Skier's thumb

Contents

Search Strategy

Keywords:
Gamekeeper's thumb; Skier’s thumb; UCL injury of the thumb; Thumb injury; Ulnar collateral ligament injury; Stener lesion; Thumb sprain; Sprained thumb; Wackeldaum; Bennet fracture; Rolando fracture

Databases searched:
Medscape, Pedro, Google Scholar, Pubmed, Cochrane library, Web of Knowledge, Library of the VUB, ScienceDirect


Definition/description

Skier's thumb is a acute partial or complete rupture of the ulnar collateral ligament (UCL) of the thumb’s metacarpophalangeal joint (MCPJ) due to a hyperabduction trauma of the thumb.

Whilst both terms are often used interchangeably, skier’s thumb refers to the cause being acute injury. Gamekeeper’s thumb specifically refers to the cause being chronic injury to the UCL in which it became attenuated through repetitive stress.
UCL damage caused by Chronic injury may have a serious risk of disabling instability, pinch strength, and pain-free motion if not treated adequately .[10][12][13]][38][41][42]

In 64–87% of total UCL tears, Stener lesion can occur. A Stener lesion occurs when the adductor aponeurosis becomes interposed between the ruptured UCL and its site of insertion at the base of the proximal phalanx. Hence making it impossible for the loosened ligament to reconnect with the site of insertion, necessitating surgery.[43]

Video illustration:
Stener lesion: https://www.youtube.com/watch?v=RLskrc7qifY
Skier’s thumb: https://www.youtube.com/watch?v=qFbxlgztK5U

Clinically Relevant Anatomy

The metacarpophalangeal joint of the thumb is a diarthrodial joint, reinforced by a capsule and by other soft tissue structures. The surrounding soft tissue offers both dynamic and static stability.[2]

The passive stability is provided by the following structures:
● Proper collateral ligament
● Accessory collateral ligament
● Volar plate
● Dorsal capsule[31]



The proper collateral ligament extends from a point slightly dorsal to the mid-axis of the metacarpal head to the palmar aspect of the proximal phalanx (Fig. 1). The proper collateral ligament prevents palmar subluxation of the proximal phalanx and serves as the primary restraint to valgus stress with the metacarpophalangeal joint in flexion. The accessory collateral ligament courses palmarly to insert onto the volar plate. The accessory collateral ligament is contiguous with the proper collateral ligament proximally. The volar plate and the accessory collateral ligament function as the principal restraints to valgus stress with the metacarpophalangeal joint in extension. [31]

Dynamic stabilizers to valgus stress consist of the intrinsic and extrinsic muscles of the thumb:
● Extensor pollicis brevis
● Extensor pollicis longus
● Flexor pollicis longus
● Adductor pollicis
● Flexor pollicis brevis

The adductor mechanism presents as an aponeurosis superficial to the metacarpophalangeal joint capsule and ulnar collateral ligament. The adductor mechanism maintains dual insertions. The superficial insertion of the adductor mechanism is the extensor expansion via the adductor aponeurosis; the deep insertion extends to the palmar aspect of the proximal phalanx via the ulnar sesamoid of the metacarpophalangeal joint. [2][13] [31]

The range of motion is highly variable at the thumb metacarpophalangeal joint. [31]
The movement association with the thumb MCPJ include flexion, extension, rotation, abduction and adduction. [2]


There are two main supporting ligaments traversing the MCPJ of the thumb:
1) the UCL ligament
2) the radial collateral ligament (RCL)
The UCL and RCL arise from the medial and lateral tubercles of the metacarpal condyles and insert into the base of the proximal phalanx on their respective sides, beneath the adductor aponeurosis (Figure 1b).[2][3] The UCL prevents the thumb from pointing too far away from the hand.[10]

Epidemyology/ etiology

Skier’s thumb is caused by forced abduction and hyperextension of the thumb. [9] The UCL tears mostly find place at the distal attachment of the proximal phalange. But proximal avulsion, proximal and distal bony avulsion, isolated mid-substance tears and mid-substance tears with bony avulsion do also occur. [8]


● Mechanism of injury.
It is important to note that this injury is not exclusive to skiers and can occur to anyone where there is an extreme valgus stress force applied to the thumb in abduction and extension. [18]
An acute UCL injury occurs following a sudden, hyperabduction and hyperextension forces[8] at the MCP joint, whereas a forced adduction movement would cause injury to the RCL (Figure 2A).[2] With regards to skiing, the injury often occurs when a person lands on an outstretched hand while holding a ski pole, which causes forced abduction of the thumb with extension (Figure 2B).[1] It is called skier’s thumb but can also occur in football, handball, basketball, rugby, soccer and even a handshake. [8] If the injury to the UCL is not treated properly this can lead to chronic laxity, joint instability, pain, weakness and arthritis in the MCPJ.


