A 29 year old male resident presents to the local emergency department directly from the residency ski trip. He was cruising down the slopes at high speed, hit a hidden patch of ice and fell onto his right hand, hyperextending his thumb. He tried to avoid coming to the emergency department, but the thumb remains painful and he noted exquisite pain every time he put his hand in his jacket pocket.
The astute resident tells you he already knows what you’re going to find on your x-ray. What injury does he suspect?
An avulsion fracture of the proximal phalanx of the thumb, or skier’s thumb. In this injury, the ulnar collateral ligament (UCL) is partially or completely torn, and the attachment site at the thumb is often avulsed. While classically associated with skiing, it can occur with any sort of fall onto an outstretched hand (FOOSH) injury. This injury may also be referred to as a “gamekeeper’s thumb,” as Scottish gamekeepers were known to hyperextend their thumbs sacrificing game.
The patient should be placed in a thumb spica splint (including the intraphalangeal joint) and prompt orthopedics followup should be arranged, as complete UCL tears and complicated, displaced or rotated fractures may need operative repair.
Thanks to Dr. Scofi for inspiring this pearl.
