Gamekeeper's thumb

Gamekeeper's thumb (also known as skier's thumb

or UCL tear) is a type of injury to the ulnar collateral
ligament (UCL) of the thumb. The UCL is torn at (or
in some cases even avulsed from) its insertion site
into the proximal phalanx of the thumb in the vast
majority (approximately 90%) of cases.[1] This
condition is commonly observed among gamekeepers
and Scottish fowl hunters, as well as athletes. It also
occurs among ordinary people who sustain a fall onto
an outstretched hand.
SYMTOMS
Symptoms of gamekeeper's thumb are instability of the
MCP joint of the thumb, accompanied by pain and
weakness of the pinch grasp. The severity of the
symptoms are related to the extent of the initial tear of
the UCL (in the case of Skier's thumb), or how long the
injury has been allowed to progress (in the case of
gamekeeper's thumb).
Characteristic signs include pain, swelling, and
ecchymosis around the thenar eminence, and
especially over the MCP joint of the thumb. Physical
examination demonstrates instability of the MCP
joint of the thumb.
The patient will often manifest a weakened ability to
grasp objects or perform such tasks as tying shoes
and tearing a piece of paper. Other complaints
include intense pain experienced upon catching the
thumb on an object, such as when reaching into a
pants pocket.

Gamekeeper's thumb
Classification and external resources

Avulsion fractures of the ulnar base of the proximal

phalanx of the thumb ( Gamekeeper's fracture )
 DIAGNOSIS
Gamekeeper's thumb and skier's thumb are two
similar conditions, both of which involve
insufficiency of the ulnar collateral ligament (UCL)
of the thumb. The chief difference between these two
conditions is that Skier's thumb is generally
considered to be an acute condition acquired after a
fall or similar abduction injury to the
metacarpophalangeal (MCP) joint of the thumb,
whereas gamekeeper's thumb typically refers to a
chronic condition which has developed as a result of
repeated episodes of lower-grade hyperabduction
over a period of time. Gamekeeper's thumb is more
difficult to treat because the UCL has lengthened and
become thinner as a result of repeated injury.
In addition to skiing, this injury (resulting from forced
abduction or hyperextension of the proximal phalanx of the
thumb) is seen in a wide variety of other athletic endeavors.
The most common mechanism of injury appears to be when a
person extends the arm in an attempt to block a fall. The stress
resulting from falling onto an abducted thumb produces a
valgus force on the MCP joint of the thumb, resulting in a
sprain or tear of the UCL.
In a recent study, 49% of UCL disruptions of the thumb were
caused by a fall onto an outstretched hand. Sports injuries
accounted for most of the remaining injuries, with only 2.4%
acquired as a result of skiing injuries.[2]
TREATMENT

A post-operative photo of repair of a complete

rupture of the ulnar collateral ligament. Note the K-
wire to brace the joint.
The ulnar collateral ligament is an important
stabilizer of the thumb. Thumb instability resulting
from disruption of the UCL profoundly impairs the
overall function of the involved hand. Because of
this, it is critical that these injuries receive
appropriate attention and treatment.
In most cases of a complete tear, the aponeurosis of
the adductor pollicis muscle may be interposed
between the bones of the MCP joint and the torn
ligament. When this condition (referred to as a Stener
lesion) occurs, the adequate healing of the tear is
prevented altogether. For a Stener lesion to occur, a
complete tear of the ulnar collateral ligament must be
present. However, the Stener lesion can occur even in
the absence of a tear of the accessory collateral
ligament or volar plate. The Stener lesion is present
in more than 80% of complete ruptures of the UCL of
the thumb.
When approaching this type of injury, the physician
must first determine whether there is an incomplete
rupture (or sprain) of the UCL, or a complete rupture.
If the UCL is completely disrupted, the physician
must then determine whether there is interposition of
the adductor aponeurosis (Stener lesion), or simply a
complete rupture of the UCL with anatomic or near-
anatomic position. Radiographs are helpful in
determining the possible presence of an avulsion
fracture of the proximal phalanx insertion site of the
ulnar collateral ligament. stress examination, or one
done under fluoroscopic guidance, can hep determine
the integrity of the ligament.
Most gamekeeper's thumb partial injuries are treated
by simply immobilizing the joint in a thumb spica
splint or a modified wrist splint and allowing the
ligament to heal. However, near total or total tears of
the UCL may require surgery to achieve a
satisfactory repair, especially if accompanied by a
Stener lesion.[3]
HISTORY

CS Campbell, an orthopedic surgeon, originally

coined the term gamekeeper's thumb in 1955, after he
observed this condition in a series of 24 Scottish
gamekeepers.[4] The injury appeared to occur as a
result of the particular manner in which they killed
small animals such as rabbits; the animals were
placed on the ground, and their necks were broken as
the gamekeeper exerted downward pressure with the
thumb and index finger. This maneuver would place a
valgus force upon the abducted metacarpophalangeal
(MCP) joint. Over time, this would lead to
insufficiency of the ulnar collateral ligament (UCL)
of the thumb.
Others have noted that Scottish fowl or game hunters
would develop this type of injury after carrying their
game home in a leather thong, which they would attach
to their thumb and drape over their shoulder.
The term skier's thumb is derived from the fact that
skiers often acquire this type of injury by falling
against a planted ski pole, tearing the UCL by
hyperabducting it.