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Thumb Ulnar Collateral Ligament Sprain (Skier’s Thumb)



Ovid: 5-Minute Sports Medicine Consult, The


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
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.
Codes
ICD9
841.1 Ulnar collateral ligament sprain


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