Orthopedic Surgery for Gamekeeper's (Skier's) Thumb Treatment & Management

Nonsurgical treatment can be considered for partial tears of the ulnar collateral ligament (UCL)—that is, grade I or grade II tears. These tears usually involve an isolated rupture of the proper collateral ligament.

Complete ruptures of the UCL can be determined by means of physical examination, including stress testing. Radiographic stress testing can be performed, but the evaluating surgeon should perform these tests because radiographic stress test findings can be misleading.

In pediatric gamekeeper's (skier's) thumb, the injury usually involves a Salter-Harris type III fracture of the thumb proximal phalanx. ^[11]  If the fragment is displaced by less than 2 mm, nonsurgical management is indicated. For greater displacement, the fracture should be opened and reduced.

Occasionally, significant ligamentous injury may occur without immediate gross instability, which can be masked by swelling and muscle spasm. At this point, a repeat examination can be performed after 1 week; if the swelling persists and motion has not been regained, surgical fixation may be considered.

In gamekeeper's thumb, no absolute contraindications for surgery exist. Relative surgical contraindications include the following:

• A patient who is too infirm to tolerate surgery, regardless of whether a complete UCL tear is present
• In a child, gamekeeper's thumb with less than 2 mm of displacement of the Salter-Harris type III fracture
• Chronic instability of the thumb due to a chronic UCL rupture

Chronic instability of the thumb due to a chronic UCL rupture is difficult to treat, and repair using the capsuloligamentous structures of the ulnar border of the metacarpophalangeal (MCP) joint has had limited success. Even surgical repair that is performed 6 weeks after the complete UCL rupture has had limited success. Essentially, the longer a complete rupture of the UCL exists, the smaller the possibility of stability restoration with anatomic repair (see Complications).

Some surgeons have reported success with dynamic transfer of a tendon (eg, the adductor pollicis) from its insertion on the ulnar sesamoid to the ulnar base of the proximal phalanx. Other surgeons have reported success with the use of static tendon transfers, which have the theoretical advantage of an inherent blood supply if some continuity of the tendon with its musculotendinous unit is preserved.

MCP fusion has been recommended by some surgeons in cases of chronic gamekeeper's thumb; in some cases, this procedure is reserved for use in patients who have concomitant osteoarthritis.

The future management of gamekeeper's thumb injuries is targeted at preventing the injury and improving the outcome of reconstruction in chronic complete UCL ruptures. Although multiple procedures have been attempted in efforts to improve the outcome for chronic UCL ruptures, no procedure has yet been proved to be as effective as direct repair of the acutely ruptured UCL. Arthrodesis of the MCP joint is still the standard salvage procedure in chronic gamekeeper's thumb injuries.

Nonsurgical treatment can be considered in partial tears of the UCL, which usually involve an isolated rupture of the proper collateral portion of the ligament. This injury may be treated by immobilizing the thumb in a spica-type cast for 4 weeks (see the images below). The cast should be well molded around the MCP joint, and the interphalangeal (IP) joint can be left free. With appropriate closed treatment, good-to-excellent results can be expected in 90% of such injuries. ^[21]

Nonsurgical treatment can also be considered in patients who either refuse surgery or are too infirm to tolerate a surgical procedure. In these patients, a functional brace or well-molded spica splint can be applied, but full recovery and complete healing of the UCL cannot be expected if the tear is complete.

Some reports in the literature support the use of functional bracing and early range-of-motion (ROM) exercises in these patients, as well as in those with Stener lesions or complete tears. ^{[22, 21]} Such reports suggest that patients recover equally well with a functional brace and daily ROM therapy, regardless of the completeness of the UCL tears. However, poor UCL healing in the presence of a Stener lesion is also repeatedly confirmed in the literature. ^{[16, 21]}

Medications that decrease acute swelling and allow better follow-up examination should be administered in the acute phase. Nonsteroidal anti-inflammatory drugs (NSAIDs), which decrease pain and swelling, are the drugs of choice.

Complete UCL tears necessitate surgical intervention. Some reports in the literature suggest that immobilization with a special brace designed to resist the ulnar and radial deviation of the thumb may be as beneficial as surgery in patients with these injuries. ^[21] However, confirmations of these suggestions are limited.

Christensen et al evaluated long-term outcomes of ligamentous repair rather than reconstruction in 12 patients with chronic thumb UCL injuries who were followed for longer than 15 years (average, 24.5 y; range, 16.9-35.6). ^[23] They found that repair of such injuries with available local tissue appeared to be a reasonable alternative to ligament reconstruction that yielded durable long-term outcomes despite the majority of patients (88%) progressing to osteoarthritis.

