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Gamekeeper's Thumb Workup

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

Laboratory Studies

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  • No laboratory tests are necessary for the diagnosis of gamekeeper's thumb.
  • In cases that require surgical intervention, routine preoperative laboratory workup is indicated.
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Imaging Studies

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  • Radiographs
    • Before any manipulation of the thumb, obtain standard anteroposterior, lateral, and oblique radiographs to exclude metacarpal fractures and gamekeeper's fractures. Examples of an anteroposterior and lateral radiograph of a gamekeeper's thumb, respectively, are shown below.
      Anteroposterior radiograph displaying a gamekeeperAnteroposterior radiograph displaying a gamekeeper's fracture.
      Lateral radiograph displaying a gamekeeper's fractLateral radiograph displaying a gamekeeper's fracture.
    • Small, nondisplaced avulsion fractures that are associated with rupture of the insertion point of the UCL are not contraindications to manipulation. If displacement of these fractures did not take place at the time of injury and greatest stress, it is believed that they are stable enough for the manipulation of stress testing.
    • Three millimeters of volar subluxation of the phalanx on the metacarpal is suggestive of complete UCL rupture and instability.
    • Instability is also indicated in cases in which there is a radial deviation of >40º in extension and >20º in flexion.
    • Stress radiographs: Radiographs obtained with the thumb in the flexed and extended positions and with valgus stress at the MCP joint can help the physician to determine the degree of instability of partial tears of the UCL (see the following image).
      Radiographic stress test view of the thumb, showinRadiographic stress test view of the thumb, showing an ulnar collateral ligament tear.
  • Arthrography, ultrasound, and magnetic resonance imaging (MRI) have been used to identify complete tears; however, these tests are not particularly cost effective.[2, 6, 7] Careful stress examination is still the optimal method for determining ligament integrity.
  • A study used magnetic resonance imaging to investigate the degree of UCL displacement in order to create a simple classification to aid in determining which UCL injuries require surgery. The study concluded that tears of the UCL with more than 3 mm of displacement are likely to require operative repair even in the absence of a true Stener lesion since 90% of these cases failed treatment with immobilization alone.[8]
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Procedures

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  • Stress testing under local anesthesia (see the following 2 images)
    Ulnar collateral ligament stress test in full exteUlnar collateral ligament stress test in full extension.
    Ulnar collateral ligament stress test in a flexed Ulnar collateral ligament stress test in a flexed position to isolate the proper portion of the ligament.
    See the list below:
    • The patient often has considerable pain in the thumb; stressing the MCP joint leads to patient guarding and, thus, misleading findings on examination.
    • The thumb is best examined under local anesthesia, which can be administered in the emergency department (ED) or office setting. Often, 2-3 mL of 1% lidocaine administered into the MCP joint of the thumb is sufficient to relieve the pain and relax the patient's guarding.
    • If more anesthesia is required, perform a metacarpal or digital block. Some authors recommend the use of an ulnar or median nerve block to negate the effects of the intrinsic muscles. If the injection into the joint relieves the pain, no further anesthesia is necessary.
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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
  1. Campbell CS. Gamekeeper''s thumb. J Bone Joint Surg Br. 1955 Feb. 37-B(1):148-9. [Medline]. [Full Text].

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

  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].

  7. 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].

  8. 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].

  9. 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].

  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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