● Frequency.
An often-encountered problem. It concerns 86% of all injuries to the base of the thumb.
Injuries to the ulnar collateral ligament of the thumb are the second most common ski-related injury. Prevalence of this injury during skiing varies from 7% up to as high as 32% of all skiing injuries and is the most frequent injury of the upper extremity that skiers experience.(figure 2C)[18][19][38]
This type of injury is also seen in other sports, especially those that use a stick or ball, such as hockey or basketball. Only an estimated 10% of the patients diagnosed with a skier’s thumb had acquired this injury skiing. A fall on the hand, usually from a bicycle or motorcycle (in which the thumb gets stuck behind the handlebars), is a much more common cause of skier’s thumb, seen in approximately 40 % of all patients(figure 2B). Other sports such as soccer or fighting are responsible for another estimated 30% of the causes(figure 2A).
In children, who still have an immature skeleton, hyperabduction trauma mostly leads to a Salter-Harris III avulsion of the UCL insertion and rarely to a true rupture of the UCL. [38]

Mechanism of injury by falling.

Figure 2A. Mechanism of injury by falling.[1]

Mechanism of injury by skiing

Figure 2B. Mechanism of injury by skiing.[2]


● Prevention.
Preventive measures should include instruction in proper pole technique for powder skiing, avoidance of pole dragging and deep pole plants and downsizing baskets from the standard 4-inch diameter to 2.5-inches. Pole length should be 2 inches shorter than the recommended length for that skier. [17]

Strapless poles do not reduce the chance of injuries, but if skiers are trained to discard the pole during a fall the risk might be reduced. [41]

Risk of injury can be further reduced by wearing a properly designed ski-glove which not only prevents extreme movement of the thumb, but also incorporates a mechanism for the ejection of the ski-pole. [20]

Characteristics/Clinical Presentation

The most common presentation is pain over the ulnar aspect of the MCPJ of the thumb. If the injury is acute there will be bruising and inflammation (Figure 4). There may be tenderness with palpation, which localizes the injury to the ulnar aspect of the thumb where the UCL is lesioned. In more chronic cases the patients typically complain of pain and weakness when using a pincer grip. There also can be instability of the thumb while doing these tasks. [8][2] In the instance of a Stener lesion, there may also be a palpable mass proximal to the adductor aponeurosis.[1]

● Symtoms.
These symptoms may occur minutes to hours after the fall that created the injury:[29]
‒ Pain at the base of the thumb in the web space between thumb and index finger.
‒ Swelling of your thumb.
‒ Inability to grasp or weakness of grasp between your thumb and index finger.
‒ Tenderness to the touch along the index finger side of your thumb.
‒ Blue or black discoloration of the skin over the thumb.
‒ Thumb pain that worsens with movement in any or all directions.
‒ Pain in the wrist (which may be referred pain from your thumb).

● Grades of thumb sprains.
Thumb sprains are ranked by how much the ligament is pulled or torn away from the bone. [31]
‒ Grade 1: Ligaments are stretched, but not torn. This is a mild injury. It can improve with some light stretching.
‒ Grade 2: Ligaments are partially torn (less than 3mm) [5]. This injury may require wearing a splint or a cast for 5 to 6 weeks.
‒ Grade 3: Ligaments are completely torn or more than 3mm[5]. This is a severe injury that usually requires surgery.
‒ Grade 4: Failed immobilization and required surgery as did all of those with a Stener lesion[5].






Haley-resized.jpg

Figure 4. Presentation of an ulnar collateral ligament injury with an avulsion fracture. Photo courtesy H. Stevenson.

Differential Diagnosis


The injury can involve other structures such as the adductor aponeurosis, the accessory collateral ligament, bony structures, tendons and neurological tissues.[1] The injuries all present with pincer grasp weakness. However they may be differentiated by the location of tenderness.
For al thumb injuries, radiographs should be obtained of the patient suspected to have a skier’s thumb. It’s important to remember that a skier’s thumb may or may not be visible on X-ray and the most common radiographic finding is an avulsion fracture of the proximal thumb phalanx at the site of UCL attachment. MRI can be usefull because it has the highest spicificity and sensivisity.[12]


  •  Skier’s thumb (UCL tear):

is characterized by point tenderness and instability at the thumb MCP joint, while

  •  Stener lesion:

is a particular type of UCL injury with palmar subluxation of the base of the proximal phalanx.