In a single-center retrospective study of 55 patients with chronic posttraumatic thumb MCP joint instability who were managed surgically and followed for a mean of 84 months, Agout et al compared three techniques—primary repair, ligament reconstruction, and arthrodesis—with respect to subjective and objective outcomes and complication rates at last follow-up. ^[24] They concluded that primary repair deserves preference whenever possible, and they found that outcomes after ligament reconstruction were not superior to those after arthrodesis.

Delma et al evaluated patient satisfaction and functional outcomes after primary suture anchor repair with local soft-tissue advancement (N = 36) for both acute (n = 19) and chronic (n = 17) thumb UCL injuries. ^[25]  Functional outcomes, postoperative pain, and satisfaction were similarly acceptable in the two groups. The authors found primary suture anchor repair without ligament reconstruction to be a safe and effective option for thumb UCL injuries, even chronic ones.

Preparation for surgery

Before embarking on surgical repair, determine whether the UCL tear is partial or complete. In addition, determine whether the UCL tear is chronic or acute, because the procedure may be different if the UCL tear is chronic.

Radiographs should be available for assessing the presence of a fracture or subluxation of the MCP joint. If the fracture fragment is large or displaced or if it represents more than 10% of the articular surface, fixation is required. Small displaced avulsion fractures may be excised.

Operative details

Make an incision over the ulnar border of the MCP joint of the thumb. Incise the adductor aponeurosis longitudinally, and retract it distally. Next, expose the dorsal capsule, and assess the proper and accessory collateral ligaments. During the surgical dissection, take care to identify and protect the sensory branch of the radial nerve; it is commonly seen within the surgical field. Even with careful dissection and retraction, postoperative radial nerve neurapraxia can still occur.

If the joint is subluxed and if the soft-tissue repair seems insufficient to hold the reduced joint, a small-gauge Kirschner wire (K-wire) can be inserted to maintain the MCP joint in position. The UCL can then be repaired. In a fresh injury, the torn ends of the UCL can be directly repaired. If this approach is not possible, other techniques include attachment of the ligament to the periosteum, its reattachment to the bone by using a pull-out wire, or its fixation via the periosteum and bone flap.

After the UCL is repaired, reattach the adductor aponeurosis. If a small piece of avulsed bone is present, remove it; a large bone fragment should be reduced and preserved.

For chronic UCL tears older than 6 weeks, consider repairs using the capsuloligamentous structures on the ulnar border of the MCP joint. If no degenerative changes are present at the MCP joint, consider 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 arthrodesis of the MCP joint. This does not lead to significant impairment if the motion of the IP and carpometacarpal (CMC) joints is maintained.

Suture tape augmentation may help expedite recovery and rehabilitation after isolated thumb UCL repair. ^[26]

Postoperatively, place the patient's thumb in a spica splint, and begin carefully monitored ROM exercises of the IP and MCP joints. Alternatively, total cast immobilization for 4 weeks may be used; at 4 weeks after surgery, a removable thumb spica cast can be fabricated, and light activities of daily living (ADLs) can be initiated. The brace should be removed only for performing exercises and for hygiene. 

Chronic instability is a complication of UCL rupture. The common cause is failure to seek medical attention for diagnosis and treatment in a timely fashion. The longer a complete UCL rupture exists, the more likely it is to progress to chronic instability, even after repair. Success in repairing the tissues after 6 weeks has been limited. The dorsal capsule, the extensor pollicis brevis, and the extensor pollicis longus become attenuated, adding to the dorsal instability of the MCP joint. The thumb then tends to become displaced volarly and to rotate into a supinated position.

Chronic instability of the MCP joint can occur despite a good repair, especially if motion and return to play are resumed prematurely. This instability is difficult to treat and can lead to arthritic changes in the MCP joint, as well as a weak pinch grasp in the long term.

Stiffness of the MCP and IP joints is a common complication. This stiffness is usually not a functional problem, and it tends to improve with time.

Neurapraxia of the radial sensory nerve may occur, even if care is taken to isolate and protect the nerve during surgical repair. The neurapraxia usually resolves spontaneously.

Ski gloves are being designed to help prevent UCL tears that are caused by a fall onto a hand holding a ski pole. As yet, these gloves are not commercially available, and they have not been proved to be beneficial.

After 4 weeks, the thumb spica splint and any pins that were placed may be removed. A hand-based splint that immobilizes the MCP joint is then applied 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, including the resumption of full ADLs, is begun at 3 months.