Torn ligaments in the thumb: The Gamekeeper Thumb

“I’m sick, I’m weak, I’m tired and I’m torn.  I fell like I’m dying but I hardly been born”

from “Ode to Woody” by Bob Dylan performed by The Earl Scruggs Review

The thumb is the most important part of hand.  If you look at a disability chart that analyzes the value of each of our digits, the thumb is considered to be worth 50% of the hand, or equal to the value of all four fingers.  The thumb is an amazing digit.  It can move in multiple planes and allows us to do all sorts of different activities including grasping, pinching and even lifting.  The specialized function of the thumb makes an injury to the thumb even more of a problem than injuring the other fingers, and unfortunately injuries to the thumb are fairly common.  The thumb sticks away from the hand and can be injured in falls or accidents.  You can break a bone, rupture a tendon, or tear a ligament at different places in the thumb.

A ligament is a structure that holds two bones together at a joint.  Each joint in your hand usually has at least two ligaments, and some joints have even more.  The most commonly injured ligament in the thumb occurs at the metacarpal phalangeal joint.  This is the joint that moves up and down at the point where the thumb joins to your hand.  The joint on the inside of the thumb, the side that is towards the fingers, can be injured in a number of ways.  Snow skiers can get their thumbs caught in their ski poles or someone falling on their hand can get their thumb pulled away from the hand.  These injuries can stretch the ligament and sometimes tear the ligament completely.  The ligament is called the ulnar collateral ligament, and if the ligament is torn it is often called a “gamekeeper thumb.”

The name “gamekeeper thumb” originated in England.  It was actually used to describe a chronic stretching of the ligament which occurred in gamekeepers who had to kill wild hares by breaking their necks between the thumb and the hand.  This caused a chronic stretching of the ligament and usually caused pain and decreased use of the thumb.  Chronic injuries are not very common today, and most of the patients I see with “gamekeeper thumbs” have had some sort of accident such as a fall or were involved in a car accident.

Initially patients have pain and swelling on the inside of their thumb.  They usually have a sensation that something’s not right with their hand.  An x-ray needs to be taken to make sure the bone isn’t broken.  Sometimes instead of tearing the ligament will pull of a piece of bone.  If the x-rays don’t show a break, the next step is to test the joint to see how stable it is. In other words, does the joint move too much from side to side?  Sometimes this is very obvious to both the patient and the doctor, but sometimes it’s hard to tell if the ligament has been completely torn.  This is important because if the ligament if just partly torn it can heal with either a brace or a cast.  A completely torn ligament usually requires surgery.  If it’s not 100% clear if the ligament is torn then an MRI can tell you for sure.

If the ligament is completely torn, or if the ligament has pulled a piece of bone away then surgery is the best way to fix the thumb.  The ligament usually pulls away from one of the two bones rather than tearing in the middle, and at surgery the end of the tendon can be identified and reattached to the bone.  There are a number of ways to do this and I usually use a device call a suture anchor.  The company I use has a little metal corkscrew that you can put in the bone right where the ligament belongs.  The corkscrew has sutures attached to it and you can pull the ligament right back where it belongs.  If a piece of bone is pulled off you can sometimes put a small screw or wire, or you can use the corkscrew and suture the bone back in place.

After surgery it’s best to wear a splint or cast for around 6 weeks.  After that the thumb is usually pretty stiff but most patients get back a lot of their motion.  I think most people do pretty well with this surgery.  I’ve done this surgery on a couple of friends of mine and their thumbs have held up well for over 15 years.

The take home from this is that if you fall or hurt your thumb and something doesn’t feel right, there’s a good chance something is wrong and it’s a good idea to get it checked out by a physician.