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Basics ⬇

Author: CoreyCarson, MD, CAQSM

Description

  • Synonym(s): skier’s thumb; gamekeeper’s thumb
  • Sprain of the ulnar collateral ligament (UCL) of the 1st metacarpophalangeal (MCP) joint with or without a bony avulsion from the insertion on the phalanx
  • Stener lesion:
    • Displacement of the ruptured ligament proximal to the adductor pollicis aponeurosis, effectively preventing healing without surgical intervention
    • Incidence with a complete tear is reported between 64% and 87% (1).

Epidemiology

  • As high as 50 per 100,000 and 10 times more likely than radial collateral ligament injuries
  • Represents 5–7% of all skiing injuries and second in frequency only to knee injuries in skiers

Risk-Factors

Ski poles likely increase the risk of UCL injury:

  • Wrist straps on the ski poles do not likely increase the risk of UCL injury further.

Diagnosis ⬆ ⬇

Avulsion of bony fragment at the insertion of UCL on the phalanx may be associated with this condition.

History

  • Stress to the thumb in extended and/or abducted position
  • Usually in skiing but often occurs in other sports, such as football and mixed martial arts
  • Historically called gamekeeper’s thumb as a reference to chronic UCL injuries suffered by gamekeepers while twisting the necks of small game like rabbits while hunting

Physical Exam

  • Diagnosis may be made based on physical examination if the examination is done within a couple of hours.
  • Pain, swelling, and muscle spasm may make clinical diagnosis of a complete tear difficult if the examination is performed later:
    • Local anesthetic may be helpful for the diagnosis in these cases (2)[C].
  • Pain at the origin and insertion of the UCL
  • Swelling and tenderness over the ulnar aspect of the 1st MCP joint
  • Mild-to-complete instability on stress testing of UCL with MCP joint in flexion, depending on whether it is a 1st-, 2nd-, or 3rd-degree sprain:
    • Tested at 0 and 30 degrees of metacarpal phalangeal joint flexion
    • There is significant side-to-side variability in UCL testing in noninjured individuals (3)[B]:
      • Most important physical finding is lack of an end point because this indicates complete ligament disruption.

Differential Diagnosis

  • Radial collateral ligament sprain
  • Metacarpal fracture
  • Proximal phalanx fracture
  • MCP sprain

Diagnostic Tests & Interpretation

  • X-rays (posteroanterior [PA]/lateral) (2):
    • Rule out bony avulsion or other fractures.
    • Stress x-rays to determine if the tear is partial (usually treated conservatively) or complete (often treated surgically)
    • Because of associated muscle spasm, many clinicians advise local anesthetic infiltration before x-rays.
    • “Sag sign”: Volar subluxation of the proximal phalanx in relation to the metacarpal at the MCP joint may indicate UCL injury (2).
  • Ultrasound (US):
    • Excellent accuracy when performed by an experienced ultrasonographer (4)[C]:
      • Full thickness tears are characterized by nonvisualization of the UCL and visualization of a heterogeneous mass proximal to the MCP joint representing the retracted ligament known as a “stump sign.”
  • Magnetic resonance imaging (MRI) (5):
    • Ordered to diagnose whether there is a complete tear or to evaluate for a Stener lesion: 96% sensitivity and 95% specificity

Treatment ⬆ ⬇

  • Ice, elevation, and immobilization should be used immediately after the injury for protection and pain control.
  • Partial tears:
    • Nonsurgical treatment is generally successful for these injuries (1,2)[C].
  • Protection with thumb spica splint or cast:
    • 2 to 4 wk of immobilization followed by 2 to 4 wk of protection during activity
    • Start range of motion after period of immobilization.
    • Progress to strengthening exercises as symptoms allow.
  • Complete tears:
    • If a Stener lesion can be ruled out with MRI or MR arthrogram, good results can be expected with conservative treatment (i.e., brace or cast) (1,2)[C].
    • If a Stener lesion is present, treatment should be surgical (1,2)[C].
    • If the presence of a Stener lesion cannot be determined, management is controversial. Because surgical repair generally yields excellent results, surgery is preferred by many clinicians. However, even after failure of nonoperative treatment at anywhere from 1 mo to >6 yr, nearly all patients achieve complete pain relief and normal strength, stability, and range of motion after surgical reconstruction (6)[A]. Therefore, some clinicians will treat patients with a trial of conservative treatment and reserve surgery for patients who continue to have symptoms.
  • Avulsion fractures:
    • If avulsion-type fracture is present, treatment is a thumb spica cast for 4 to 6 wk (1,2)[C]:
      • Casting may be modified to a hand-based thumb spica (wrist out) as symptoms allow.

