Ulnar collateral ligament injury (gamekeeper's or skier's thumb)
- Matthew Gammons, MD
Matthew Gammons, MD
- Medical Director of Sport Medicine
- Vermont Orthopaedic Clinic
- Section Editor
- Karl B Fields, MD
Karl B Fields, MD
- Editor-in-Chief — Primary Care Sports Medicine (Adolescents and Adults)
- Section Editor — Biomechanics, Rehabilitation, and Recovery; Sports-Related Injuries; Symptom Assessment and Physical Examination
- Professor of Family Medicine and Sports Medicine
- University of North Carolina at Chapel Hill
- Deputy Editor
- Jonathan Grayzel, MD, FAAEM
Jonathan Grayzel, MD, FAAEM
- Senior Deputy Editor — UpToDate
- Deputy Editor — Emergency Medicine (Adult and Pediatric)
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Assistant Professor of Emergency Medicine
- University of Massachusetts Medical School
Gamekeeper's thumb (or skier's thumb) derives its name from court gamekeepers who developed chronic degeneration of the ulnar collateral ligament (UCL) of the metacarpophalangeal joint from repeatedly twisting the necks of fowl and other game caught while hunting. Today, ski pole injuries and other athletic injuries are the most common cause of this condition.
The diagnosis and management of UCL injury of the thumb is reviewed here. Other thumb and hand injuries are discussed separately. (See "Evaluation of the patient with thumb pain" and "Overview of finger, hand, and wrist fractures" and "History and examination of the adult with hand pain" and "Overview of hand infections" and "Scaphoid fractures" and "Overview of carpal fractures".)
Skiing accidents in which the thumb strikes a fixed ski pole and other athletic injuries involving thumb abduction are the most common cause of ulnar collateral ligament tears [1-3]. Complete ruptures are often caused by non-sport-related falls . The injury occurs more commonly in males, with a ratio of 3:2. Thumb injuries are second in frequency only to knee injuries among skiers .
MECHANISM OF INJURY
Forced abduction and hyperextension of the thumb metacarpophalangeal joint is the usual mechanism causing injury of the thumb ulnar collateral ligament (UCL) [1,2,6-8]. This can occur if someone falls onto their thumb or the thumb is struck, violently forcing it into abduction. A similar mechanism occurs when a ski pole becomes fixed in the ground and the momentum of the skier drives the thumb into the pole handle. This usually occurs when a skier falls. Disruption of the UCL may occur from repetitive use as well as acute injury, but this is less common.
Patient presentation — Patients with an ulnar collateral ligament (UCL) injury complain of pain, which is exacerbated by thumb extension or abduction, and swelling along the ulnar aspect of the thumb metacarpophalangeal (MCP) joint [1-3,6-9]. Paradoxically, pain may be minimal when presenting for medical evaluation in patients with a complete UCL tear compared to those with a partial tear. The patient often takes the thumb and first finger and rubs over the MCP joint when describing the condition. If the patient presents several weeks to months after the injury, pain, weakness, or loss of stability are the usual complaints. These may be exacerbated by pinching or grasping objects.
- Richard JR. Gamekeeper's thumb: ulnar collateral ligament injury. Am Fam Physician 1996; 53:1775.
- Anderson D. Skier's thumb. Aust Fam Physician 2010; 39:575.
- Madan SS, Pai DR, Kaur A, Dixit R. Injury to ulnar collateral ligament of thumb. Orthop Surg 2014; 6:1.
- Chuter GS, Muwanga CL, Irwin LR. Ulnar collateral ligament injuries of the thumb: 10 years of surgical experience. Injury 2009; 40:652.
- Engkvist O, Balkfors B, Lindsjö U. Thumb injuries in downhill skiing. Int J Sports Med 1982; 3:50.
- Heyman P. Injuries to the Ulnar Collateral Ligament of the Thumb Metacarpophalangeal Joint. J Am Acad Orthop Surg 1997; 5:224.
- Ritting AW, Baldwin PC, Rodner CM. Ulnar collateral ligament injury of the thumb metacarpophalangeal joint. Clin J Sport Med 2010; 20:106.
- Rhee PC, Jones DB, Kakar S. Management of thumb metacarpophalangeal ulnar collateral ligament injuries. J Bone Joint Surg Am 2012; 94:2005.
- Schroeder NS, Goldfarb CA. Thumb ulnar collateral and radial collateral ligament injuries. Clin Sports Med 2015; 34:117.
- Mahajan M, Tolman C, Würth B, Rhemrev SJ. Clinical evaluation vs magnetic resonance imaging of the skier's thumb: A prospective cohort of 30 patients. Eur J Radiol 2016; 85:1750.
- Heyman P, Gelberman RH, Duncan K, Hipp JA. Injuries of the ulnar collateral ligament of the thumb metacarpophalangeal joint. Biomechanical and prospective clinical studies on the usefulness of valgus stress testing. Clin Orthop Relat Res 1993; :165.
