• Skip to main content
  • Skip to primary sidebar
  • Skip to footer
  • General Ortho
  • Procedures
  • Spine
  • Upper Limb
  • Lower Limb
  • Pain
  • Trauma
  • Tumors
  • Newsletter/Updates
  • About Us
  • Contact Us

Bone and Spine

Orthopedic health, conditions and treatment

Skier’s thumb – Causes, Symptoms and Teatment

By Dr Arun Pal Singh

In this article
    • Relevant Anatomy
    • Mechanism of Injury
    • Clinical Presentation
    • Classification of Skier’s Thumb
    • Differential Diagnoses
    • Lab Studies
    • Imaging
      • MRI
      • Ultrasound
    • Treatment of Skier’s Thumb
      • Nonoperative treatment
      • Surgical Treatment
      • Complications
    • References

Terms Skier’s thumb and Gamekeeper’s thumb are used for injuries to the ulnar collateral ligament of first metacarpal joint. While Gamekeeper’s thumb was the older term, Skier’s thumb is used more commonly.

Ulnar collateral ligament injury of the metacarpal joint was found earlier in people of Europe who wrung the neck of the game like chicken, rabbits, between index finger and thumb. It leads to the stretching of the ligament resulting in instability of the metacarpophalangeal joint. That is why the condition was called the gamekeeper’s thumb.

However, today the acute trauma is the most common cause of the injury instead of chronic and repetitive. Because skiing accidents are most commonly responsible, the injury is known nowadays as Skier’s thumb.

Occasionally, the injury avulses the bone at its insertion and leads to a gamekeeper’s fracture or Skier’s fracture.

The injury of occurs when a skier’s hand lands on a ski pole, causing a valgus force on the thumb.

Skier’s thumb is the most frequent injury of the upper limb in skiers. There is no known sex predilection

Relevant Anatomy

Ulnar collateral ligament originates from the ulnar aspect of the metacarpal head and inserted distally on the ulnar aspect of the base proximal phalanx.

The metacarpophalngeal joint is a diarthrodial joint and mainly carries flexion and extension movements.

The joint stability is provided by the static and dynamic stabilizers.

Extrinsic and intrinsic hand muscles are the dynamic stabilizers especially adductor mechanism that also inserts on to the extensor expansion[The  aponeurosis connecting the two is superficial to ulnar collateral ligament]

The static restraints include

  • Collateral ligament (mostly in flexion)
  • Accessory collateral ligament (mostly in extension)
  • Palmar plate (mostly in extension)
  • Dorsal capsule (limited, in flexion).

Normal variations of the joint movement at metacarpophlangeal joint are

  • 5-115 degrees in flexion-extension plane
  • Valgus laxity
    • 6 degrees in extension
    • 12-15 degrees in flexion

Mechanism of Injury

Acute abduction is the most common cause of ulnar collateral ligament.

A combination of torsion, abduction, and hyperextension at the first metacarpophalangeal joint may add to the injury.

The ligament may tear partially or completely

Most of the skier’s thumbs are injured due to fall on the ski poles which requires to strap and a sword-like grip formation. During fall this transmits the force to the thumb.

However, a simple fall on outstretched hand could lead to the injury too.

Other sports where the injury can occur  are ball sports like football, basketball or those which use sticks like basketball or football.

Most tears occur distally, near the insertion of the ligament into the proximal phalanx, but canoccur proximally near the origin on the metacarpal head.

Stener lesion refers to the interposition of the adductor aponeurosis between the ruptured ulnar collateral ligaments and its site of insertion at the base of the proximal phalanx. This causes the distal portion of the ligament to retract and point  superficially and proximally. It is felt as a lump.

It prevents the reduction of ulnar collateral ligament and the ligament cannot heal unless it is dealt surgically.

A rupture of the proper and accessory collateral ligaments must occur for this injury to happen.

Clinical Presentation

The patient complains of jamming of thumb and pain on the ulnar side of thumb following a fall, with ski pole or ball.

In case of chronic repeated injury, the patient reports of weakness in grasping or pinching ability. In case of complete tears, the patient is unable to perform these movements.

On examination, there could be swelling, discoloration and tenderness at the metacarpophalngeal joint. The severity of soft tissue changes often points to the severity of ligament damage.

