Ulnar collateral ligament injury of the thumb

Last updated
Gamekeeper's thumb
Other namesUCL tear
Game keepers.png
Avulsion fractures of the ulnar base of the proximal phalanx of the thumb ( Gamekeeper's fracture )
Specialty Hand surgery, orthopedics

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 may be merely stretched, or it may be torn from its insertion site into the proximal phalanx of the thumb; [1] in approximately 90% of cases part of the bone is actually avulsed from (sheared away from) the joint. [2] This condition is commonly observed among gamekeepers and Scottish fowl hunters, as well as athletes (such as volleyballers and soccer goalkeepers). It also occurs among people who sustain a fall onto an outstretched hand while holding a rod, frequently skiers grasping ski poles. [3]

Contents

Signs and symptoms

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 is 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).[ citation needed ]

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.[ citation needed ]

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.[ citation needed ]

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. [4] There are four types of Skier's thumb injury: [4]

Gamekeeper's thumb is more difficult to treat because the UCL has lengthened and become thinner as a result of repeated injury. It is moderately painful compared to similar injuries.

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. [5]

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. [6]

Treatment

A post-operative photo of repair of a complete rupture of the ulnar collateral ligament. Note the K-wire to brace the joint. Surgical Repair of Gamekeeper's Thumb Injury.jpg
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.[ citation needed ]

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.[ citation needed ]

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 help determine the integrity of the ligament.[ citation needed ]

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. [7]

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. [8] 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.[ citation needed ]

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. [9]

See also

Related Research Articles

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<span class="mw-page-title-main">Ulnar nerve</span> Nerve which runs near the ulna bone

In human anatomy, the ulnar nerve is a nerve that runs near the ulna bone. The ulnar collateral ligament of elbow joint is in relation with the ulnar nerve. The nerve is the largest in the human body unprotected by muscle or bone, so injury is common. This nerve is directly connected to the little finger, and the adjacent half of the ring finger, innervating the palmar aspect of these fingers, including both front and back of the tips, perhaps as far back as the fingernail beds.

<span class="mw-page-title-main">Sprain</span> Damage to one or more ligaments in a joint

A sprain is a soft tissue injury of the ligaments within a joint, often caused by a sudden movement abruptly forcing the joint to exceed its functional range of motion. Ligaments are tough, inelastic fibers made of collagen that connect two or more bones to form a joint and are important for joint stability and proprioception, which is the body's sense of limb position and movement. Sprains may be mild, moderate, or severe, with the latter two classes involving some degree of tearing of the ligament. Sprains can occur at any joint but most commonly occur in the ankle, knee, or wrist. An equivalent injury to a muscle or tendon is known as a strain.

<span class="mw-page-title-main">Upper limb</span> Consists of the arm, forearm, and hand

The upper limbs or upper extremities are the forelimbs of an upright-postured tetrapod vertebrate, extending from the scapulae and clavicles down to and including the digits, including all the musculatures and ligaments involved with the shoulder, elbow, wrist and knuckle joints. In humans, each upper limb is divided into the arm, forearm and hand, and is primarily used for climbing, lifting and manipulating objects.

<span class="mw-page-title-main">Ulnar collateral ligament of elbow joint</span> Ligament on the elbow

The ulnar collateral ligament (UCL) or internal lateral ligament is a thick triangular ligament at the medial aspect of the elbow uniting the distal aspect of the humerus to the proximal aspect of the ulna.

<span class="mw-page-title-main">Extensor digitorum muscle</span> Muscle of the posterior forearm

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<span class="mw-page-title-main">Palmar interossei muscles</span> Muscles between the metacarpals

In human anatomy, the palmar or volar interossei are four muscles, one on the thumb that is occasionally missing, and three small, unipennate, central muscles in the hand that lie between the metacarpal bones and are attached to the index, ring, and little fingers. They are smaller than the dorsal interossei of the hand.

<span class="mw-page-title-main">Carpometacarpal joint</span>

The carpometacarpal (CMC) joints are five joints in the wrist that articulate the distal row of carpal bones and the proximal bases of the five metacarpal bones.

<span class="mw-page-title-main">Dorsal interossei of the hand</span> Muscles between the metacarpals

In human anatomy, the dorsal interossei (DI) are four muscles in the back of the hand that act to abduct (spread) the index, middle, and ring fingers away from hand's midline and assist in flexion at the metacarpophalangeal joints and extension at the interphalangeal joints of the index, middle and ring fingers.

