Introduction
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.
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.
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.1,2,3,4
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.5 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 (see Images 1-2 or below).1,2,3,4
Anteroposterior radiograph displaying a gamekeeper's fracture.
Lateral radiograph displaying a gamekeeper's fracture.
A large number of skiing injuries are attributed to ski poles, in which 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 [FOOSH injury]), 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), in which the sporting equipment can forcefully abduct the thumb during sport activity.
Clinical
History
- Patients with skier's thumb 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 of a skier's thumb
- 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 (see Image 3 or below).
Radiograph displaying a stress test of a torn ulnar collateral ligament.
- 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) (see Images 4-5 or below).
Stress testing of the metacarpophalangeal joint of the thumb in flexion.
Stress testing of the metacarpophalangeal joint of the thumb in extension.
- 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.6
- 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 (see Image 3 or below).
Causes
Traumatic injuries in cases of skier's thumb 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.
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 |
| Next Page » |
References
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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].
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].
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].
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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].
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].
Hergan K, Mittler C, Oser W. Pitfalls in sonography of the Gamekeeper's thumb. Eur Radiol. 1997;7(1):65-9. [Medline].
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].
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].
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].
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].
Badia A. Arthroscopic reduction and internal fixation of bony gamekeeper's thumb. Orthopedics. Aug 2006;29(8):675-8. [Medline].
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].
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].
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].
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Further Reading
Clinical Trials
- CMC (Carpometacarpal) OA (Osteoarthritis) Thumb Splint Study
- Prolotherapy Versus Steroids for Thumb Carpo-Metacarpal Joint Arthritis
- Return to Work After Hand Injury: the Role of Medical, Demographic and Psycho-Social Factors
National Guidelines Clearinghouse
- ACR Appropriateness Criteria® acute hand and wrist trauma. American College of Radiology - Medical Specialty Society. 1998 (revised 2005). 8 pages. [NGC Update Pending] NGC:004607
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
