand Surg [Am]. 1990 May. 15(3):457-60. [Medline].

  13. Baskies MA, Tuckman D, Paksima N, Posner MA. A new technique for reconstruction of the ulnar collateral ligament of the thumb. Am J Sports Med. 2007 Aug. 35(8):1321-5. [Medline].

  14. Gerber C, Senn E, Matter P. Skier's thumb. Surgical treatment of recent injuries to the ulnar collateral ligament of the thumb's metacarpophalangeal joint. Am J Sports Med. 1981 May-Jun. 9(3):171-7. [Medline].

  15. Heyman P. Injuries to the ulnar collateral ligament of the thumb metacarpophalangeal joint. J Am Acad Orthop Surg. 1997 Jul. 5(4):224-9. [Medline].

  16. Michaud EJ, Flinn S, Seitz WH Jr. Treatment of grade III thumb metacarpophalangeal ulnar collateral ligament injuries with early controlled motion using a hinged splint. J Hand Ther. 2010 Jan-Mar. 23(1):77-82. [Medline].

  17. Ritting AW, Baldwin PC, Rodner CM. Ulnar collateral ligament injury of the thumb metacarpophalangeal joint. Clin J Sport Med. 2010 Mar. 20(2):106-12. [Medline].

  18. Stener B. Displacement of the ruptured ulnar collateral ligament of the metacarpo-phalangeal joint of the thumb. J Bone Joint Surg [Br]. July 1962. 44:869-79. [Full Text].

 
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Lateral radiograph displaying a gamekeeper's fracture.
Anteroposterior radiograph displaying a gamekeeper's fracture.
Radiographic stress test view of the thumb, showing an ulnar collateral ligament tear.
Ulnar collateral ligament stress test in full extension.
Ulnar collateral ligament stress test in a flexed position to isolate the proper portion of the ligament.
Anterior view of a hand placed in a thumb spica splint.
Lateral view of a hand placed in a thumb spica splint.
 
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