- Malik AK, Morris T, Chou D, et al. Clinical testing of ulnar collateral ligament injuries of the thumb. J Hand Surg Eur Vol 2009; 34:363.
- Merrell G, Slade JF. Dislocations and ligament injuries in the digits. In: Green's Operative Hand Surgery, 6th ed, Wolfe SW, Hotchkiss RN, Pederson WC, Kozin SH (Eds), Elsevier, Philadelphia 2011. Vol I, p.291.
- Harley BJ, Werner FW, Green JK. A biomechanical modeling of injury, repair, and rehabilitation of ulnar collateral ligament injuries of the thumb. J Hand Surg Am 2004; 29:915.
- Hintermann B, Holzach PJ, Schütz M, Matter P. Skier's thumb--the significance of bony injuries. Am J Sports Med 1993; 21:800.
- Adler T, Eisenbarth I, Hirschmann MT, et al. Can clinical examination cause a Stener lesion in patients with skier's thumb?: a cadaveric study. Clin Anat 2012; 25:762.
- Murphey SL, Hashimoto BE, Buckmiller J, et al. Ultrasonographic stress testing of ulnar collateral ligament injuries of the thumb. J Ultrasound Med 1997; 16:201.
- Jones MH, England SJ, Muwanga CL, Hildreth T. The use of ultrasound in the diagnosis of injuries of the ulnar collateral ligament of the thumb. J Hand Surg Br 2000; 25:29.
- Melville DM, Jacobson JA, Fessell DP. Ultrasound of the thumb ulnar collateral ligament: technique and pathology. AJR Am J Roentgenol 2014; 202:W168.
- Patel A, Patel A, Edelstein D, Choueka J. Fluoroscopy-assisted stress testing of the thumb metacarpophalangeal joint to assess the ulnar collateral ligament. Hand (N Y) 2013; 8:205.
- Avery DM 3rd, Caggiano NM, Matullo KS. Ulnar collateral ligament injuries of the thumb: a comprehensive review. Orthop Clin North Am 2015; 46:281.
- Plancher KD, Ho CP, Cofield SS, et al. Role of MR imaging in the management of "skier's thumb" injuries. Magn Reson Imaging Clin N Am 1999; 7:73.
- Melville D, Jacobson JA, Haase S, et al. Ultrasound of displaced ulnar collateral ligament tears of the thumb: the Stener lesion revisited. Skeletal Radiol 2013; 42:667.
- Arend CF, da Silva TR. The role of US in the evaluation of clinically suspected ulnar collateral ligament injuries of the thumb: spectrum of findings and differential diagnosis. Acta Radiol 2014; 55:814.
- Fricker R, Hintermann B. Skier's thumb. Treatment, prevention and recommendations. Sports Med 1995; 19:73.
- Samora JB, Harris JD, Griesser MJ, et al. Outcomes after injury to the thumb ulnar collateral ligament--a systematic review. Clin J Sport Med 2013; 23:247.
- Landsman JC, Seitz WH Jr, Froimson AI, et al. Splint immobilization of gamekeeper's thumb. Orthopedics 1995; 18:1161.
- Arranz López J, Alzaga F, Molina J. Acute ulnar collateral ligament injuries of the thumb metacarpophalangeal joint: an anatomical and clinical study. Acta Orthop Belg 1998; 64:378.
- Christensen T, Sarfani S, Shin AY, Kakar S. Long-Term Outcomes of Primary Repair of Chronic Thumb Ulnar Collateral Ligament Injuries. Hand (N Y) 2016; 11:303.
- Papandrea RF, Fowler T. Injury at the thumb UCL: is there a Stener lesion? J Hand Surg Am 2008; 33:1882.
- Sourmelis SV. Repair of the ulnar collateral ligament of the thumb. Technique and outcome in 21 patients followed for minimum 1.5 years. Acta Orthop Scand Suppl 1997; 275:52.
- Werner BC, Hadeed MM, Lyons ML, et al. Return to football and long-term clinical outcomes after thumb ulnar collateral ligament suture anchor repair in collegiate athletes. J Hand Surg Am 2014; 39:1992.
- Goldfarb CA, Puri SK, Carlson MG. Diagnosis, Treatment, and Return to Play for Four Common Sports Injuries of the Hand and Wrist. J Am Acad Orthop Surg 2016; 24:853.
- MECHANISM OF INJURY
- CLINICAL FEATURES
- Patient presentation
- Examination findings
- DIAGNOSTIC IMAGING
- Approach to and methods for imaging
- DIFFERENTIAL DIAGNOSIS
- INDICATIONS FOR SURGICAL REFERRAL AND SURGICAL OUTCOMES
- NONSURGICAL MANAGEMENT
- Acute therapy, splinting, and rehabilitation
- Persistent symptoms
- RETURN TO WORK OR SPORT
- SUMMARY AND RECOMMENDATIONS