Skier's Thumb Treatment & Management
- Author: Patrick M Foye, MD; Chief Editor: Sherwin SW Ho, MD more...
Patients with hand injuries are sometimes treated by a physical therapist, but these individuals are more frequently referred to an occupational therapist, particularly one with special training in hand therapy. During the acute injury phase, local modalities (eg, icing) may be helpful to decrease the pain of patients who have nonsurgical cases of UCL injuries.
When the UCL is completely ruptured, the adductor pollicis muscle can interpose between the fragments and hinder ligament healing (see the image below). This is referred to as a Stener lesion and results in permanent instability at the MCP joint if treated conservatively. Therefore, the presence of a Stener lesion, although difficult to identify clinically, is an indication for surgical repair (see the image or below).[1, 2, 3, 4, 17]
Stress testing, or clinical stability testing, is key to making the diagnosis of UCL injury; however, it is theoretically possible that this provocative maneuver could cause a Stener lesion.
A recent study investigated this with 10 Thiel fixated cadaveric hands. Clinical stability testing was performed in 30° of flexion and extension by 2 hand surgeons using maximum strength. When only the UCL was disrupted, only mild MCP joint instability was noted in flexion and the joint was stable in extension. After disruption of the UCL and the accessory collateral ligament (ACL), clinically significant instability was present in both flexion and extension; however, no Stener lesions were provoked. The only way the researchers were able to simulate a Stener lesion was by cutting the UCL, ACL, and the adhesive fibers connecting these ligaments to the joint capsule and adductor aponeurosis and then pulling directly on the cut fibers of the ligaments to displace them. When the ligaments were then returned back to normal position, repeat clinical stability testing did not reproduce the displacement.
Thus, since no clinical stability testing was able to produce a Stener lesion, it was concluded that only high-energy injuries that disrupted the UCL, ACL, and adductor aponeurosis would cause enough damage to cause a Stener lesion.
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
Grade 3 classification 
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.
A study by Milner et al that developed a 4-stage treatment-oriented classification of thumb UCL injury found that partial and minimally displaced UCL tears and tears displaced less than 3 mm typically healed by immobilization alone, whereas 90% of tears displaced more than 3 mm failed immobilization and required surgery as did all of those with a Stener lesion.
Direct reinsertion of the ligament onto the bone is the most secure method of fixation. In cases of fracture, a fragment accompanying a ruptured ligament can be excised if it constitutes less than 15% of the articular surface; otherwise, the fragment is also reinserted.
Cases of skier's thumb that meet the clinical criteria for surgical repair should be promptly sent for consultation with an orthopedic hand surgeon.
Grades 1 and 2 skier's thumbs and incomplete UCL ruptures can be treated conservatively (nonsurgically) with proper immobilization. The patient is placed in a forearm cast or splint with a thumb spica for 3-4 weeks (see Images 8-9 or below). The MCP 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.
During management of acute UCL injuries during competition (or for avid recreational skiers who are reluctant to forego their time on the slopes), a decision must be made as to whether the patient should continue to ski. No firmly established criteria exist for making this clinical decision, although the severity of the symptoms and the degree of joint laxity may be important considerations.
If there is a clinical decision to allow the patient to continue skiing after a recent injury to the UCL at the thumb, then protective splinting should be considered. Options include moldable fiberglass splints (which can be adapted to the ski pole) or athletic taping, either in wrist/thumb spica style, or the athletic trainer's figure-8 approach.
Before these interventions, the patient should have a clear understanding that there is a potential for worsening of their condition from further injury. Always include proper documentation of the patient's severity of symptoms and degree of joint laxity, as well as documentation of discussions with the patient regarding recommendations, interventions, prognosis, and activity.
After 3-4 weeks of immobilization for an incomplete UCL tear, reassess the thumb. If swelling and tenderness have diminished and the joint remains stable, the patient should continue to wear either a volar gutter or thumb spica splint for an additional 2-4 weeks, with removal of the splint several times daily for the performance of active-range-of-motion (AROM) exercises.
In surgically repaired skier's thumb injuries, a volar plaster splint is used to immobilize the thumb and wrist for 4-5 weeks following the operation. After this period, the splint should be worn for an additional week, but it can be removed several times a day for AROM exercises. The splint is then discontinued and the frequency of exercises is increased to an hourly basis.