Lump at the ulnar aspect of the metacarpophalangeal joint is indicative of a Stener lesion.

Pinch is markedly weakened.

Stress Testing

If the stress test is painful, examination can be performed under local anesthetic.

Stress testing is done by applying radially directed force on the metacarpophlangeal joint. The joint mobility in extension and 30 degrees flexion is compared with normal side.

A difference of more than 30 degrees compared to normal side is considered suggestive of rupture.

The test is positive in chronic instability also in spite minimal symptoms.

Classification of Skier’s Thumb

  • Grade 1 – Sprain without instability of the metacarpophalangeal joint.
  • Grade 2 – An incomplete tear with joint laxity.
  • Grade 3 – A complete tear with instability of the joint.

Differential Diagnoses

  • Metacarpophalangeal Joint Dislocation
  • Phalangeal Fractures

Lab Studies

No lab tests are required for the diagnosis, but routine work up is needed for surgical intervention.

Imaging

Anteroposterior, lateral, and oblique x-rays are done to exclude metacarpal fractures and skier’s fractures.

X-rays should be performed before anymanipulation like stress test is done.

skier's thumb or gamekeeper's thumb

Following suggest instability

  • Volar subluxation of 3 mm or more
  • Instability is also indicated in cases in which there is a radial deviation of >40 degrees in extension and >20 degrees in flexion.

Stress radiographs [valgus stress] in flexion and extension to determine the degree of instability. A joint opening that is greater than 30º while the MCP is fully flexed is consistent with a complete rupture of the ulnar collateral ligament.

Sag Sign

The sag sign is a volar subluxation of the proximal phalanx relative to the metacarpal at the metacarpophalangeal joint, evident on plain film. In indicates UCL insuffiency.

MRI

MRI is useful but not always necessary and is not cost-effective. It outlines the details of the injury better. 

Ultrasound

Ultrasonography can help differentiate between complete and incomplete tears.

Treatment of Skier’s Thumb

Grades 1 and 2 skier’s thumbs and incomplete UCL ruptures can be treated conservatively with proper immobilization. For small, nondisplaced avulsion fractures of the proximal phalanx that are found to be stable on stress testing, nonoperative treatment by a spica-type cast for 4 weeks can be completed with good results.

Nonoperative treatment can also be considered in patients that either refuse surgery or who are too infirm to tolerate an operative procedure

A 50% failure rate is reported with complete tears that are treated with bracing and early motion

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. 

Stener lesion results in permanent instability and is an indication for surgical repair.

Nonoperative treatment

This may be treated with immobilization in a thumb spica-type cast for 4 weeks. The metacarpophlangeal 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.

After 4 weeks, active-range-of-motion exercises,  stretching exercises and strengthening exercises can be used to help the return of strength and functioning.

Surgical Treatment

Complete ruptures of are repaired preferably in the first week or within three weeks as the repair of these lesions after 3 weeks has an increased incidence of weakness and pain on pinch grasp.

It could be just soft-tissue repair seems or aided by a small-gauge Kirschner wire to the metacarpophalangeal joint in position in case the soft tissue repair does not reduce the joint.

In the case of chronic instaity ligament reconstruction using a free tendon, usually the palmaris longus] is done.

If arthritis is present an arthrodesis of the metacarpophalangeal joint is considered.

After surgery,  a volar plaster splint is used to immobilize the thumb and wrist for 4-5 weeks following the operation.

At 4 weeks, the cast and any pins that were placed may be removed. The patient is then placed in a hand-based splint that immobilizes the MCP joint for 2 weeks. The splint is removed for therapy during this 2-week period, and active motion of the MCP joint is begun. Unrestricted usage is allowed at 3 months.

Complications

  • Radial sensory nerve injury
  • Postsurgical stiffness of the MCP and interphalangeal joints to improve with time.

