A 42-Year-Old Man with Thumb Pain After a Fall

A 42-year-old man arrived at your urgent care center complaining of thumb pain a day after taking a fall while skiing. You find that the pain is worse with movement in any direction; in addition, he exhibits limited ability to grip anything using his thumb.

View the image taken (Figure 1) and consider what your diagnosis and next steps would be. Resolution of the case is described on the next page.

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Differential Diagnosis

• Avulsion fracture at the ulnar collateral ligament attachment
• Distal metacarpal fracture
• Extensor tendon rupture
• Metacarpophalangeal joint dislocation
• Proximal phalanx fracture

Diagnosis
Review of the x-ray reveals a small defect at the ulnar corner base of proximal phalanx, seen on the AP view. The patient sustained an avulsion fracture at the ulnar collateral ligament attachment.

Learnings

• Historically known as gamekeeper’s thumb, this injury more currently is also referred to as skier’s thumb because of the frequency with which it’s associated with skiing accidents where the thumb is bent back by the ski pole
• This injury is often seen only on a good AP view of the thumb, and may not be visible on a standard hand x-ray exam

Pearls for Urgent Care Management and Consideration for Transfer

• Initial treatment is aimed at reducing swelling and pain, and immobilization of the affected joint
• Conservative treatment is possible for nondisplaced fractures. For displaced fractures, refer the patient for surgical consideration. Patients are most likely to require surgical repair if the ligament injury is complete or displaced, so prompt orthopedic consultation is recommended