In the reevaluation of an incomplete UCL tear, if the joint is significantly unstable, operative repair should be considered. In the weeks following the initial injury, a ligament that folds upon itself may develop scarring that precludes primary repair and may require reconstruction with the use of a tendon graft.
If necessary (such as after prolonged immobilization), the patient with skier's thumb can be instructed in the use of stretching exercises to assist with a full return of ROM. Also, strengthening exercises can be used to help the return of strength and functioning. The strengthening program should be well rounded but should also focus particularly on the strength components that are necessary to the athlete's particular sport (eg, grip strength in a hockey player or a lacrosse player, both sports that require a firm hold onto a stick).
Connolly JF. Dislocations of the thumb and fingers. Fractures and Dislocations - Closed Management. Philadelphia, Pa: WB Saunders Co; 1995. Vol 2: 1508-9.
Nicholas JA, Hershman EB. The Upper Extremity in Sports Medicine. St. Louis, Mo: Mosby; 1995. 557-64, 598-9, 873.
Snider RK. The Essentials of Musculoskeletal Care. Rosemont, Ill: American Academy of Orthopaedic Surgeons; 1997. 257-9.
Aluisio FV, Christensen CP, Urbaniak JR, et al, eds. Orthopaedics. 2nd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 1998. 205-6.
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. 2009 Mar. 13(1):7-10. [Medline].
Schroeder NS, Goldfarb CA. Thumb ulnar collateral and radial collateral ligament injuries. Clin Sports Med. 2015 Jan. 34 (1):117-26. [Medline].
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. [Medline].
Lee AT, Carlson MG. Thumb metacarpophalangeal joint collateral ligament injury management. Hand Clin. 2012 Aug. 28(3):361-70, ix-x. [Medline].
Koslowsky TC, Mader K, Gausepohl T, Heidemann J, Pennig D, Koebke J. Ultrasonographic stress test of the metacarpophalangeal joint of the thumb. Clin Orthop Relat Res. 2004 Oct. 115-9. [Medline].
Gurdezi S, Mok D. Sag sign'—A simple radiological sign for detecting injury to the thumb ulnar collateral ligament. Injury Extra. 2008.
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. 1999 Feb. 7(1):73-84, viii. [Medline].
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]. 2000 Feb. 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. 2002 Jul. 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. 1999 Sep. 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. 2008 Oct. 27(5):216-21. [Medline].
Adler T, Eisenbarth I, Hirschmann MT, Müller-Gerbl M, Fricker R. Can clinical examination cause a Stener lesion in patients with skier's thumb?. Clin Anat. Nov 2011. 10:[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. 2006 Sep. 73(5):818-21. [Medline].
Milner CS, Manon-Matos Y, Thirkannad SM. Gamekeeper's thumb--a treatment-oriented magnetic resonance imaging classification. J Hand Surg Am. 2015 Jan. 40 (1):90-5. [Medline].
Ritting AW, Baldwin PC, Rodner CM. Ulnar collateral ligament injury of the thumb metacarpophalangeal joint. Clin J Sport Med. Mar 2010. 20(2):106-12. [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. 2005 Apr. 17(2):132-6. [Medline].
Ahn JM, Sartoris DJ, Kang HS, et al. Gamekeeper thumb: comparison of MR arthrography with conventional arthrography and MR imaging in cadavers. Radiology. 1998 Mar. 206(3):737-44. [Medline].
Badia A. Arthroscopic reduction and internal fixation of bony gamekeeper's thumb. Orthopedics. 2006 Aug. 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. 2006 Sep. 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. 1993 Nov-Dec. 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. 1997 Mar-Apr. 15(2):193-6. [Medline].
O'Callaghan BI, Kohut G, Hoogewoud HM. Gamekeeper thumb: identification of the Stener lesion with US. Radiology. 1994 Aug. 192(2):477-80. [Medline].
Levin OS, Polunina AG, Demyanova MA, Isaev FV. Steroid myopathy in patients with chronic respiratory diseases. J Neurol Sci. 2014 Mar 15. 338(1-2):96-101. [Medline].