9.24 Third Degree Tear of Ulnar Collateral Ligament 
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(Skipole or Gamekeeper's Thumb)
agk's Library of Common Simple Emergencies

Presentation
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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:
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- 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 immob- 
    ilization 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
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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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