Gamekeeper Thumb Treatment & Management

Updated: Apr 18, 2016
  • Author: Michael A Secko, IV, MD; Chief Editor: Trevor John Mills, MD, MPH  more...
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Treatment

Prehospital Care

Ice should be applied acutely. Splinting may avoid painful motion associated with travel to the hospital.

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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 [7] )

  • 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 with all of the most commonly used operative techniques.

  • 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 with a Stener lesion. [3]

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Consultations

An orthopedic or hand surgeon should be notified if the injury requires operative management to ensure timely repair.

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