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THUMB SPRAIN (GAMEKEEPER'S THUMB)

Introduction

Gamekeeper’s thumb, also referred to as skier’s thumb, is an avulsion or rupture of the ulnar collateral ligament (UCL) of the metacarpophalangeal (MP) joint of the thumb, resulting in joint instability. It was originally described by CS Campbell,1 and the mechanism of injury is forced radial deviation (abduction). Patients can present with a broad range of ulnar instability. In 1962, Stener described a series of patients with complete rupture of the UCL, and during surgery, he found the adductor aponeurosis interposed between the distally avulsed UCL and its insertion at the base of the thumb.2 He concluded that unless contact was restored at the site of rupture, healing would result in a lax ulnar capsule, regardless of the period of immobilization.2

Related Anatomy

  • UCL
  • Proper collateral ligament
  • Accessory collateral ligament
  • Thumb IP joint
  • Thumb metacarpal head
  • Dorsal capsule
  • Dorsal aspect of volar plate
  • Adductor aponeurosis

Incidence and Related Conditions

  • Skier’s thumb accounts for 7.1% to 9.5% of all skiing injuries, corresponding to 50,000 to 200,000 injuries per year worldwide
  • Skier’s thumb is also commonly sustained during other sports, including football, hockey, wrestling and baseball.

Differential Diagnosis

  • Thumb fracture
Clinical Presentation Photos and Related Diagrams
  • Right Thumb Sprain (Gamekeeper's Thumb) secondary to rupture of ulnar collateral ligament of the thumb MP joint. (Hover over right edge to see more images)
    Right Thumb Sprain (Gamekeeper's Thumb) secondary to rupture of ulnar collateral ligament of the thumb MP joint. (Hover over right edge to see more images)
  • Left Thumb Sprain (Gamekeeper's Thumb) secondary to rupture of ulnar collateral ligament of the thumb MP joint.
    Left Thumb Sprain (Gamekeeper's Thumb) secondary to rupture of ulnar collateral ligament of the thumb MP joint.
Pathoanatomy Photos and Related Diagrams
  • Stener's lesion - A=dorsally and proximally displaced ulnar collateral ligament; B=thumb metacarpal head; C= adductor aponeurosis and arrow indicates where aponeurosis catches on base of the displaces collateral and blocks it from its intra-articular insertion on the proximal phalanx.
    Stener's lesion - A=dorsally and proximally displaced ulnar collateral ligament; B=thumb metacarpal head; C= adductor aponeurosis and arrow indicates where aponeurosis catches on base of the displaces collateral and blocks it from its intra-articular insertion on the proximal phalanx.
Symptoms
History of thumb injury, for example fall onto thumb while skiing
Pain and swelling of the thumb especially around the MP joint on the ulnar side
Bruising of the thumb around MP joint
Thumb pain with pinch, grasp and gripping
Thumb may have rotational (supination) deformity
Typical History

A skier was racing on an icy slope when he caught an edge and fell. He lost his ski pole and jammed his right thumb into the hard packed snow. An X-ray at the slope first aide facility showed no thumb or wrist fractures. A temporary splint was applied. Two days later he saw his local hand surgeon complaining of a very painful and swollen thumb with maximum tenderness at the MP joint ulnarly.

Positive Tests, Exams or Signs
Hyperligamentous Laxity
Range of Motion: Active
Range of Motion: Passive
Collateral Ligament Stability and Tenderness
Work-up Options
Radiology studies - stress X-rays
Magnetic resonance imaging - MRI without contrast
Radiology studies - arthrogram
Radiology studies - X-ray
Sonographic studies - Ultrasound
Images (X-Ray, MRI, etc.)
  • Thumb MP stress X-ray consistent with ulnar collateral ligament rupture. X-ray done after arthrogram.
    Thumb MP stress X-ray consistent with ulnar collateral ligament rupture. X-ray done after arthrogram.
Treatment Options
Conservative: 
  • Partial ruptures with <20° instability: 4–6 weeks of immobilization with thumb spica cast
Operative: 
  • Partial ruptures with >20° instability and >35° opening: ligament repair
  • Stener lesion: ligament repair
  • Chronic injury: reconstruction of ligament with tendon graft, MP fusion or adductor advancement
Complications
  • Stiffness, instability, neurovascular injury, infection, complex regional pain syndrome (CRPS)
  • Weak and unstable pinch
Outcomes
  • Treatment of partial ruptures will yield a stable joint with normal motion in most cases.
  • Complete ruptures that are repaired within 3 weeks of injury, >90% will have a good-to-excellent result; repair within 1 week of injury is optimal.
  • Stener lesion is when the adductor pollicis aponeurosis is interposed between the avulsed ulnar collateral ligament of the thumb MCP joint and its site of insertion. The healing of ulnar collateral ligament cannot be expected to occur under these circumstances.
  • Repair of complete tears of the ulnar collateral ligament gives the most predictable results.
Key Educational Points
  • This is commonly seen in skiers because of forced abduction of the thumb against a planted ski pole, and ball handling athletes.
  • The indication for surgery is instability of the MP joint (greater than 35° angulation or greater than 20° difference from the uninjured side) without an endpoint during valgus stress testing in extension and 30° flexion.
  • Testing the MP joint in extension evaluates the integrity of the accessory collateral ligament/volar plate while testing the MP joint in 30° flexion tests the proper collateral ligament.
  • The joint must be unstable in both extension and flexion to warrant surgery.
  • A Stener’s lesion is created by retraction of the collateral ligament proximal to the adductor aponeurosis. If palpable, the ligament is completely torn and retracted, necessitating surgery.


Practice and CME
References

New Articles

  1. Milner CS, Manon-Matos Y, Thirkannad SM. Gamekeeper's thumb--a treatment-oriented magnetic resonance imaging classification. J Hand Surg Am 2015;40(1):90-5. PMID: 25300993
  2. Rocchi L, et al. A modified spica-splint in postoperative early-motion management of skier's thumb lesion: a randomized clinical trial. Eur J Phys Rehabil Med 2014;50(1):49-57. PMID: 24185690

Reviews

  1. Anderson D. Skier's thumb. Aust Fam Physician 2010;39(8):575-7. PMID: 20877752
  2. Demirel M, et al. Surgical treatment of skier's thumb injuries: case report and review of the literature. Mt Sinai J Med 2006;73(5):818-21. PMID: 17008946

Classics

  1. Campbell CS. Gamekeeper’s thumb. J Bone Joint Surg Br 1955;37:148-9. PMID: 14353966
  2. Stener B. Skeletal injuries associated with rupture of the ulnar collateral ligament of the metacarpophalangeal joint of the thumb. A clinical and anatomical study. Acta Chir Scand 1963;125:583-6. PMID: 13983826