<span class="mw-page-title-main">Abductor digiti minimi muscle of hand</span> Muscle in the hypothenar compartment

In human anatomy, the abductor digiti minimi is a skeletal muscle situated on the ulnar border of the palm of the hand. It forms the ulnar border of the palm and its spindle-like shape defines the hypothenar eminence of the palm together with the skin, connective tissue, and fat surrounding it. Its main function is to pull the little finger away from the other fingers.

<span class="mw-page-title-main">Interphalangeal joints of the hand</span> Hinge joints between finger phalanges

The interphalangeal joints of the hand are the hinge joints between the phalanges of the fingers that provide flexion towards the palm of the hand.

<span class="mw-page-title-main">Collateral ligaments of metacarpophalangeal joints</span>

In human anatomy, the radial (RCL) and ulnar (UCL) collateral ligaments of the metacarpophalangeal joints (MCP) of the hand are the primary stabilisers of the MCP joints. A collateral ligament flanks each MCP joint - one on either side. Each attaches proximally at the head of the metacarpal bone, and distally at the base of the phalynx. Each extends obliquely in a palmar direction from its proximal attachment to its distal attachment. The collateral ligaments allow spreading our the fingers with an open hand but not with the hand closed into a fist.

<span class="mw-page-title-main">Palmar plate</span>

In the human hand, palmar or volar plates are found in the metacarpophalangeal (MCP) and interphalangeal (IP) joints, where they reinforce the joint capsules, enhance joint stability, and limit hyperextension. The plates of the MCP and IP joints are structurally and functionally similar, except that in the MCP joints they are interconnected by a deep transverse ligament. In the MCP joints, they also indirectly provide stability to the longitudinal palmar arches of the hand. The volar plate of the thumb MCP joint has a transverse longitudinal rectangular shape, shorter than those in the fingers.

<span class="mw-page-title-main">Ulnar claw</span> Deformity of the hand that develops due to ulnar nerve damage

An ulnar claw, also known as claw hand or 'spinster's claw', is a deformity or an abnormal attitude of the hand that develops due to ulnar nerve damage causing paralysis of the lumbricals. A claw hand presents with a hyperextension at the metacarpophalangeal joints and flexion at the proximal and distal interphalangeal joints of the 4th and 5th fingers. The patients with this condition can make a full fist but when they extend their fingers, the hand posture is referred to as claw hand. The ring- and little finger can usually not fully extend at the proximal interphalangeal joint (PIP).

<span class="mw-page-title-main">Stener lesion</span> Medical condition

A Stener lesion is a type of traumatic injury to the thumb. It occurs when the aponeurosis of the adductor pollicis muscle becomes interposed between the ruptured ulnar collateral ligament (UCL) of the thumb and its site of insertion at the base of the proximal phalanx. No longer in contact with its insertion site, the UCL cannot spontaneously heal.

<span class="mw-page-title-main">Median nerve palsy</span> Medical condition

Injuries to the arm, forearm or wrist area can lead to various nerve disorders. One such disorder is median nerve palsy. The median nerve controls the majority of the muscles in the forearm. It controls abduction of the thumb, flexion of hand at wrist, flexion of digital phalanx of the fingers, is the sensory nerve for the first three fingers, etc. Because of this major role of the median nerve, it is also called the eye of the hand. If the median nerve is damaged, the ability to abduct and oppose the thumb may be lost due to paralysis of the thenar muscles. Various other symptoms can occur which may be repaired through surgery and tendon transfers. Tendon transfers have been very successful in restoring motor function and improving functional outcomes in patients with median nerve palsy.

<span class="mw-page-title-main">Extrinsic extensor muscles of the hand</span>

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<span class="mw-page-title-main">Ulnar collateral ligament injury of the elbow</span> Medical condition

Ulnar collateral ligament injuries can occur during certain activities such as overhead baseball pitching. Acute or chronic disruption and/or attenuation of the ulnar collateral ligament often result in medial elbow pain, valgus instability, neurologic deficiency, and impaired throwing performance. There are both non-surgical and surgical treatment options.

<span class="mw-page-title-main">Muscles of the thumb</span>

The muscles of the thumb are nine skeletal muscles located in the hand and forearm. The muscles allow for flexion, extension, adduction, abduction and opposition of the thumb. The muscles acting on the thumb can be divided into two groups: The extrinsic hand muscles, with their muscle bellies located in the forearm, and the intrinsic hand muscles, with their muscles bellies located in the hand proper.

References

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  8. Campbell CS (February 1955). "Gamekeeper's thumb". J Bone Joint Surg Br. 37-B (1): 148–9. doi:10.1302/0301-620X.37B1.148. PMID   14353966.
  9. Orthopedic Surgery for Gamekeeper's Thumb at eMedicine