  •  Bennett or Rolando fracture:

Is an intra-acticular fracture luxation at the base of MC I in the CMC joint.[8]

  •  Avulsion fracture:

An avulsion fracture is an injury to the bone in a location where a tendon or ligament attaches to the bone. When an avulsion fracture occurs, the tendon or ligament pulls off a piece of the bone. [37] In children, who still have an immature skeleton, hyperabduction trauma mostly leads to a Salter-Harris III avulsion of the UCL insertion and rarely to a true rupture of the UCL. [38]

  •  Wrist sprain:

When a wrist sprain injury occurs, the ligaments of the wrist are stretched beyond their normal limits. [35]
Wrist sprains are graded according to severity:
Grade 1 (mild)
Grade 2 (moderate)
Grade 3 (severe)
Grade 4 (surgery)

  •  Wrist fracture:

A broken wrist (wrist fracture) can involve the small bones in the wrist or the ends of the forearm bones. [35]

  •  Dislocation of 1st MCP joint:

A dislocation is an injury to a joint — a place where two or more of your bones come together — in which the ends of your bones are forced from their normal positions. [33] [34]

  •  Chronic instability of the 1ste MCP joint:

Injuries to the two main supporting ligaments traversing the metacarpophalangeal (MCP) joint of the thumb can lead to symptomatic joint instability with subsequent pain, weakness and arthritis if ignored. These two ligaments are the ulnar and radial collateral ligaments. [36]

  •  Lunate dislocation:

A lunate dislocation is an injury to one of the small bones of the wrist. Lunate dislocations usually occur as part of a major injury such as a fall from a height or an automobile collision. When a lunate dislocation occurs, one of the small bones of the wrist, called the carpal bones, comes out of its normal position. [30]

  •  Neuropraxia of the radial nerve

arises secondary to traction, swelling or stiffness.

Diagnostic procedures

The type of lesion can be accurately derived by means of ultrasound ( approx. 90% accurate ) or MRI ( approx 100% accurate )
For non-displaced lesions, conservative treatment is possible and has yielded excellent results. However, misinterpretation and incorrect diagnosis can and have lead to unsatisfactory clinical results, leading many to favour surgery. [25]
Displaced lesions ( Stener lesions ) cannot be treated conservatively due to impaired healing and require surgical intervention in order to achieve full recovery.


In all instances, hand surgery is strongly recommended. Post-operatively a cast, brace, or splint to partially immobilise the hand is mandatory due to the likelihood of long-term complications if left mobile and to avoid stiffness that may result from complete immobilisation. [25]

X-rays
Anteroposterior and lateral X-ray films of the thumb are taken to rule out any associated bony injuries. Associated bony avulsion fractures are seen in 20%–30% of UCL ruptures. The position of an avulsed bony fragment usually indicates the position of the distal end of the UCL.[23] Indications for surgical treatment based on imaging include avulsion fractures with displacement of greater than 5 mm or any fracture involving 25% or more of the MCP joint surface . Stress X-ray films of the thumb MCP joint have also been used for diagnosis.[24] Local anaesthetic infiltration increases the accuracy of assessment of ulnar collateral ligament injuries RCT.

Ultrasound
Ultrasound (US) is an excellent and cost-effective modality for diagnosing UCL tears because it allows direct visualization of the entire UCL and surrounding structures. It locates the torn end of the UCL in almost 90% of cases. [25][28]The diagnosis should be done by US before conservative therapy is performed with a glove spica cast.[25] There are some limitations when applying, for example the ultrasound cannot be performed later than 1 week after the initial trauma because shrinking of the torn ligament and scar tissue can be confounding when making a diagnosis. [12] The sensitivity of US was 95.4% with a specificity of 80% for detection of Stener lesions. US, with the use of this specific dynamic maneuver is a reliable and reproducible tool for detecting Stener lesions.

MRI
MRI can be seen as a gold standard with a sensitivity of 96%-100% and specificity of 95-100%. An alternative can be an ultrasound of the thumb. [12] It is considered by some as the best modality for evaluating UCL injuries. Like US, MRI allows direct visualization of the UCL and surrounding structures and is safe and non-invasive; however, it is more costly and less readily available. [26]

Arthrography
Arthrography involves distension of the MCP joint by injecting contrast material and then visualizing the joint by X-ray or MRI (MR-arthrography). UCL injuries are diagnosed by direct visualization of any focal defect or by extravasation of contrast from the joint, suggesting rents in the ligaments. [8] Another indirect finding on arthrography suggestive of UCL tear is demonstration of the heads of the adductor pollicis muscle. [27] The various modalities used for diagnosis of UCL injury are presented in Table 2. [8]
Clinical and anatomical findings and the understanding of the injury mechanism show that stability testing (performed with the joint in full flexion) and additional standard radiographs remain the keystones in decision making in all MCPJ sprains
● Complications.
If the UCL is ruptured there is a possibility that the distal end may become interposed by the adductor aponeurosis, which is referred to as a Stener lesion (Figure 5). A Stener lesion is difficult to diagnose but leads to poor healing and usually indicates operative management. If left untreated, a torn UCL can lead to joint instability and a weak pinch grip.[6]
Figure 5 Stener lesion.[6]


Image:Stener_lesion.gif

Figure 5. Stener lesion.[3]

