Ulna collateral ligament




Injury to ulnar collateral ligament of thumb MCPJ


Interferes with pinch grip and grasp and thumb is ineffective as a post


Gamekeeper 2Gamekeeper 1




Valgus / forced abduction


10 x more common than injuries to radial collateral ligament


Gamekeeper's thumb's

- secondary to repetitive breaking pheasant's neck

- chronic injury


Skier's thumb

- acute injury




UCL anatomy


Ulna collateral ligament



- origin dorsal metacarpal head

- passes to volar aspect proximal phalanx



- volar side of proper ligament

- attaches to volar plate


Adductor aponeurosis 


Superficial to ulna collateral ligament

- inserts into ulna border thumb extensor mechanism

- via the ulna sesamoid




Stener lesion

- distal end of UCL flipped superficially over adductor aponeurosis

- will not heal

- may be able to palpate a lump

- use MRI to diagnose


Stener lesion






Painful, swollen MCPJ


Tenderness along UCL


Abduction Stress Test


Game exam


In full extension and 30° compared to other side

- increased opening at 30o - injury to ulna collateral ligament proper only

- increased opening at 30 and full extension - injury to both accessory and ulna collateral ligament




Bony avulsion


1. Small fragment pulled away from proximal phalanx


Bony gamekeepersBony gamekeepers


2. Large intra-articular fracture involving >1/4 articular surface


Bony gamekeepers largeBony ORIF


3. Salter Harris III in pediatric population






MRI Anatomy


A.  Undisplaced


Game MRIGamekeepers MRI

Distal tear of ulna collateral ligament on coronal MRI


MRI gameMRI game

Distal tear of ulna collateral ligament on coronal MRI


B.  Displaced UCL


UCL dispUCL disp 2

Coronal MRI demonstrating displaced distal UCL avulsion




Non operative




Partial tear

Undisplaced complete tear

Undisplaced bony fragment




6/52 thumb spica




Indications for surgery


Stener lesion

Complete tear with displacement

Displaced bony fragment

Salter Harris III

Chronic injury with instability


Acute injury




Milner et al J Hand Surg Am 2015

- 43 cases acute UCL injury with MRI

- all partial tears / minimally displaced / displaced < 3 mm healed with immobilisation

- tears displaced > 3 mm failed immobilisation


Dar et al J Hand Surg Am 2021

- biomechanical study

- primary repair + suture tape augmentation > primary repair > ligament reconstruction


Gibbs et al Orthop J Sports Med 2020

- 18 thumbs in athletes

- primary repair of acute UCL injury augmented with suture tape

- average return to sport 5 weeks


Surgical technique


Gamekeepers repair


AO foundation surgical approach


Vumedi primary repair with suture anchor


Arthrex internal brace surgical technique PDF


Vumedi primary repair augmented with internal brace


Dorso-ulnar approach to the MCPJ of the thumb

- dorsal incision along ulna border MCPJ

- divide Adductor pollicis aponeurosis

- leave cuff for lateral repair

- identify UCL


Fixation options

- bony anchors for proximal or distal tears +/- internal brace

- direct repair of midsubstance +/- internal brace

- screw fixation of bony avulsions


Post operative management

- 6/52 thumb spica


Chronic Injuries




Primary UCL repair +/- suture tape augmentation

Adductor advancement

Tendon reconstruction

MCPJ fusion




Agout et al Ortho Traumatol Surg Res 2017

- 55 chronic injuries

- compared repair when able with reconstruction and fusion

- primary repair > fusion > reconstruction


Tendon reconstruction


UCL reconstructionUCL recon suture anchor

Figure 8 reconstruction                                         Single bundle reconstruction with suture tape augmentation


Graft options

- palmaris longus

- strip of FCR if palmaris absent

- fourth toe extensor tendon



- figure of 8 through drill holes

- suture anchor fixation +/- suture tape augmentation


Vumedi tendon reconstruction with suture anchors and suture tape augmentation


MCPJ fusion


Thumb fusion