Medication

Acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) are generally adequate for pain control.

Additional Therapies

  • Rehabilitation may be helpful in regaining full range of motion and strength postoperatively or in those with difficulty regaining motion and strength after conservative treatment.
  • Early range of motion may be acceptable postoperatively (2)[C].

Surgery/Other Procedures

  • Acute operative treatment (1,2):
    • Several different surgical techniques for repair are used and will depend on the exact nature of the injury and surgeon experience.
    • Cast or splint is used for 4 to 6 wk at which time range of motion and strengthening exercises are initiated.
    • Full unrestricted activity is generally allowed at 12 wk.
    • Protected activity may be allowed sooner depending on the surgical technique and surgeon preference.
  • Chronic operative treatment (6)[A]:
    • Generally requires surgical reconstruction of the UCL.
  • Patients generally experience excellent clinical outcomes after surgical treatment of both acute and chronic UCL injury without any significant difference between repair and reconstruction for acute and chronic injury, respectively.

Ongoing Care ⬆ ⬇

  • Surgery is the preferred treatment for chronic instability (6)[A].
  • Conservative treatment is limited to bracing and strengthening exercises.

Prognosis

  • Prognosis is excellent for partial UCL injuries (1,3)[C].
  • Prognosis is excellent for complete tears treated surgically (6)[A].

Complications

  • Most common complication is instability, resulting in decreased pinch strength:
  • Other complications are related to surgical interventions (local numbness and infection).

Additional Reading ⬆ ⬇

  • Avery DM III, Caggiano NM, Matullo KS. Ulnar collateral ligament injuries of the thumb: a comprehensive review. Orthop Clin North Am. 2015;46(2):281–292.
  • Avery DM III, Inkellis ER, Carlson MG. Thumb collateral ligament injuries in the athlete. Curr Rev Musculoskelet Med. 2017;10(1):28–37.

References ⬆ ⬇

  1. Baskies MA, Lee SK. Evaluation and treatment of injuries of the ulnar collateral ligament of the thumb metacarpophalangeal joint. Bull NYU Hosp Jt Dis. 2009;67(1):68–74.
  2. Johnson JW, Culp RW. Acute ulnar collateral ligament injury in the athlete. Hand Clin. 2009;25(3):437–442.
  3. Malik AK, Morris T, Chou D, et al. Clinical testing of ulnar collateral ligament injuries of the thumb. J Hand Surg Eur Vol. 2009;34(3):363–366.
  4. Melville D, Jacobson JA, Haase S, et al. Ultrasound of displaced ulnar collateral ligament tears of the thumb: the Stener lesion revisited. Skeletal Radiol. 2013;42(5):667–673.
  5. Plancher KD, Ho CP, Cofield SS, et al. Role of MR imaging in the management of “skier’s thumb” injuries. Magn Reson Imaging Clin N Am. 1999;7(1):73–84.
  6. Samora JB, Harris JD, Griesser MJ, et al. Outcomes after injury to the thumb ulnar collateral ligament—a systematic review. Clin J Sport Med. 2013;23(4):247–254.

Clinical Pearls ⬆

Timing for return to play depends on severity and whether surgery is performed. Incomplete tears usually are treated with splinting for 4 to 8 wk, with range of motion exercises and strengthening beginning after 3 wk. A protective splint should be worn for sports until range of motion and strength have returned to normal, usually within 6 to 8 wk of injury. If surgery is performed, range of motion and strengthening exercises usually begin 6 wk after surgery. A protective splint usually is prescribed until range of motion and strength have returned to normal.