Outcome measures

Outcome Measures 

There are many ways to manage both acute and chronic thumb UCL deficiency
and controversy persists as to the best treatment options. This systematic review
(http://www.medscape.com/viewarticle/807179_1) has demonstrated excellent
clinical outcomes (pain, strength, motion, and stability) after surgical treatment
(repair and autograft reconstruction) of both acute and chronic UCL injury,
without any significant difference between repair and reconstruction for acute and
chronic injury. Non-operative treatment of acute UCL injury (with or without a
Stener lesion) frequently fails. This leads to chronic pain, instability, weakness
and eventually prompting surgical intervention. Thus, a patient with delayed
presentation of UCL injury can still achieve predictably successful outcomes,
equivalent to acute repair, with autograft UCL reconstruction. No significant
difference in the outcome was demonstrated between different types of autograft
used for UCL reconstruction. Complications, failures and reoperations are rare
after surgical treatment of UCL injury. [21]

● Follow up.
The orthopedic surgeon will see the patient after surgical repair or after a period of
immobilization in a cast. The patient's thumb will be reexamined. The doctor will
decide if the patient need to continue to immobilize the thumb or if physical
therapy is needed to regain movement. The remainder of the rehabilitation and the
management of any chronic problems that may arise from the injury will be
addressed by your orthopedic or hand surgeon. [29]

Examination

Begin looking for deformities with observation of the hand at rest and in flexion. Then
test the sensation in the hand followed by active range of motion (AROM). AROM
should be followed by passive range of motion (PROM) and resisted movement to
assess tendon integrity, if possible. [2]
Clinical examination may occasionally reveal a tender swelling and a hematoma at the
ulnar side of the base of the thumb. [38] Sometimes a mass can be felt in that area,
which suggests a Stener lesion; however, it is not pathognomonic.
If there is any concern about the possibility of fractures to the first metacarpal or
proximal phalanx of the thumb, plain radiographs are indicated prior to stress testing
of the UCL. If there is no associated fracture of the shaft, the thumb MCP joint
stability is tested by executing the following stress tests chronologically:


1) Testing of the UCL with MCP in extension (Figure…)
- Extend the MCP joint
- Stabilise the thumb metacarpal proximal to the joint to stop rotation and
radially angulating the thumb
- Apply a valgus stress by which the proper ulnar collateral ligament is
brought under tension
- Meaning: to assess the integrity of the volar plate and the accessory
collateral ligament


2) Testing of the UCL with MCP in flexion (Figure…)
- Bring MCP joint in flexion of at least 25°.
- Stabilise the thumb metacarpal proximal to the joint to stop rotation and
radially angulating the thumb
- Apply a valgus stress by which the proper ulnar collateral ligament is
brought under tension
- Meaning: Testing the stability of the thumb MCP joint when the volar plate
is relaxed and the UCL is taut. When positive, it means the accessory ulnar
collateral ligament is also torn. [13]
These tests for accessing the laxity of the MCP joint, and thus the rupture of the
proper collateral ligament, are referred to as the Valgus Stress to UCL tests.
It is worth noting that it is impossible for this test to, when correctly executed,
accidently cause a Stener lesion if one is not already present. A valgus stress test can
only cause this when all stabilizing ligaments of the thumb have been severed, which
does not occur under natural circumstances. ( cadaver study stener lesion clinical test 39 )
If a Stener lesion is already present however, then applying a valgus stress test can
cause possible avulsed bone fragments to displace, further impending healing.
Therefore this test should not be executed if an RX has yet to be taken. [25]

When the accessory UCL (or ACL) is still intact, a Stener lesion is less likely. It is
important to note that pain when examining can cause apprehension with subsequent
tensing of surrounding muscles and can lead to a false negative. Therefor the
investigation under local anesthesia can be useful. A study by Cooper et al. [Local
anaesthetic infiltration increases the accuracy of assessment of ulnar collateral igament injuries] described how Oberst
anesthesia (in which 1–2 ml of lidocaine is injected in the MCP joint) increases the
clinical accuracy from 28% to 98% after an average of one week after the initial
trauma [2, 38]
Inter-individual differences in normal range of motion of the MCP joint makes it
difficult to say when a true laxity of the joint is seen. In most of the literature the
following standard has been used for laxity of the MCP joint:
- lateral deviation more than 35° during valgus stress
OR
- more than a 15° difference compared to the uninjured/contralateral side
OR
The absence of a firm endpoint during testing is a more reliable criterion when
clinically diagnosing a complete rupture of the UCL[13],[38]

Image:Valgus_stress.gif

Figure 6. Valgus stress to UCL - compare stability in injured thumb to uninjured thumb.[3]

