What is Ulnar Collateral Ligament Injury (Gamekeeper’s Thumb)?
To clear up any confusion, this article is talking about injuries to the ulnar collateral ligament in the thumb, also known as Gamekeeper’s thumb, not injuries to the same ligament in the elbow which often result in Tommy John surgery.
The injury known as Gamekeeper’s thumb was initially noticed among gamekeepers who frequently had to break the necks of small animals like birds and rabbits. This common action caused their thumbs to repeatedly bend backwards too much, leading to wear and tear and eventually tears in the ulnar collateral ligament – this is the ligament at the base of the first joint of the thumb. Nowadays, this kind of injury is also called skier’s thumb. This is because it’s often seen in people who fall while holding ski poles, which triggers the same sort of excessive thumb bending.
What Causes Ulnar Collateral Ligament Injury (Gamekeeper’s Thumb)?
The ulnar collateral ligament is a band of tissue at the base of your thumb where it joins to the first long bone of the hand. This ligament helps to keep your thumb steady when you use it.
If your thumb is suddenly pushed or pulled away from your hand, as might happen during a fall or if you hit your thumb, this can cause damage to the ulnar collateral ligament. For instance, if your thumb is bent or stretched in an abnormal way, it may push this ligament too far, causing injury.
This kind of injury is more common among skiers, because they often fall and hit their thumbs against their ski poles.
Also, if you repeatedly bend and straighten your thumb over a long period of time, like the actions commonly done by gamekeepers, it can cause a long-term ulnar collateral ligament injury.
Risk Factors and Frequency for Ulnar Collateral Ligament Injury (Gamekeeper’s Thumb)
Ulnar collateral ligament injuries, which are more common in males, can be caused by various factors. These injuries are often seen in people who take part in certain sports like skiing, baseball, and javelin throwing. Also, simple actions like falling can result in this type of injury, especially in older individuals or those living with disabilities.
- Ulnar collateral ligament injuries are 60% more common in males.
- People who play sports like skiing, baseball, and javelin are at risk.
- Simple actions, like falling, can cause this injury, especially in older or disabled individuals.
Signs and Symptoms of Ulnar Collateral Ligament Injury (Gamekeeper’s Thumb)
An ulnar collateral ligament injury typically results in discomfort around the base of the thumb. The patient might also experience swelling in this area. This kind of injury often occurs due to falls or trauma that pushes the thumb into an extreme position, like being stretched too far away from the hand or bent too far back. The onset of the injury can be immediate or it can be chronic, manifesting over a longer period. In both instances, the person could experience pain and sometimes weakness, especially when they try to grasp objects between their thumb and forefinger.
During a physical examination, the doctor might perform a valgus stress test. This involves stretching the thumb away from the hand to check for looseness or total disruption of the ulnar collateral ligament. By comparing with the other thumb, the doctor can get a sense of the extent of the damage. The thumb, if partially torn, will exhibit increased flexibility or movement during this test. If the ligament is completely torn, there won’t be a clear limit to how far the thumb can be stretched, indicating total instability.
One way to specifically evaluate the ulnar collateral ligament is by asking the patient to bend the first joint of the thumb at a 45-degree angle. This allows for more accurate assessment than examining other thumb ligaments.
Research in orthopedics states that an abnormal degree of flexibility that should raise suspicions of ulnar collateral ligament injury is anything more than 15 to 20 degrees when the thumb is stretched or pushed away from the hand. This should be compared with the unaffected thumb. If the flexibility is more than 30 degrees, this strongly suggests a tear in the ulnar collateral ligament. It is worth noting that this degree of flexibility might be challenging to measure accurately in an actual clinical setting.
Testing for Ulnar Collateral Ligament Injury (Gamekeeper’s Thumb)
Normally, imaging isn’t very useful if you’ve hurt your ulnar collateral ligament, which is a ligament in your thumb. But sometimes, a simple X-ray of your thumb can help the doctor see if there’s a fracture, especially near the base of your thumb. This ligament attaches to the inside (ulnar side) of the bone that is the base of your thumb, so if there’s a small crack or break in the bone, it might mean your ligament is also injured. That said, usually, an X-ray won’t show much about this type of injury and might even appear normal.
Another possibility is using ultrasound right beside your bed to check how loose the joint is where your thumb meets your hand. A skilled operator using a small, special ultrasound probe called a ‘hockey stick probe’ can have a closer look at small things like your ulnar collateral ligament. The ultrasound can be done on both thumbs. This can help the doctor see what’s normal for you by looking at your uninjured thumb.
