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Skier's Thumb
Article Last Updated: Oct 8, 2007
AUTHOR AND EDITOR INFORMATION
Section 1 of 11  
Author: Patrick M Foye, MD, FAAPMR, FAAEM, Associate Professor of Physical Medicine and Rehabilitation, Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, Director of Coccyx Pain (Tailbone Pain, Coccydynia) Service, UMDNJ-New Jersey Medical School
Patrick M Foye is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists, and International Spine Intervention Society
Coauthor(s):
Jonathan Raanan, MD, Staff Physician, Department of Physical Medicine and Rehabilitation, University Hospital of Newark;
Todd P Stitik, MD, Professor, Department of Physical Medicine and Rehabilitation, Acting Director of Sports Medicine, UMDNJ-New Jersey School of Medicine; Lead Physician, Practice Medical Director of University Hospital PM & R Clinic;
Scott F Nadler, DO, Assistant Director of Occupational/Musculoskeletal Medicine, Assistant Professor of Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey, Director of Sports Medicine, University Hospital
Editors: Anthony J Saglimbeni, MD, Staff Physician, Family Practice Residency, Medical Director, Center for Sports Medicine, O'Connor Hospital; Private Practice; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Henry T Goitz, MD, Chief, Sports Medicine, Associate Professor, Department of Orthopaedic Surgery, Medical College of Ohio; Jon B Whitehurst, MD, Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner and Executive Board Member, Rockford Orthopedic Associates; Orthopedic Chairman, Rockford Memorial Hospital; Sherwin SW Ho, MD, Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago
Author and Editor Disclosure
Synonyms and related keywords:
gamekeeper's thumb, break dancer's thumb, injury to the ulnar collateral ligament of the first metacarpophalangeal joint, UCL injury
Background
Injuries to the ulnar collateral ligament (UCL) of the thumb were first recognized as an occupational condition in European gamekeepers. By repetitively wringing the necks of game (eg, chickens) between their thumb and index finger, these workers produced a chronic stretching of the UCL that resulted in instability at the first metacarpophalangeal (MCP) joint. The condition became known as gamekeeper's thumb. Today, the injury is primarily caused by acute (rather than chronic and repetitive) damage to the UCL, most often due to a skiing accident; hence, the condition is now commonly referred to as skier's thumb.
Frequency
United States
Skier's thumb represents 5-10% of all skiing injuries; this condition is the most frequent injury of the upper extremity that skiers experience.
Functional Anatomy
The MCP joint of the thumb is primarily stabilized by the UCL. The origin of this ligament is found on the ulnar aspect of the metacarpal head, whereas the insertion of the UCL is located distally on the proximal phalanx.
Sport-Specific Biomechanics
The most common cause of UCL injury is an acute abducting (radially directed) force upon the thumb. Damage may also result from a combination of torsion, abduction, and hyperextension at the first MCP joint. Depending on the degree of impact of these forces at the MCP joint, the UCL may either tear partially or completely. A large amount of skiing injuries are attributed to ski poles, where the strap or sword grip lies across the palm and transmits the damaging force to the thumb during a fall. Football players may develop UCL damage either traumatically (eg, while making a tackle, falling on an outstretched hand), or chronically (eg, linemen, who repetitively stress the thumb radially while blocking). The injury is also common among athletes who handle balls (eg, basketball, football) and among those who use sticks (eg, hockey, lacrosse), where the sporting equipment can forcefully abduct the thumb during sports activity.
History
- Patients often describe jamming their thumb, either during a fall or with an object such as a ski pole or ball.
- Pain is reported along the ulnar side of the MCP joint.
- In cases of UCL laxity, patients often report weakness in their grasping or pinching ability; patients with UCL tears may report inability to perform these movements.
Physical
- Inspection and palpation
- Examination of the injured thumb may reveal swelling at the MCP joint, as well as discoloration and tenderness to palpation along the ulnar aspect. Marked swelling and ecchymosis are suggestive of severe UCL damage.
- The location at which the patient has maximal tenderness indicates the site of the ligament injury. Most UCL tears occur distally, near the insertion of the ligament into the proximal phalanx, but proximal rupture also occurs (near the origin on the metacarpal head).
