eMedicine Specialties > Sports Medicine > Wrist and Hand

Skier's Thumb: Differential Diagnoses & Workup

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 Service (Tailbone Pain Service: www.TailboneDoctor.com), University of Medicine and Dentistry of New Jersey, New Jersey Medical School
Coauthor(s): Jonathan Raanan, MD, Assistant Professor of Physical Medicine and Rehabilitation, Department of Neurosurgery, Stony Brook University Medical Center; Todd P Stitik, MD, Professor, Department of Physical Medicine and Rehabilitation; Director, Outpatient Occupational/Musculoskeletal Medicine, UMDNJ-New Jersey School of Medicine; 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
Contributor Information and Disclosures

Updated: Mar 19, 2009

Differential Diagnoses

Gamekeeper's Thumb
Metacarpophalangeal Joint Dislocation
Phalangeal Fractures
Ulnar Collateral Ligament Injury

Workup

Laboratory 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 a UCL rupture of the thumb.7  If the diagnosis of skier's thumb is uncertain or if a concomitant fracture is suspected, additional diagnostic tools may be used, such as imaging studies.7
  • Plain radiographs of the thumb are first obtained to assess for possible thumb fracture or subluxation (see Images 1-2 or below). An avulsion fracture of the volar base of the proximal phalanx commonly accompanies UCL injuries.
    Anteroposterior radiograph displaying a gamekeepe...

    Anteroposterior radiograph displaying a gamekeeper's fracture.

    [ CLOSE WINDOW ]
    Anteroposterior radiograph displaying a gamekeepe...

    Anteroposterior radiograph displaying a gamekeeper's fracture.


    Lateral radiograph displaying a gamekeeper's frac...

    Lateral radiograph displaying a gamekeeper's fracture.

    [ CLOSE WINDOW ]
    Lateral radiograph displaying a gamekeeper's frac...

    Lateral radiograph displaying a gamekeeper's fracture.

  • 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 (see Image 3 or below). 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.
    Radiograph displaying a stress test of a torn uln...

    Radiograph displaying a stress test of a torn ulnar collateral ligament.

    [ CLOSE WINDOW ]
    Radiograph displaying a stress test of a torn uln...

    Radiograph displaying a stress test of a torn ulnar collateral ligament.

  • Magnetic resonance imaging (MRI) is useful for evaluating UCL injuries,8 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.8
  • Ultrasonography is less expensive than MRI. Shortly after presentation, ultrasonography yields higher positive predictive values than clinical examination for ruptures of the UCL.9   However, some discrepancies can be found in the medical literature as to whether ultrasonography is helpful7,10 or misleading11,12 in the diagnosis of a UCL injury.

More on Skier's Thumb

Overview: Skier's Thumb
Differential Diagnoses & Workup: Skier's Thumb
Treatment & Medication: Skier's Thumb
Follow-up: Skier's Thumb
Multimedia: Skier's Thumb
References
Further Reading
[ CLOSE WINDOW ]

References

  1. Connolly JF. Dislocations of the thumb and fingers. Fractures and Dislocations - Closed Management. Vol 2. Philadelphia, Pa: WB Saunders Co; 1995:1508-9.

  2. Nicholas JA, Hershman EB. The Upper Extremity in Sports Medicine. St. Louis, Mo: Mosby; 1995:557-64, 598-9, 873.

  3. Snider RK. The Essentials of Musculoskeletal Care. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 1997:257-9.

  4. Aluisio FV, Christensen CP, Urbaniak JR, et al, eds. Orthopaedics. 2nd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 1998:205-6.

  5. Rettig A, Rettig L, Welsch M. Anatomic reconstruction of thumb metacarpophalangeal joint ulnar collateral ligament using an interference screw docking technique. Tech Hand Up Extrem Surg. Mar 2009;13(1):7-10. [Medline].

  6. Cooper JG, Johnstone AJ, Hider P, Ardagh MW. Local anaesthetic infiltration increases the accuracy of assessment of ulnar collateral ligament injuries. Emerg Med Australas. Apr 2005;17(2):132-6. [Medline].

  7. Koslowsky TC, Mader K, Gausepohl T, et al. Ultrasonographic stress test of the metacarpophalangeal joint of the thumb. Clin Orthop Relat Res. Oct 2004;427:115-9. [Medline].

  8. Plancher KD, Ho CP, Cofield SS, Viola R, Hawkins RJ. Role of MR imaging in the management of "skier's thumb" injuries. Magn Reson Imaging Clin N Am. Feb 1999;7(1):73-84, viii. [Medline].

  9. Jones MH, England SJ, Muwanga CL, Hildreth T. The use of ultrasound in the diagnosis of injuries of the ulnar collateral ligament of the thumb. J Hand Surg [Br]. Feb 2000;25(1):29-32. [Medline].

