Gamekeepers Thumb

Other Names

• Ulnar Collateral Ligament (Thumb) Injury
• Skier's Thumb
• Ulnar Collateral Ligament of the Thumb Injury
• UCL Injury
• Thumb Collateral Ligament Injury

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Background

• This page refers to injuries to the UCL of the thumb

Epidemiology

• 10 fold more common than injuries to the RCL of thumb (need citation)
• Represents 86% of all athletic thumb injuries (need citation)

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Pathophysiology

• General
  • Characterized by avulsion or rupture of the UCL of the thumb
  • UCL: Protects medial side of MCPJ of thumb
• Chronic
  • Historically, injury was seen in 'gamekeepers' from repetitive breaking of rabbit necks
  • This was a more insidious, degenerative condition
• Acute
  • Now more commonly seen in skiers, sports
  • Typically an acute injury
  • Stock-strap forcibly abducting thumb during a fall or plant maneuver with exaggerated extension abduction

Etiology

• General
  • Radial directed force causing hyperabduction of the Thumb MCPJ

Associated Conditions

• Stener Lesion
  • Surgical problem
  • Represents interposition of Adductor Pollicis Muscle and Adductor aponeurosis

Pathoanatomy

• UCL of the thumb
  • Stabilizes the ulnar side of the thumb Metacarpophalangeal Joint
  • Resists adduction of the joint

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Risk Factors

• Male > Female
• Sports
  • Alpine Skiing
  • Football
  • Soccer

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Differential Diagnosis

• Fractures
  • Phalanx Fractures (Hand)
  • Metacarpal Fractures
    • Boxer's Fracture
    • Rolando Fracture
    • Bennett Fracture
• Dislocations
  • Metacarpophalangeal Joint Dislocation
  • Proximal Interphalangeal Joint Dislocation
  • Distal Interphalangeal Joint Dislocation
  • Carpometacarpal Joint Dislocation
• Tendinopathies
  • Extensor Tendon Injuries (Hand)
  • Central Slip Extensor Tendon Injury
  • Flexor Tendon Injuries (Hand)
  • Boutonniere Deformity
  • Swan Neck Deformity
  • Jersey Finger
  • Mallet Finger
  • Trigger Finger
  • De Quervains Tenosynovitis
  • Volar Plate Avulsion Injury
  • Sagittal Band Injury
• Ligament Injuries
  • Gamekeepers Thumb (UCL)
  • Radial Collateral Ligament of the Thumb Injury (RCL)
• Neuropathies
  • Wartenbergs Syndrome
  • Carpal Tunnel Syndrome
  • Guyon Canal Syndrome
• Arthropathies
  • Carpometacarpal Arthritis
  • Finger Arthritis
  • Rheumatoid Arthritis
• Nail Bed Injuries
  • Nail Bed Lacerations
  • Nail Bed Avulsions
  • Subungual Hematoma
  • Paronychia
  • Felon
• Pediatric Considerations
  • Proximal Phalanx Avulsion Fracture (Thumb)
  • Middle and Distal Phalanx Avulsion Fracture
• Other
  • Dupuytrens Contracture
  • Intrinsic Plus

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Clinical Features

Illustration of how to perform the UCL stress test.

• History
  • Primarily a clinical diagnosis
  • Patients will report pain at the 1st MCPJ
  • Typically worse with abduction or extension
  • Swelling, ecchymosis may be present acutely
  • Fall on outstretched hand with abducted thumb
• Physical Exam: Physical Examination Hand
  • Minimal swelling, bruising
  • No deformity
  • Tenderness at site of UCL injury, typically on the phalanx
  • If palpable mass, consider stener lesion
• Special Tests
  • UCL Stress Test (Thumb): Valgus stress causes pain, laxity (> 15-20° typically considered pathologic)
  • Complete tears will lack an endpoint
  • Important to compare to unaffected thumb

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Evaluation

Thumb US showing loss of continuity of the UCL, widening of the joint space under controlled stress

Radiographs

• Standard Radiographs Hand
  • May be normal
  • Evaluate for avulsion injury
  • May see joint space widening
• Consider stress views
  • Controversial, not widely used

Ultrasound

• Can be helpful to evaluate tear
• May identify stener lesion
• Can dynamically stress the UCL

MRI

• Indications
  • Not always required
  • Aid in diagnosis if equivocal history and exam
  • Can help if other soft tissue injuries suspected
• Diagnostic accuracy (need citation)
  • Sensitivity 100%
  • Specificity 100%

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Classification

Hintermann Classification

• Type I: Fracture which is non-displaced, stable in flexion
• Type II: Displaced fracture
• Type III: No fracture, joint is stable in flexion
• Type IV: No fracture, unstable
• Type V: Fracture present, involving the volar plate, stable in flexion
• Type VI: Fracture present, involving the volar plate, unstable

UCL/RCL Instability Grading

• Grade 1
  • Sprain with no joint instability
  • Tear: Incomplete tear
• Grade 2
  • Asymmetric joint laxity but endpoint present
  • Tear: incomplete tear
• Grade 3
  • Joint instability without endpoint
  • 30-35 degrees of joint space opening or 10-15 degrees more than contralateral thumb
  • Tear: complete tear

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Management

Prognosis

• Return to play
  • In grade I/II, there is an excellent return to play rate (need citation)
  • Approaches 100% following anatomic repair (need citation)

Nonoperative

• Indications
  • Generally driven by an absence of displacement or instability
  • Most type instability grade I, II
  • Most Hinterman Type I, III, V lesions
• Immobilization
  • Thumb Spica Splint for at least 3 weeks
  • More commonly for 4-6 weeks
• Eventually begin rehabilitation

Operative

• Indications
  • Hinterman: Type II, IV, VI lesions
  • Valgus laxity >15-20°
  • Stener Lesion
• Technique
  • Reconstruction with tendon graft
  • Adductor advancement
  • MCP fusion or adductor advancement

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Rehab and Return to Play

Rehabilitation

• Needs to be updated

Return to Play/ Work

• Needs to be updated

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Complications

• Stener Lesion
  • Surgical problem
  • Represents interposition of Adductor Pollicis Muscle and Adductor aponeurosis
• Stiffness
• Persistent instability
• Superficial radial neuropraxia

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See Also

• Hand and Wrist Anatomy (Main)
• Finger Pain (Main)
• Hand Pain (Main)
• Physical Examination Hand

External

• Sports Med Review Hand Pain: https://www.sportsmedreview.com/by-joint/hand/

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