- Strength
- The patient's pinch may be markedly weakened, and the thumb may deviate radially.
- Stress testing
- In traumatic cases, to avoid inadvertent displacement of the involved bone, stress testing should not be performed until radiographs have ruled out the presence of an undisplaced fracture.
- To appreciate any instability of the MCP joint, a radially directed force is applied to the thumb whose mobility is compared with that of the uninjured hand. There are varying opinions regarding the proper thumb positioning during stress testing. Although the preferred technique is to examine the thumb in full extension, a complete evaluation of the UCL should also include assessment of the thumb in full flexion (when the ligament is maximally taut).
- Local anesthetic can be injected into the joint if provocative maneuvering proves to be too painful. If the stress-induced angulation of the injured thumb demonstrates an instability that differs by greater than 30° relative to the uninjured thumb, it can be assumed that the UCL is completely ruptured. In cases in which the UCL insufficiency is a result of chronic damage, patients may be minimally symptomatic but demonstrate UCL laxity during stress testing.
- UCL injuries of the thumb can be misdiagnosed or the severity underestimated in part because assessment of the injury is limited by patient discomfort. The infiltration of local anesthetic around the injury site can make the physical examination more tolerable for the patient and enable the physician to make a more accurate diagnosis. This simple technique may be a useful adjunct to the standard physical examination.1
Causes
Traumatic injuries occur more often and result more commonly in UCL ruptures. In addition, UCL injuries from chronic repetitive radial stresses typically lead to UCL laxity and thumb instability but without complete UCL rupture.
Gamekeeper's Thumb
Metacarpophalangeal Joint Dislocation
Phalangeal Fractures
Ulnar Collateral Ligament Injury
Lab Studies
- Laboratory studies are not indicated for the diagnosis of skier's thumb.
Imaging Studies
- Clinical examination of the thumb still remains the criterion standard in the diagnosis of UCL rupture of the thumb.2 If the diagnosis is uncertain or if a concomitant fracture is suspected, additional diagnostic tools may be used, such as imaging studies.2
- Plain radiographs of the thumb are first obtained to assess for possible thumb fracture or subluxation. An avulsion fracture of the volar base of the proximal phalanx commonly accompanies UCL injuries.
- Stress radiographs of the MCP joint are used to assess the severity of damage to the thumb and UCL. A joint opening that is greater that 30º while the MCP is fully flexed is consistent with complete rupture of the UCL; if the joint opening is less than 30° one can assume that part of the ligament remains intact. If questions arise regarding the degree of joint opening and the severity of damage, stress radiographs of the uninjured thumb can be obtained for comparison.
- Magnetic resonance imaging (MRI) is useful for evaluating UCL injuries,3 but it is expensive and not always necessary. A study by Plancher et al showed that MRI has a greater than 90% sensitivity and a greater than 90% specificity for identifying UCL tears.3
- Ultrasonography is less expensive than MRI. However, some discrepancies can be found in the medical literature as to whether ultrasonography is helpful2, 4 or misleading5, 6 in the diagnosis of UCL injury.
Acute Phase
Rehabilitation Program
Occupational Therapy
Patients with hand injuries are sometimes treated by a physical therapist, but they are more frequently referred to an occupational therapist, particularly one with special training in hand therapy. During the acute injury phase, local modalities (eg, icing) may be helpful to decrease the pain of patients who have nonsurgical cases of UCL injuries.
Medical Issues/Complications
When the UCL is completely ruptured, the adductor pollicis muscle can interpose between the fragments and hinder ligament healing. This is referred to as a Stener lesion and results in permanent instability at the MCP joint if treated conservatively. Therefore, the presence of a Stener lesion, although difficult to identify clinically, is an indication for surgical repair.
Surgical Intervention
Primary surgical repair is indicated for the following: - Complete rupture of the UCL as evidenced by joint instability
- UCL damage with any accompanying fracture that is displaced, rotated, or intra-articular
- Presence of a Stener lesion
To prevent chronic painful instability, weakness of pinch, and arthritis, surgical treatment is recommended for fractures with 2 mm or more of displacement, or significant articular involvement with incongruency or rotation.7
Direct reinsertion of the ligament onto the bone is the most secure method of fixation. In cases of fracture, a fragment accompanying a ruptured ligament can be excised if it constitutes less than 15% of the articular surface; otherwise, the fragment is also reinserted.
