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Gamekeeper thumb

Gamekeeper thumb is essentially synonymous with skier thumb, although the latter has a more acute injury connotation. It is an avulsion or rupture of the ulnar collateral ligament (UCL) of the thumb. 

Epidemiology

The repetitive breaking-of-necks of small game (rabbits and such) resulted in chronic injury to the ulnar collateral ligament of the metacarpophalangeal joint of the thumb with weakening and eventual tear. Gamekeeping and poaching have largely fallen by the wayside as a recreational activity. This injury is now seen more frequently in skiers, and in the 80's break dancers.

Clinical presentation

Typically (in skiers) the stock and stock-strap forcibly abducting the thumb during a fall or particularly agressive pole-plant results in acute pain. In gamekeepers, perhaps an unusually thick-necked rabbit was the cause?

Radiographic features

The aim or imaging is to identify a fracture; determine if there is instability (joint space widening) and identify a Stener lesion. A classification into six types has been proposed by Hintermann 1 (see classification of skier's thumb).

Plain film

This is almost always the first examination and is often able to give the diagnosis. If a small avulsion fracture is present, then this will be seen at the ulnar corner of the base of the proximal phalynx.

In the tear in midsubstance, with no associated fracture then the ulnar side of the joint may appear widened. If the diagnosis is suspected stress views were once upon a time recommended, however concern now exists that performing these views can displace the torn undisplaced end of the ligament dorsal to adductor pollicis muscle thereby creating a Stener lesion 3.

Ultrasound

Ultrasound is helpful in identifying not only the tear but also whether or not a Stener lesion is present. Clearly this requires a knowledge of local anatomy and use of a high frequency probe.

MRI

MRI is increasingly used to asses x-ray occult injuries to the ulnar collateral or to attempt to identify a Stener lesion. Findings include:

  • discontinuity of the ligament +/- joint capsule
  • bone marrow oedema and fracture
  • Stener lesion 4

Treatment

Treatment depends on classification, but essentially boils down to whether there is displacement or instability: if there is, surgical fixation is required. 

Additionally the presence of a Stener lesion (interposition of the adductor pollicis muscle and adductor aponeurosis between torn end of the ulnar collateral ligament and the base of the proximal phalynx)3.

History and etymology

It was first described in, you guessed it, Scottish gamekeepers by Campbell in 1955 2. Clearly gamekeepers who also ski are almost certain to incur this injury.

See also


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