Skier's thumb
Original Editors - Alicia Keefe and Brenna Rutledge
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Clinically Relevant Anatomy[edit | edit source]
Injury to the ulnar collateral ligament (UCL) at the metacarpophalangeal joint (MCPJ) of the thumb, also known as "skier's thumb," can involve other structures such as the adductor aponeurosis, the accessory collateral ligament, bony structures, tendons, and neurological tissues.[1]
There are two main supporting ligaments traversing the MCPJ of the thumb: the UCL and the radial collateral ligament (RCL). In general, UCL injuries account for 60-90% of ligamentous collateral injuries.[2] The UCL and RCL arise from the medial and lateral tubercles of the metacarpal condyles, respectfully, and insert into the base of the proximal phalanx on their respective sides (Figure 1).[2]
Figure 1. UCL and RCL of the thumb
The movement association with the thumb MCPJ include flexion, extension, rotation, abduction and adduction. The stability of the MCPJ arises from the bony structures of the thumb in the form of a wider, flatter metacarpal head, and soft tissue support. The surrounding soft tissue offers both dynamic and static stability. Dynamic stability is provided by the muscles of the thumb and static stability is supplied by the collateral ligaments.
Mechanism of Injury[edit | edit source]
An acute UCL injury occurs following a sudden, forced abduction movement at the MCP joint, whereas a forced adduction movement would cause injury to the RCL (Figure 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 or without extension (Figure 3). 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.
Characteristics/Clinical Presentation
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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. There may be tenderness with palpation, which localizes the injury to the ulnar aspect of the thumb where the UCL is lesioned. Patients typically complain of pain and weakness when using a pincer grip. Examples include holding a pen, grasping objects, unscrewing jar lids and turning a key or doorknob. In the instance of a Stener lesion, there may also be a palpable mass proximal to the adductor aponeurosis.
Differential Diagnosis[edit | edit source]
● RCL injury
● Avulsion fracture
● Wrist sprain
● Wrist fracture
● Dislocation of 1st MCP joint
● Chronic instability of the 1st MCP joint
● Lunate dislocation
Complications[edit | edit source]
An acute UCL injury occurs following a sudden, forced abduction movement at the MCP joint, whereas a forced adduction movement would cause injury to the RCL (Figure 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 or without extension (Figure 3). 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.
Examination[edit | edit source]
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. To test the UCL, apply a valgus stress to the thumb in 30 degrees of flexion (Figure 4). This test is referred to as the Valgus Stress Test. A rupture is likely if there is more than 30 degrees of laxity in the injured thumb or 15 degrees more laxity than on the noninjured side. To test the accessory UCL, apply a valgus stress to the thumb in full extension. A rupture is likely if there is more than 30 degrees of laxity in the injured thumb or 15 degrees more laxity than on the noninjured side. When the accessory UCL is still intact a Stener lesion is less likely. 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. 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.
Management/Intervention[edit | edit source]
A UCL injury may be managed conservatively or surgically depending on the severity of the injury, location of injury, and the patient’s goals. Chronic instability of the MCPJ can occur if the injury is not managed properly.
Physical Therapy Management
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Surgical Management
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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. There are multiple methods of repair, which can be categorized into dynamic or static.
Dynamic
● Extensor indicis proprius tendon transfer
● Extensor pollicis brevis tendon transfer
● Adductor pollicis brevis tendon transfer
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
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