  10. Schnur DP, DeLone FX, McClellan RM, Bonavita J, Witham RS. Ultrasound: a powerful tool in the diagnosis of ulnar collateral ligament injuries of the thumb. Ann Plast Surg. Jul 2002;49(1):19-22; discussion 22-3. [Medline].

  11. Hergan K, Mittler C, Oser W. Pitfalls in sonography of the Gamekeeper's thumb. Eur Radiol. 1997;7(1):65-9. [Medline].

  12. Susic D, Hansen BR, Hansen TB. Ultrasonography may be misleading in the diagnosis of ruptured and dislocated ulnar collateral ligaments of the thumb. Scand J Plast Reconstr Surg Hand Surg. Sep 1999;33(3):319-20. [Medline].

  13. Gherissi A, Moussaoui A, Liverneaux P. [Is the diagnosis of Stener's lesion echograph-dependent? A series of 25 gamekeeper's thumb] [French]. Chir Main. Oct 2008;27(5):216-21. [Medline].

  14. Demirel M, Turhan E, Dereboy F, Akgun R, Ozturk A. Surgical treatment of skier's thumb injuries: case report and review of the literature. Mt Sinai J Med. Sep 2006;73(5):818-21. [Medline]. [Full Text].

  15. Ahn JM, Sartoris DJ, Kang HS, et al. Gamekeeper thumb: comparison of MR arthrography with conventional arthrography and MR imaging in cadavers. Radiology. Mar 1998;206(3):737-44. [Medline].

  16. Badia A. Arthroscopic reduction and internal fixation of bony gamekeeper's thumb. Orthopedics. Aug 2006;29(8):675-8. [Medline].

  17. Bekler H, Gokce A, Beyzadeoglu T. Avulsion fractures from the base of phalanges of the fingers. Tech Hand Up Extrem Surg. Sep 2006;10(3):157-61. [Medline].

  18. Hintermann B, Holzach PJ, Schütz M, Matter P. Skier's thumb--the significance of bony injuries. Am J Sports Med. Nov-Dec 1993;21(6):800-4. [Medline].

  19. Musharafieh RS, Bassim YR, Atiyeh BS. Ulnar collateral ligament rupture of the first metacarpophalangeal joint: a frequently missed injury in the emergency department. J Emerg Med. Mar-Apr 1997;15(2):193-6. [Medline].

  20. O'Callaghan BI, Kohut G, Hoogewoud HM. Gamekeeper thumb: identification of the Stener lesion with US. Radiology. Aug 1994;192(2):477-80. [Medline].

[ CLOSE WINDOW ]

Keywords

skier's thumb, gamekeeper's thumb, thumb pain, broken thumb, break dancer's thumb, injury to the ulnar collateral ligament of the first metacarpophalangeal joint, UCL injury

[ CLOSE WINDOW ]

Contributor Information and Disclosures

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 Service (Tailbone Pain Service: www.TailboneDoctor.com), University of Medicine and Dentistry of New Jersey, New Jersey Medical School
Patrick M Foye, MD, FAAPMR, FAAEM 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
Disclosure: Nothing to disclose.

Coauthor(s)

Jonathan Raanan, MD, Assistant Professor of Physical Medicine and Rehabilitation, Department of Neurosurgery, Stony Brook University Medical Center
Jonathan Raanan, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation and Physiatric Association of Spine, Sports and Occupational Rehabilitation
Disclosure: Nothing to disclose.

Todd P Stitik, MD, Professor, Department of Physical Medicine and Rehabilitation; Director, Outpatient Occupational/Musculoskeletal Medicine, UMDNJ-New Jersey School of Medicine
Todd P Stitik, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, Association of Academic Physiatrists, Phi Beta Kappa, and Physiatric Association of Spine, Sports and Occupational Rehabilitation
Disclosure: Nothing to disclose.

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
Scott F Nadler, DO is a member of the following medical societies: American College of Occupational and Environmental Medicine, American College of Sports Medicine, American Medical Association, Association of Academic Physiatrists, North American Spine Society, and Physiatric Association of Spine, Sports and Occupational Rehabilitation
Disclosure: Nothing to disclose.

Medical Editor

Anthony J Saglimbeni, MD, Staff Physician, Family Practice Residency, President, South Bay Sports and Preventive Medicine Associates; Private Practice; Team Internist, San Francisco Giants; Team Internist, West Valley College; Team Physician, Bellarmine College Prep; Team Physician, Presentation High School
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Henry T Goitz, MD, Fellowship Director, Sports Medicine, Department of Orthopedic Surgery, Henry Ford Hospital
Henry T Goitz, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons and American Orthopaedic Society for Sports Medicine
Disclosure: Nothing to disclose.

CME Editor

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
Jon B Whitehurst, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

Chief Editor

Sherwin SW Ho, MD, Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago
Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.