Gamekeeper's thumb

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

Repetitive injury of the ulnar collateral ligament of the thumb metacarpophalangeal joint caused when the gamekeeper broke the neck of game, using their thumb, index finger and the ground, leading to eventual tear of the ligament. 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 80s, break dancers.

More chronic presentations will present will laxity. Typically (in skiers) an awkward fall with the pole in hand can forcibly abduct the thumb during a fall. 

The aim of imaging is to define any fracture, determine if there is instability (joint space widening), and identify a Stener lesion. A classification into six types has been proposed by Hintermann et al. in 1993 1 (see the classification of gamekeeper's thumb).

If a small avulsion fracture is present, then this could be seen at the ulnar corner of the base of the proximal phalanx or ulnar 1st metacarpal head.

If the tear is in the mid-substance, 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, the 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 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 the use of a high-frequency probe. The adductor aponeurosis will not slide freely over the UCL on passive thumb IPJ flexion in a Stener injury.  

MRI is increasingly used to assess 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 edema and fracture
  • Stener lesion 4

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 the torn end of the ulnar collateral ligament and the base of the proximal phalanx) is an indication for surgery 3.

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.

Fractures

Article information

rID: 1367
Synonyms or Alternate Spellings:
  • Skier's thumb
  • Break-dancer thumb
  • Break-dancer's thumb
  • Skier thumb
  • Gamekeeper's thumb

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Cases and figures

  • Case 1
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  • Figure 2: gamekeeper thumb
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  • Case 2
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  • Figure 3: gamekeeper thumb and Stener lesion
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  • Case 3
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  • Case 4
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  • Case 5
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  • Case 6
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  • Case 7: Stener lesion
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  • Case 8
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  • Case 9
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  • Case 10
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  • Case 11
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  • Case 12
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  • Case 13: with normal for comparison
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