9.24 Third Degree Tear of Ulnar Collateral Ligament (Skipole or Gamekeeper’s Thumb)

agk’s Library of Common Simple Emergencies

Presentation

The patient fell while holding onto a ski pole, banister, or other fixed object, forcing his thumb into abduction. (This same lesion may be produced by the repeated breaking of the necks of game birds – hence the name.) The metacarpophalangeal joint of the thumb is swollen, tender, and stiff; but, when tested for stability, can be deformed towards the radial (or palmar) aspect more than the metacarpophalangeal joint of the other thumb. The patient’s power pinch between the thumb and index finger, if possible at all, is less strong than with the other hand.

What to do:

• Examine thoroughly and obtain x rays, which should be negative or show a small avulsion fracture at the insertion of the ulnar collateral ligament.
• Treat with ice, elevation, rest, anti-inflammatory medications, and immobilization in a radial gutter splint, including the thumb.
• Explain to the patient that this particular injury may not heal with closed immobilization, but sometimes requires operative repair; and arrange for re-examination and orthopedic referral after a few days, when the swelling is decreased.

Discussion

The ulnar collateral ligament of the metacarpophalangeal joint of the thumb, once completely torn, may retract its torn ends under other structures, where they are no longer apposed and cannot b depended upon to heal. An operation may be required to reappose the two ends of the ligament or reattach an avulsed insertion, but this is not usually done immediately. Left unrepaired, a gamekeeper’s thumb remains unstable, and weak in pinching and holding. For minor sprains or partial ligament tears, an elastic wrap tha incorporates the thumb may be all that is required to reduce mobility and provide comfort.

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