Finally, a technique called Magnetic Resonance Imaging (MRI) can be used. It’s often hard to arrange for one of these tests right away, but an MRI is the most accurate way of diagnosing an injury to your ulnar collateral ligament, including any tearing or rupture. The accuracy rate for an MRI in diagnosing this specific injury is nearly 100%.
Treatment Options for Ulnar Collateral Ligament Injury (Gamekeeper’s Thumb)
Ulnar collateral ligament injuries are common musculoskeletal injuries and can be treated initially with R-I-C-E therapy. This stands for Rest (avoiding activities that cause pain), Ice (applying cold packs for 15 minutes every hour), Compression (pressure on the injury to reduce swelling), and Elevation (raising the injured area above heart level to reduce swelling). It can also be beneficial to immobilize the injured area with a specific type of splint known as a thumb spica splint.
If the injury has led to a bone damage like an avulsion fracture (where a small piece of bone is pulled off by a tendon or ligament), it’s necessary to see an orthopedic or hand specialist urgently. It’s also important to see a hand surgeon urgently if there’s extreme looseness in the thumb (more than 15 to 20 degrees compared to the healthy thumb or more than 30 degrees in general).
A hand surgeon should still evaluate partial tears (where the ligament is not completely broken apart), but these injuries might not require surgery. Immobilizing the thumb with a splint can help these types of injuries heal and is typically recommended for three weeks. After that, physical therapy and rehabilitation can strengthen the thumb and wrist. If not in therapy, the thumb should remain immobilized for another three weeks, making a total of six weeks of immobilization therapy. If a patient still has weakness or pain after this period, they should be referred for a surgical evaluation.
Patients who have complete ligament tears (where the ligament is entirely broken) often recover well from surgery without major complications. One study even showed that over 98% of athletes were able to return to their sport following surgery without a decrease in performance and with a 10.3% rate of post-surgery complications. However, surgery is usually required immediately for these types of injuries to prevent a complication called a Stener lesion. This happens when the torn end of the ligament moves to the surface of a muscle in the thumb, preventing it from healing naturally. In such cases, surgery is typically the best course of action.
What else can Ulnar Collateral Ligament Injury (Gamekeeper’s Thumb) be?
When a doctor is trying to diagnose an injury to the ulnar collateral ligament (a ligament in your thumb), they need to consider other possible injuries that can affect your hand and thumb. These may include:
- Injuries to the tendons, like a disruption to the adductor pollicis (a muscle in your thumb.)
- Dislocation of the thumb at the joint connecting the thumb to the hand (known as the metacarpophalangeal joint.)
- Specific types of bone breaks in the hand, known as Rolando or Bennett fractures.
- Arthritis of the thumb joint.
What to expect with Ulnar Collateral Ligament Injury (Gamekeeper’s Thumb)
Partial tears of the ulnar collateral ligament, a vital ligament in the elbow, are usually managed by simply using a splint or brace. Even though this means the arm must be immobilized for an extended period, the ligament often heals well. In a few cases, patients may continue to experience stiffness and pain.
Surgery is generally a safe option for treating complete tears of the ulnar collateral ligament. However, in people who end up developing Stener lesions (a type of injury where the ligament gets displaced) or those who go without treatment, they may experience long-term changes in the space of the metacarpophalangeal joint (the joint where the fingers meet the hand).
Typically, patients should wait at least six weeks before they can go back to work or sports activities.
Possible Complications When Diagnosed with Ulnar Collateral Ligament Injury (Gamekeeper’s Thumb)
The primary method of treating minor tears and strains involves activities like resting, applying ice, elevating the injured area, managing pain with readily available anti-inflammatory and pain relievers, and using splints. However, rushing back to regular activity without proper rehabilitation might lead to a decrease in its function. As with any surgical procedure, there are inherent risks such as potential allergic reactions to anesthesia, risk of infection after the surgery, and possible nerve damage. Failing to repair more severe injuries through surgery could also lead to functional loss.
Common Treatment Methods And Risks:
- Rest
- Ice application
- Elevation of injury
- Over-the-counter anti-inflammatory and analgesic drugs
- Splinting
- Potential decrease in function if returning to activity too soon
- Risks related to surgery, such as allergic reactions to anesthesia and infection
- Potential nerve damage from surgery
- Potential decrease in function if severe injuries are not surgically repaired
Preventing Ulnar Collateral Ligament Injury (Gamekeeper’s Thumb)
It’s important for patients to understand ways to manage their pain, such as using ice and keeping the injured hand stabilized with a splint until the doctor gives permission to start rehabilitation. If the doctor says that surgery is part of the treatment, then they should also provide guidance on how to take care of yourself at home after the surgery. It’s also crucial to learn about how to avoid future falls and injuries to reduce the risks.