Consultations
Cases that meet the clinical criteria for surgical repair should be promptly sent for consultation with an orthopedic hand surgeon.
Other Treatment
Incomplete UCL rupture can be treated conservatively (nonsurgically) with proper immobilization. The patient is placed in a forearm cast or splint with a thumb spica for 3-4 weeks. The MCP joint is left in 20° of flexion with mild ulnar deviation (adduction) to reduce stress on the ligament, and the interphalangeal joint is also placed in slight flexion. During management of acute UCL injuries during competition (or for avid recreational skiers who are reluctant to forego their time on the slopes), a decision must be made as to whether the patient should continue to ski. No firmly established criteria exist for making this clinical decision, although the severity of the symptoms and the degree of joint laxity may be important considerations. If there is a clinical decision to allow the patient to continue skiing after a recent injury to the UCL at the thumb, then protective splinting should be considered. Options include moldable fiberglass splints (which can be adapted to the ski pole) or athletic taping, either in wrist/thumb spica style, or the athletic trainer's figure-8 approach. Before these interventions, the patient should have a clear understanding that there is a potential for worsening of their condition from further injury. Always include proper documentation of the patient's severity of symptoms and degree of joint laxity, as wellas documentation of discussions with the patient regarding recommendations, interventions, prognosis, and activity.
Recovery Phase
Rehabilitation Program
Occupational Therapy
After 3-4 weeks of immobilization for an incomplete UCL tear, reassess the thumb. If swelling and tenderness have diminished and the joint remains stable, the patient should continue to wear either a volar gutter or thumb spica splint for an additional 2-4 weeks, with removal of the splint several times daily for the performance of active-range-of-motion (AROM) exercises.
Surgical Intervention
In surgically repaired thumb injuries, a volar plaster splint is used to immobilize the thumb and wrist for 4-5 weeks following the operation. After this period, the splint should be worn for an additional week, but it can be removed several times a day for AROM exercises. The splint is then discontinued and the frequency of exercises is increased to an hourly basis. In the reevaluation of an incomplete UCL tear, if the joint is significantly unstable, operative repair should be considered. In the weeks following the initial injury, a ligament that folds upon itself may develop scarring that precludes primary repair and may require reconstruction with the use of a tendon graft.
Maintenance Phase
Rehabilitation Program
Occupational Therapy
If necessary (such as after prolonged immobilization), the patient can be instructed in the use of stretching exercises to assist with a full return of ROM. Also, strengthening exercises can be used to help the return of strength and functioning. The strengthening program should be well rounded but should also focus particularly on the strength components that are necessary to the athlete's particular sport (eg, grip strength in a hockey player or a lacrosse player, both sports which require a firm hold onto a stick).
For this musculoskeletal condition, medications are primarily used to decrease pain and inflammation. Thus, the most commonly used medications are oral nonsteroidal anti-inflammatory drugs (NSAIDs) in conjunction with the rest of the rehabilitation plan.
Drug Category: Nonsteroidal anti-inflammatory drugs (NSAIDs)
Various oral NSAIDs can be used to decrease pain and inflammation, and the drug of choice (DOC) is largely a matter of convenience (eg, what is the best dosing frequency to achieve adequate analgesic and anti-inflammatory effects?), the safety profile, and cost.
| Drug Name | Ibuprofen (Motrin, Advil, Nuprin, Rufen) |
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| Description | A commonly used NSAID. DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis. Many doses are available without a prescription. |
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| Adult Dose | 200-800 mg PO tid/qid |
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| Pediatric Dose | <6 months: Not established
6 months to 12 years: 4-10 mg/kg/dose PO tid/qid
>12 years: Administer as in adults |
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| Contraindications | Documented hypersensitivity; peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or high risk of bleeding |
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| Interactions | May increase sodium and fluid retention and may raise BP with concurrent use of ACE-inhibitors and diuretics; may increase risk of bleeding (eg, GI) with concurrent use of alcohol, aspirin, corticosteroids, heparin, and warfarin |
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| Pregnancy | B - Usually safe but benefits must outweigh the risks.