Medical management

A UCL injury may be managed conservatively or surgically depending on various factors that primarily include: timing of presentation (acute or chronic); grade (severity of injury); displacement (Stener lesion); location of tear (mid-substance or peripheral); associated or concomitant surrounding tissue injury (bone, volar plate, etc.); and patient related factors (occupational demands, etc.)[8]
Indication for operative treatment of ulnar collateral ligament injuries of the thumb should be made on the basis of whether the ligament is displaced proximal to the adductor aponeurosis or not (Stener Leasion). Thus the diagnostic efforts should concentrate on ligament displacement rather than whether the ligament is ruptured totally or partially. [24]
An injury that is not managed properly can lead to chronic instability of the MCPJ.[1]

Operative management depends on a timely diagnosis of the injury; chronic lesions become more difficult to repair with increased time since injury since remaining tissue becomes attenuated not robust enough to provide adequate support to the joint.[7] There are multiple methods of repair, which can be categorized into dynamic or static.[2][7]


● Dynamic:
- Extensor indicis proprius tendon transfer
- Extensor pollicis brevis tendon transfer
- Adductor pollicis brevis tendon transfer
Dynamic procedures are more likely to loosen with time while usually preserving a good mobility of the MCP joint. [15]


● Static:
- Figure-of-eight grafting
- Parallel configuration graft
- Triangular configuration with proximal apex graft
- Triangular configuration with distal apex graft
- Dually opposed biotenodesis fixation of tendon graft
- Tendon graft weaves
- Dually opposed suture anchor fixation
- Hybrid technique
- Free tendon graft: an insertion is made on the ulnar side of the thumb, exposing the ligament remnant. A tendon graft is used to connect the bones. The tendon graft replaces the ligament and is proximal bound to the ligament remnant and distal to the phalangeal bone. [14] (level of evidence: 2B)
There is a wide variety in static operations and there is still a lot of discussion which treatment is the best. Most treatments give positive results which lead to a lot of discussion.[15] [16]

Provided surgery has been performed timely ( quality of results drops when surgery is delayed, good results can still be achieved after 3–4 weeks. à
a period of usually 6 weeks of immobilization is applied, after which a new radiograph is made and physical therapy of the hand can be started.
When the pain has subsided and the range of motion has completely returned, the hand can be used again to full effect. Usually this takes about 3 months
Patients with worse outcomes are mostly patients with a delay in presentation. When repaired in a timely manner, complications are rare.

Different surgical techniques can be used. Which one applies depends on the anatomy of the lesion and can often only be decided upon during surgery. The UCL can be fixated with a suture anchor or with transosseous stitches. Small bone fragments can be removed; larger ones can be fixated with a Kirschner wire or a small screw. Results seem to be independent of the chosen technique, and successful recovery to the patient’s level before the initial trauma occurs in 90%-96% of all patients [8,21,22]. This means that the question remains whether the patients mentioned above (with persisting complaints after the first non-surgical and later surgical treatment) would have benefitted from initial surgical intervention

Not enough information is available on the chances for recurrence with this type of injury.
Also, no trials have even been set up to investigate whether a surgical intervention is really superior to a non-surgical treatment.[38]

Physical Therapy Management

The treatment of skier’s thumb is different for partial and a complete ruptures. Partial ruptures are treated conservatively. The MCP joint is immobilized, with the MCP fixed and the IP joint remaining free to prevent unnecessary stiffness. A navicular cast or brace is usually used. Swelling can be controlled with elevation while supine and the use of cold compresses as needed.[7, LOE:3B]
The primary goal of rehabilitation is enhancing the patients' function and reducing the time of functional recovery, the reported treatment presents potential advantages in the management of this frequent acute hand injury.


● Conservative treatment
Partial UCL injuries like ligament strains, partial tears, low-demand patients and poor-operative candidates, including patients with degenerative MCP joint disease are effectively treated conservatively.[7, LOE:3B]
Controversy also exists about treating a bony skier’s thumb without surgery. The literature however shows that if the MCP joint is stable during testing and there is no dislocation of the fragment, this injury can be treated conservatively without reason for concern.

  ❖ For patients with:
- less than 30 degrees of valgus laxity of extension of the MCPJ
- less than 15 degrees difference between sides and no signs of avulsion fracture on radiographs.[1, LOE:3B]


  ❖ Immobilisation:
from 10 days up to 6 weeks, depending on the degree of laxity during the initial examination. Authors of a recent review on skier’s thumb agreed on a 4-week period. [38, LOE:1A]

      ■ suggestions:

- A short-arm thumb spica cast
- Thermoplastic splint:allows for the patient to begin movement of the interphalangeal joint.[1, LOE:3B]
- A hand-based removable thumb spica orthosis. The MCP joint is immobilized, with the MCP fixed and the IP joint remaining free to prevent unnecessary stiffness.(Figure 7)[1, LOE:3B] [38, LOE:1A][39, LOE:2B]
Wearing a splint will avoid putting radial stress on the thumb and gives the ligament time to heal.[1: LOE:3B] The optimal positioning for the splint involves holding the MCPJ in slight flexion with a slight ulnar deviation; the interphalangeal joints should not be immobilized in the splint.[1: LOE:3B]


