We need you! See something you could improve? Make an edit and help improve WikSM for everyone.
Gamekeepers Thumb
From WikiSM
Other Names
- Ulnar Collateral Ligament (Thumb) Injury
- Skier's Thumb
- Ulnar Collateral Ligament of the Thumb Injury
- UCL Injury
- Thumb Collateral Ligament Injury
Background
- This page refers to injuries to the UCL of the thumb
History
Epidemiology
- 10 fold more common than injuries to the RCL of thumb (need citation)
- Represents 86% of all athletic thumb injuries (need citation)
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
Risk Factors
- Male > Female [1]
- Sports
- Alpine Skiing
- Football
- Soccer
Differential Diagnosis
- Fractures
- Dislocations
- Tendinopathies
- Ligament Injuries
- Neuropathies
- Arthropathies
- Nail Bed Injuries
- Pediatric Considerations
- Other
Clinical Features

Illustration of how to perform the UCL stress test.[2]
- 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
Evaluation

Thumb US showing loss of continuity of the UCL, widening of the joint space under controlled stress[3]
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%
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
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
Rehab and Return to Play
Rehabilitation
- Needs to be updated
Return to Play/ Work
- Needs to be updated
Complications
- Stener Lesion
- Surgical problem
- Represents interposition of Adductor Pollicis Muscle and Adductor aponeurosis
- Stiffness
- Persistent instability
- Superficial radial neuropraxia
See Also
External
- Sports Med Review Hand Pain: https://www.sportsmedreview.com/by-joint/hand/
References
- ↑ Chuter GS, Muwanga CL, Irwin LR. Ulnar collateral ligament injuries of the thumb: 10 years of surgical experience. Injury. 2009 Jun;40(6):652-6
- ↑ Leggit JC et al. Acute finger injuries: Part II. Fractures, dislocations, and thumb injuries. Am Fam Physician. 2006;73(5):827-834
- ↑ https://radiopaedia.org/cases/gamekeeper-thumb-4?lang=us
Created by:
John Kiel on 18 June 2019 23:14:29
Authors:
Last edited:
16 October 2022 00:20:15
Categories: