Gamekeeper's Thumb

A valgus force placed onto the abducted metacarpophalangeal (MCP) joint, leading to a n ulnar collatera l ligament injur y and resulting in instability that is accompanied by pain and weakness of the pinch grasp .

Anatomy
Stability of thumb from ulnar side is contributed by four important structures:
1. 2. 3. 4. The Adductor Aponeurosis The Adductor Pollices muscle The proper and accessory collateral ligaments The volar plate

The UCL is a 4- to 8-mm X 12- to 14-mm band that originates from the metacarpal head and inserts into the medial aspect and base of the proximal phalanx of the thumb. The UCL provides resistance to radially directed forces(pinching or holding large objects) A torn UCL weakens the pinch grasp strength and allows volar subluxation of the proximal phalanx

 The most common mechanism is a skier landing on the ground with his or her hand braced on a ski pole, causing a valgus force on the thumb Fall on hyper extended or abducted thumb. Grades
Grade 1 Microscopic tear No or minimal laxity Mild tenderness Mild swelling Good prognosis Grade 2 Grade 3 macroscopic tears complete tear joint laxity joint laxity severe tenderness marked pain and tenderness swelling require conservative managmnt operative m/g

 A STENER LESION occurs when the adductor aponeurosis becomes interposed between the ruptured UCL and its site of insertion at the base of the proximal phalanx. Thus, the distal portion of the ligament retracts and points superficially and proximally. Occasionally, failure of the UCL avulses a small portion of the proximal phalanx at its insertion, leading to a GAMEKEEPER'S FRACTURE

Clinical features
swelling and pain at the ulnar aspect of the metacarpophalangeal joint. Ecchymosis A palpable mass on the ulnar aspect of the MCP joint may represent the retracted ulnar collateral ligament stump that is displaced proximally and dorsally relative to the adductor aponeurosis In full extension, valgus laxity averages 6 Although a gamekeeper's fracture is a contraindication to stress testing, a nondisplaced avulsion fracture is not. If the patient's pain is severe, the joint may be anesthetized with a lidocaine injection before the stress testing. A laxity of 30 or one that is 15 more than that on the uninjured side represents a ruptured proper collateral ligament in this position (the proper collateral ligament runs from the metacarpal head to the volar aspect of the proximal phalanx) A Stener lesion can be present only when both the proper and accessory collateral ligaments are ruptured. In more than 80% of complete ruptures of the UCL, a Stener lesion is present, whether it is palpable or not

Treatment
STABLE SKIERS THUMB :
healing will occur with non operative treatment thumb is immobilized for 4 weeks in the short arm spica cast or thermoplastic splint with IP joint free Active and passive exercises to begin after 4 weeks but avoid valgus stress Grip strengthening exercises to begin after 6-7 weeks Brace is worn for 2 months

 Unstable thumb/