Figure 7. Thumb spica splint.[3]LOE: 5


  ❖ Exercise therapy:
After the period of immobilization is over, the therapy can be started. Most likely the patient will perform exercises that help strengthen and stretch the joint in order to regain full function in your thumb. (11) The patient should begin supervised hand therapy during the period of immobilization.[1] Gentle flexion and extension range of motion exercises can begin after about four weeks, with the patient continuing to wear the splint between therapy sessions. After 8 weeks progressive strengthening exercises may begin, but unrestricted activity is not allowed until after 12 weeks.[1] Gripping and pinching activities should not started until 10-12 weeks and should be advanced as tolerated; forceful gripping activities are typically not tolerated until about week 12.[7, LOE:3B]

● Treatment after surgery
The content of the physical therapy after surgery is the same as those of the conservative treatment, besides:
- Duration of Immobilisation: usually 6 weeks is applied
- Control radiograph after immobilisation

Following surgery a splint is usually worn for four to five weeks. Immediate postoperative motion of the operated joint produced faster and better functional results. Therefor the use of a functional splint is preferred, as well as the early progressive start with moving within the boundaries of pain. [39] Athletes whose injuries require surgery can usually return to play in about three to four months. [11] The study of Derkash, considering pain, stability, muscular force (tweezers grip) and functionality in ADL, shows that less than 5% of the patients experience a weakened tweezers grip and stiffness. Pain was absent or mild in 99% of the cases. 96% of the treated patients were satisfied with the results of the operation. When a secondary operation is required results were less successful. [40]
When the pain has subsided and the range of motion has completely returned, the hand can be completely used again. Usually this takes about 3 months.[38, LOE:1A]


  ❖ Exercises. [32, LOE:1A]
- Thumb active range of motion: With your palm flat on a table or other surface, move your thumb away from your palm as far you can. Hold this position for 5 seconds and bring it back to the starting position. Then rest your hand on the table in a handshake position. Move your thumb out to the side away from your palm as far as possible. Hold for 5 seconds. Return to the starting position. Next, bring your thumb across your palm toward your little finger. Hold this position for 5 seconds. Return to the starting position. Repeat this entire sequence 15 times. Do 2 sets of 15. [32,LOE:1A]
- Wrist range of motion
- Flexion: Gently bend your wrist forward. Hold for 5 seconds. Do 2 sets of 15. [32, LOE:1A]
- Extension: Gently bend your wrist backward. Hold this position 5 seconds. Do 2 sets of 15. [32, LOE:1A]
- Side to side: Gently move your wrist from side to side (a handshake motion). Hold for 5 seconds in each direction. Do 2 sets of 15. [32, LOE:1A]
- Thumb strengthening: Pick up small objects, such as paper clips, pencils, and coins, using your thumb and each of your other fingers, one at a time. Practice this exercise for about 5 minutes. [32, LOE:1A]
- Finger spring: Place a large rubber band around the outside of your thumb and fingers. Open your fingers to stretch the rubber band. Do 2 sets of 15. [32, LOE:1A]
- Grip strengthening: Squeeze a soft rubber ball and hold the squeeze for 5 seconds. Do 2 sets of 15. [32, LOE:1A]
- Wrist flexion: Hold a can or hammer handle in your hand with your palm facing up. Bend your wrist upward. Slowly lower the weight and return to the starting position. Do 2 sets of 15. Gradually increase the weight of the can or weight you are holding. [32, LOE:1A]
- Wrist extension: Hold a soup can or hammer handle in your hand with your palm facing down. Slowly bend your wrist up. Slowly lower the weight down into the starting position. Do 2 sets of 15. Gradually increase the weight of the object you are holding. [32, LOE:1A]

Key evidence

Recources

Links to other physiopedia’s: Bennett fracture, ultrasound, MRI, X-rays and Valgus Stress to UCL

Clinical bottom line

Skier’s thumb, also known as gamekeepers thumb, is an injury to the metacarpal phalangeal joint of the thumb. It can occur to the medial side of the thumb, but this is rare. The chance of an medial side injury is as small as 10-30%.
When there is abnormal movement like hyperabduction of the thumb or a sudden force on the thumb then the ligament can rupture (with or without an avulsion fracture). We diagnose an UCL rupture mostly with an ultrasound, which is the most reliable and not costly. We can also palpate an rupture by doing the stress test.
UCL rupture can be treated with an operation but this depends on different factors(see medical management). When an operation is needed, the treatment will likely be decided by the surgeon. This will also depend on some factors but most surgeons have a favourite treatment in the wide variety of operations.
Partial tears and strains are mostly not treated with an operation. It comes first with the immobilization of the MCP joint to give some rest and so that the body can recover. After that, the patients starts wearing a splint and gets six weeks of therapy sessions (this also includes for post-operative treatments). Where in the mobility and strength get back to the normal values compared with the contralateral thumb.