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| Precautions | Category D in third trimester of pregnancy due to the potential risk of affecting closure of the fetal ductus arteriosus; caution in patients with CHF, hypertension, and decreased renal and hepatic function; caution in the presence of anticoagulation abnormalities or during anticoagulant therapy; caution in those taking systemic corticosteroids. To minimize side effects, avoid administration of multiple NSAIDs concurrently. |
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| Drug Name | Ketoprofen (Orudis, Actron, Oruvail) |
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| Description | For relief of mild to moderate pain and inflammation.
Small dosages are initially indicated for small and elderly patients and in those with renal or liver disease.
Doses over 75 mg do not increase therapeutic effects. Administer high doses with caution, and closely observe the patient for response. |
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| Adult Dose | 25-50 mg PO q6-8h prn; not to exceed 300 mg/d |
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| Pediatric Dose | <3 months: Not established
3 months to 12 years: 0.1-1 mg/kg PO q6-8h
>12 years: Administer as in adults |
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| Contraindications | Documented hypersensitivity |
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| Interactions | Coadministration with aspirin increases risk of inducing serious NSAID-related side effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and β-blockers; may decrease diuretic effects of furosemide and thiazides; may increase risk of methotrexate toxicity; phenytoin levels may be increased with concurrent administration. Monitor prothrombin time closely (instruct patients to watch for signs of bleeding). |
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| Pregnancy | B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
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| Precautions | Category D in third trimester of pregnancy; caution in patients with CHF, hypertension, and decreased renal and hepatic function; caution in the presence of anticoagulation abnormalities or during anticoagulant therapy. |
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| Drug Name | Naproxen (Aleve, Naprelan, Anaprox, Naprosyn) |
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| Description | For relief of mild to moderate pain; inhibits inflammatory reactions and pain by decreasing cyclooxygenase activity, which results in a decrease of prostaglandin synthesis. |
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| Adult Dose | 500 mg PO followed by 250 mg q6-8h; not to exceed 1.25 g/d |
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| Pediatric Dose | <2 years: Not established
>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d |
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| Contraindications | Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency |
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| Interactions | Coadministration with aspirin increases the risk of inducing serious NSAID-related side effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and β-blockers; may decrease diuretic effects of furosemide and thiazides; may increase risk of methotrexate toxicity; may increase phenytoin levels with concurrent administration. Monitor prothrombin time closely (instruct patients to watch for signs of bleeding). |
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| Pregnancy | B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
|
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| Precautions | Category D in third trimester of pregnancy; acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and levels usually return to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug. |
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Return to Play
In addition to the 6-8 weeks of immobilization with casting or splinting, the patient should avoid activities that risk reinjury for approximately another 6 weeks. An orthosis can be fitted to protect the patient's thumb to prevent further delay in return to activity.
Complications
Osteoarthritis of the first MCP joint may occur.
Prevention
A small dorsal (or radial) gutter splint can be designed to fit within the glove of skiers and other athletes.
Prognosis
When properly treated, patients with a UCL injury have a good prognosis for returning to their premorbid level of functioning. A missed diagnosis that delays the repair of a complete UCL rupture leads to a less favorable prognosis.
Education
For excellent patient education resources, visit eMedicine's Hand, Wrist, Elbow, and Shoulder Center and Sports Injury Center. Also, see eMedicine's patient education article Skier's Thumb and Repetitive Motion Injuries.
Medical/Legal Pitfalls
- In traumatic cases of UCL injury of the thumb, to avoid inadvertent displacement of the involved bone, stress testing should not be performed until radiographs have ruled out an undisplaced fracture.
- A missed diagnosis that delays the repair of a complete UCL rupture can lead to a less favorable prognosis.
Greg Gazzillo, 4th year medical student, New Jersey Medical School–UMDNJ, Class of 2007, assisted with the 2006 revision of this manuscript. Debra Ibrahim, 4th year medical student, New York College of Osteopathic Medicine, Class of 2008, assisted with the 2007 revision of this manuscript.
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Skier's Thumb excerpt Article Last Updated: Oct 8, 2007
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