References

  • Hung CY, Chang KV. Gamekeepers Thumb (Skiers, Ulnar Collateral Ligament Tear). 2018 Jan. 35(8):1321-5.
  • Gerber C, Senn E, Matter P. Skier’s thumb. Surgical treatment of recent injuries to the ulnar collateral ligament of the thumb’s metacarpophalangeal joint. Am J Sports Med. 1981 May-Jun. 9(3):171-7.
  • Heyman P. Injuries to the ulnar collateral ligament of the thumb metacarpophalangeal joint. J Am Acad Orthop Surg. 1997 Jul. 5(4):224-9.
  • Ritting AW, Baldwin PC, Rodner CM. Ulnar collateral ligament injury of the thumb metacarpophalangeal joint. Clin J Sport Med. 2010 Mar. 20(2):106-12.
Spread the Knowledge
  • 1
    Share
  •  
    1
    Share
  • 1
  •  
  •  
  •  
  •  

Filed Under: Hand and Upper Limb

About Dr Arun Pal Singh

Arun Pal Singh is an orthopedic and trauma surgeon, founder and chief editor of this website. He works in Kanwar Bone and Spine Clinic, Dasuya, Hoshiarpur, Punjab.

This website is an effort to educate and support people and medical personnel on orthopedic issues and musculoskeletal health.

You can follow him on Facebook, Linkedin and Twitter

Primary Sidebar

Ligaments of Lumbar spine

Segmental Instability of Lumbar Spine

Segmental instability of lumbar spine is one of the important causes of back pain. When the forces within physiological limits are applied to the spine, the movements occur within the specific physiological range, with small person-to-person variations. During spinal movements, the adjacent vertebrae maintain their relationship with each other due to the configuration, orientation and […]

muscle power grading

Muscle Power Grading

Muscle power grading is a frequent and important part of the neurological examination. The neurological examination consists of sensory and motor examination. Muscle power grading is part of motor system examination. Before muscle power grading is done, limbs or trunk are examined for the tone of the muscles, the bulk of the muscles. The limbs […]

Deformed pelvis oseomalcia

Osteomalacia Causes and Treatment

Osteomalacia is a  metabolic bone disease where defective mineralization results in bone soften due to a large amount of unmineralized osteoid. Osteomalacia (mollities ossium) is characterized by softening of the bones because of an accumulation of osteoid tissue. Osteoid is the bone matrix which is mineralized to form bone. Like rickets, osteomalacia also affects the […]

Subperiosteal bone resorption and tuft . Not the radial side concavity on distal phalanges showing subperiosteal resorption

Primary Hyperparathyroidism – Symptoms and Treatment

Primary hyperparathyroidism is state of high levels of parathyroid hormone due to unregulated overproduction of parathyroid hormone. It is also known by the names osteitis fibrosa cystica, von Recklinghausen’s disease and parathyrotoxicosis. Physiology of Parathyroid Hormone Parathyroid hormone plays an important role in the metabolism of calcium and hyperparathyroidism results in abnormal calcium homeostasis. Parathyroid […]

What is Pyomyositis

Pyomyositis or Muscle Abscess – Causes and Treatment

Pyomyositis is characterized by suppuration within skeletal muscles, manifesting as single or multiple abscesses. It is also known as tropical pyomyositis as it affected tropical people more commonly. Pyomyositis is common in tropical regions but is rare in temperate climates but showing rise and association with HIV infection or other immunosuppressive conditions, including diabetes mellitus, […]

neck pain causes

Neck Pain Causes and Treatment

Neck pain is almost as common a complaint as low back pain. Most cases of neck pain are due to minor muscular or ligament stresses. But there could be many other causes including the serious ones. Most of the neck pain cases are short-lasting and often can be managed at home. But a chronic pain […]

selective nerve root blocks

Selective Nerve Root Block – Indications and Applications

Selective nerve root block is similar in approach to facet joint injections but they address different pathologies. Both of these might be used in the same patient for the diagnostic purpose [to find if the pain is due to facet joint or nerve root] but as therapeutic measure, they address different issues. As in epidural […]

Browse Articles

Footer

Pages

  • About
    • Policies
    • Contact Us

Featured Article

Subaxial Cervical Spine Injury or Injury to C3-C7 vertebrae

The term lower cervical spine injury refers to the Injury of the subaxial cervical spine or that is below axis. It includes injuries to C3-C7 vertebra … [Read More...] about Subaxial Cervical Spine Injury or Injury to C3-C7 vertebrae

Search Articles

© Copyright: BoneAndSpine.com