Recent Related Research (from Pubmed)

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Injuries in World Cup telemark skiing: a 5-year cohort study.

References

1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 Anderson D. Skier’s thumb. Aust Fam Physician. 2010;39(8):575-577.
LEVEL OF EVIDENCE: 3B
2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 Patel S, et al. Collateral ligament injuries of the metacarpophalangeal joint of the thumb: a treatment algorithm. Strat Trauma Limb Recon. 2010;5:1-10.
LEVEL OF EVIDENCE: 3B
3. ↑ 3.0 3.1 American Society for Surgery of the Hand. Thumb sprains. www.assh.org/Public/HandConditions/Pages/ThumbSprains.aspx (accessed 18 March 2011).
LEVEL OF EVIDENCE: 5
4. ↑ Zeigler T. Thumb sprain also known as “skier’s thumb” or “gamekeeper’s thumb”. www.sportsmd.com/Articles/tabid/1010/id/50/Default.aspx?n=thumb_sprain_also_known_as_skier%E2%80%99s_thumb_or_gamekeeper%E2%80%99s_thumb (accessed 13 March 2011).
LEVEL OF EVIDENCE: 5
5. Milner CS, et al., Gamekeeper’s thumb—a treatment – oriented magnetic resonance imaging classification. J Hand Surg. Am., 2015; 40(1): 90-5.
LEVEL OF EVIDENCE: 1A
6. ↑ 6.0 6.1 6.2 6.3 Leggit JC et al. Acute finger injuries: Part II. Fractures, dislocations, and thumb injuries. Am Fam Physician. 2006;73(5):827-834.
LEVEL OF EVIDENCE: 4
7. ↑ 7.0 7.1 7.2 7.3 7.4 Rettig A et al. Anatomic reconstruction of thumb metacarpophalangeal joint ulnar collateral ligament using an interference screw docking technique. Tech Hand Up Extrem Surg. 2009;13(1):7-10.
LEVEL OF EVIDENCE: 3B
8. Madan, S. S., Injury to Ulnar Collateral Ligament of Thumb. Orthopaedic Surgery. 2014;6:1–7.
LEVEL OF EVIDENCE: 2A
9. Pediatric Trauma Care II: A clinical reference for physicians and nurses caring for the acutely injured child‬. AHC Media. LLC. 2014;6:52-53‬.
LEVEL OF EVIDENCE: 5
10. Jonathan Cluett, Gamekeeper's Thumb. 2014
LEVEL OF EVIDENCE: 5
11. Clifford D. Stark, Living with Sports Injuries. Infobase Publishing. 2010‬;6:84- 86‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬
LEVEL OF EVIDENCE: 5
12. Mandhkani Mahajan. Rupture of the ulnar collateral ligament of the thumb. Mahajan and Rhemrev International Journal of Emergency Medicine. 2013;6:31.
LEVEL OF EVIDENCE: 1A
13. Chrysi Tsiour. Injury to the Ulnar Collateral Ligament of the Thumb. American Association for Hand Surgery;2008.
LEVEL OF EVIDENCE: 1A
14. G.I Mitsionis. treatment of chronic injuries of the ulnar collateral ligament of the thumb using a free tendon graft and bone suture anchors. The Journal of Hand Surgery:British & European volume. 2000; Vol 25:2:208–211.
LEVEL OF EVIDENCE: 2B
15. C. Fusetti. The ECRL bone-tendon ligamentoplasty for chronic ulnar instability of the metacarpophalangeal joint of the thumb. Hand Surgery Unit, Chirurgie de la Main. 2005; Vol 24:5:217–221.
LEVEL OF EVIDENCE: 1B
16. Başar H. Comparison of results after surgical repair of acute and chronic ulnar collateral ligament injury of the thumb. Chirurgie de la Main. 2014;vol 33:6:384–389.
LEVEL OF EVIDENCE: 2B
17. Palmer DH et al. Helicopter skiing wrist injuries. A case report of "bugaboo forearm".; Am J Sports Med. 1994 Jan-Feb;22(1):148-9.
LEVEL OF EVIDENCE: 1A
18. J. B. Engelhardt, Rupture of the ulnar collateral ligament of the metacarpophalangeal joint of the thumb.injury.1993;vol24:1:21-24.
LEVEL OF EVIDENCE: 2B
19. G.S.J. Chuter,Ulnar collateral ligament injuries of the thumb: 10 years of surgical experience. Injury. June 2009;vol40:6:652-656.
LEVEL OF EVIDENCE: 2B
20. J. A. Fairclough et al. Skier’s thumb-a method of prevention; Injury 1986; 17,203-204
