Gamekeeper's (Skier's) Thumb in the ED Treatment & Management

Updated: Nov 10, 2021
  • Author: Michael A Secko, IV, MD; Chief Editor: Trevor John Mills, MD, MPH  more...
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Treatment

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 [12] ) have been described as follows:

  • 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 to all of the most commonly used operative techniques.

In cases of 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 in which a Stener lesion was present. [7]

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Complications

Chronic instability is a major complication of UCL rupture. An unstable MCP joint can lead to degenerative joint changes and cause weakness of power grasp as well as decreased dexterity of fine pincher-type movements.

The most common cause is failure to seek medical attention in a timely fashion or a missed diagnosis.

Risk factors for chronic instability include the following:

  • Larger tears
  • Those left untreated or have delayed treatment more than 6 weeks
  • Return to play/activities too prematurely
  • May even occur after adequate repair

Stiffness of the metacarpal and interphalangeal joint may be seen, especially following cast removal. Most improve with time and range-of -exercises.

Transient neurapraxia of the branch of the superficial radial nerve may be a complication after undergoing surgery.

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Long-Term Monitoring

Conservative management with a functional brace

Once the cast or splint has been removed, a period of active MCP flexion exercises should be followed with gradual return to activities.

Patients should be advised to avoid heavy gripping or grasping until the grip strength has returned to normal.

Surgical management

Patients should be placed in a short arm thumb spica cast for 4 weeks.

The thumb spica cast and pins (if any were placed) are removed after 4 weeks.

For the ensuing 2 weeks, a splint that immobilizes the MCP is applied and removed for therapy of the MCP.

Next is active range of motion of the MCP joint, and unrestricted usage is allowed at about 3 months postoperatively.

Follow-up care should be arranged with an orthopedic or a hand surgeon.

Surgery may be necessary in patients who do not respond to conservative therapy initially.

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