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Thumb Ulnar Collateral Ligament Sprain (Skier’s Thumb)

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Thumb Ulnar Collateral Ligament Sprain (Skier's Thumb)
Ian Shrier
Dan Somogyi
Basics
Description
  • Synonym(s): Gamekeeper thumb; Skier'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:
    • Proximal end of the ligament becomes trapped superficial to the adductor pollicis aponeurosis
    • Incidence with a complete tear is reported between 64 and 87% (1)
Epidemiology
5–7% of all skiing injuries (2)
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 judo
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 in the diagnosis in these cases (3)[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° of metacarpal phalangeal joint flexion
    • There is significant side to side variability in UCL testing noninjured individuals (4)[B]:
      • Most important physical finding is lack of an endpoint, as this indicates complete ligament disruption.
Diagnostic Tests & Interpretation
Imaging
  • X-rays (posteroanterior/lateral) (3):
    • 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:
      • Unclear benefit of stress views
    • “Sag sign”: Volar subluxation of the proximal phalanx in relation to the metacarpal at the MCP joint may indicate UCL injury (3).
  • US:
    • Appears to have excellent accuracy, but is operator-dependent and requires experience (5,6):
      • Can be used to delineate partial from complete tears as well as identification of a Stener lesion
  • MRI (7,8):
    • Ordered to diagnose whether there is a complete tear or if there is a Stener lesion present:
      • 96% sensitivity and 95% specificity
    • Unclear whether arthrography provides additional benefit over simple MRI
Differential Diagnosis
  • Radial collateral ligament sprain
  • Metacarpal fracture
  • Proximal phalanx fracture
  • MCP sprain
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 (1,3)[C].
  • Protection with thumb spica splint or cast:
    • 2–4 wks of immobilization followed by 2–4 wks 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 magnetic resonance arthrography, good results can be expected with conservative treatment (ie, brace or cast) (1,3)[C].
    • If a Stener lesion is present, treatment should be surgical (1,3)[C].
    • If presence of a Stener lesion cannot be determined, management is controversial. As early surgical repair yields superior results compared with conservative treatment, surgery is preferred by many clinicians. However, most late repairs are successful; therefore, some clinicians will treat patients with a trial of conservative treatment and reserve surgery for patients who continue to have symptoms:
      • In the absence of a Stener lesion, there is no data evaluating outcomes of surgical vs conservative treatment of complete UCL injuries.
      • Surgical repairs within 3 wks have good results.

    • P.593


  • Avulsion fractures:
    • If avulsion-type fracture is present, treatment is a thumb spica cast for 4–6 wks (1,3)[C]:
      • Casting may be modified to a hand-based thumb spica (wrist out) as symptoms allow.
    • Studies on outcomes of UCL injuries with avulsion injuries are mixed, so these should be followed closely to ensure joint stability is regained (1,3).
Medication
  • Acetaminophen or NSAIDs are generally adequate for pain control.
  • Some cases may require short-term, short-acting narcotic use.
Additional Treatment
  • 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 (3)[C].
Surgery/Other Procedures
  • Acute operative treatment (1,3):
    • Primary repair is best performed in the 1st 3 wks (1)[C].
    • Several different surgical techniques are used and will depend on the exact nature of the injury and surgeon experience.
    • Cast or splint is used for 4–6 wks at which time range of motion and strengthening exercises are initiated.
    • Full unrestricted activity is generally allowed at 12 wks.
    • Protected activity may be allowed sooner depending on the surgical technique and surgeon preference.
  • Chronic operative treatment (1)[C]:
    • Generally requires surgical reconstruction of the UCL
    • Several different surgical techniques are used and will depend on the exact nature of the injury and surgeon experience.
    • Surgical repair becomes less reliable the more time that has passed from the injury.
Ongoing Care
  • Surgery is the preferred treatment for chronic instability, but is not as successful as when performed acutely (1)[C].
  • Conservative treatment is limited to bracing and strengthening exercises, but the majority of patients do not obtain satisfactory results.
Prognosis
  • Prognosis is excellent for partial UCL injuries (1,3)[C].
  • Prognosis is excellent for complete tears treated surgically (1,3)[B]:
    • In the absence of a Stener lesion, there is no data evaluating outcomes of surgical vs conservative treatment of complete UCL injuries.
Complications
  • Most common complication is instability, resulting in difficulty pinching the 2nd and 1st fingers together:
    • Long-term instability may increase the risk of osteoarthritis.
  • Other complications are related to surgical interventions (local numbness, infection).
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;67:68–74.
2. Deibert MC, Aronsson DD, Johnson RJ, et al. Skiing injuries in children, adolescents, and adults. J Bone Joint Surg Am. 1998;80A:25–32.
3. Johnson JW, Culp RW. Acute ulnar collateral ligament injury in the athlete. Hand Clin. 2009;25:437–442.
4. Malik AK, Morris T, Chou D, et al. Clinical testing of ulnar collateral ligament injuries of the thumb. J Hand Surg Eur Vol. 2009;34:363–366.
5. Ebrahim FS, De Maeseneer M, Jager T, et al. US diagnosis of UCL tears of the thumb and stener lesions: technique, pattern-based approach, and differential diagnosis. Radiographics. 2006;26:1007–1020.
6. Schnur DP, DeLone FX, McClellan RM, et al. Ultrasound: a powerful tool in the diagnosis of ulnar collateral ligament injuries of the thumb. Ann Plast Surg. 2002;49:19–22; discussion 22–23.
7. 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;7:73–84, viii.
8. Harper MT, Chandnani VP, Spaeth J, et al. Gamekeeper thumb: diagnosis of ulnar collateral ligament injury using magnetic resonance imaging, magnetic resonance arthrography and stress radiography. J Magn Reson Imaging. 1996;6:322–328.
Additional Reading
Ballas MT, Tytko J, Mannarino F. Commonly missed orthopedic problems. Am Fam Physician. 1998;57:267–274.
Husband JB, McPherson SA. Bony skier's thumb injuries. Clin Orthop Relat Res. 1996;327:79–84.
Richard OR. Gamekeeper's thumb: ulnar collateral ligament injury. Am Fam Physician. 1996;53:775–780.
Codes
ICD9
841.1 Ulnar collateral ligament sprain
Clinical Pearls
When one can return to play depends on severity and whether surgery is performed. Incomplete tears usually are treated with splinting for 4–8 wks, with range of motion exercises and strengthening beginning after 3 wks. A protective splint should be worn for sports until range of motion and strength have returned to normal, usually within 6–8 wks of injury. If surgery is performed, range of motion and strengthening exercises usually begin 6 wks after surgery. A protective splint usually is prescribed until range of motion and strength have returned to normal.


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