Level of evidence: 1A
21. Samora J.B. Outcomes After Injury to the Thumb Ulnar Collateral Ligament,, Clin J Sport Med. 2013;23(4):247-254.
LEVEL OF EVIDENCE: 3A
22. Schroeder NS.Thumb ulnar collateral and radial collateral ligament injuries.
Clin Sports Med. 2015;34(1):117-26.
Level of evidence: 2C
23. Thirkannad S, et al. The “two fleck sign” for an occult Stener lesion. J Hand Surg Eur Vol, 2008; 33: 208–211.
LEVEL OF EVIDENCE: 3B
24. Abrahamsson SO, et al. Diagnosis of displaced ulnar collateral ligament of the metacarpophalangeal joint of the thumb. J Hand Surg Am. 1990; 15: 457–460.
LEVEL OF EVIDENCE: 2B
25. Hergan K, et al. Pitfalls in sonography of the Gamekeeper's thumb. Eur Radiol. 1997; 7: 65–69.
LEVEL OF EVIDENCE: 2B
26. Lohman M, et al. MR imaging in chronic rupture of the ulnar collateral ligament of the thumb. Acta Radiol. 2001; 42: 10–14.
LEVEL OF EVIDENCE: 3B
27. Ganel A, et al. “Gamekeeper's thumb”. Injuries of the ulnar collateral ligament of the metacarpophalangeal joint. Br J Sports Med. 1980; 14: 92–96.
LEVEL OF EVIDENCE: 4
28. G.S.J. Chuter. Ulnar collateral ligament injuries of the thumb: 10 years of surgical experience. Departments of A&E. 2009;Vol 40,Issue 6,:652–656
LEVEL OF EVIDENCE: 2B
29. Glickel SZ, et al. Dislocations and ligament injuries in the digits. Green DP, Hotchkiss RN, Pederson WC, eds. Green's Operative Hand Surgery. 4th ed. New York, NY: Churchill Livingstone. 1999; 772-807.
LEVEL OF EVIDENCE: 2C
30. Zemel NP. Metacarpophalangeal joint injuries in fingers. Hand Clin. 1992; 8(4):745-54.
LEVEL OF EVIDENCE: 2C
31. Sebastin S, et al. Overview of finger, hand and wrist fractures. http://www.uptodate.Foye PM et al, Skier's Thumb. Medscape. 2010
LEVEL OF EVIDENCE: 2C
32. Mayfield JK, et al. Carpal dislocations: pathomechanics and progressive perilunar instability. J Hand Surg Am. 1980;5 (3): 226-41. -Pubmed citation
LEVEL OF EVIDENCE: 3B
33. Michael A. et al, Evaluation and Treatment of Injuries of the Ulnar Collateral Ligament of the Thumb Metacarpophalangeal Joint, Bulletin of the NYU Hospital for Joint Diseases. 2009;67(1):68-74
LEVEL OF EVIDENCE: 1A
34. Hall ™, et al. Therapeutic Exercise Moving Toward Function. 3rd ed; Lippincott, Williams and Wilkins, 2010
LEVEL OF EVIDENCE: 2C
35. com/home. Accessed March 4, 2014.
LEVEL OF EVIDENCE: 2C
36. Shelain Patel, et al. Collateral ligament injuries of the metacarpophalangeal joint of the thumb: a treatment algorithm; Strategies Trauma Limb Reconstr. 2010; 5(1): 1–10.
LEVEL OF EVIDENCE: 2A
37. Laub Jr DR et al, Thumb Fractures and Dislocations, Medscape, Sep 2010
LEVEL OF EVIDENCE: 2C
38. Mandhkani M, et al. Rupture of the ulnar collateral ligament of the thumb – a review. Int J Emerg Med. 2013; 6: 31. doi: 10.1186/1865-1380-6-31PMCID: PMC3765347
LEVEL OF EVIDENCE: 1A
39. Rocchi L1, et al. A modified spica-splint in postoperative early-motion management of skier's thumb lesion: a randomized clinical trial.
LEVEL OF EVIDENCE: 2B
40. Derkash RS, et al. Acute surgical repair of the skier's thumb. Clin Orthop Relat Res 1987;(216):29-33.
LEVEL OF EVIDENCE: 2B
41. Fricker R1, et al.Skier's thumb. Treatment, prevention and recommendations.
LEVEL OF EVIDENCE:
42. Ritting et al., Ulnar Colletral Ligament Injury of the Thumb Metacarpophalangeal Joint. Sport Med; 2010; 20(2):106–112.
LEVEL OF EVIDENCE:
43. Ebrahim FS et al. US diagnosis of UCL tears of the thumb and Stener lesions: technique, pattern-based approach, and differential diagnosis. Radiographics. 2006; 26(4): 1007-20
LEVEL OF EVIDENCE: 1B