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