eMedicine Specialties > Sports Medicine > Wrist and Hand
Skier's Thumb: Treatment & Medication
Updated: Mar 19, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Acute Phase
Rehabilitation Program
Occupational Therapy
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.
Medical Issues/Complications
When the UCL is completely ruptured, the adductor pollicis muscle can interpose between the fragments and hinder ligament healing (see Image 6 or 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 Image 7 or below).1,2,3,4,13
Ruptured ulnar collateral ligament.
Completed repair using suture anchors for fixation.
Surgical Intervention
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.14
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.
Consultations
Cases of skier's thumb that meet the clinical criteria for surgical repair should be promptly sent for consultation with an orthopedic hand surgeon.
Other Treatment
Incomplete UCL rupture 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.
Anterior view of a hand in a thumb spica splint.
Lateral view of a hand in a thumb spica splint.
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.
Recovery Phase
Rehabilitation Program
Occupational Therapy
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.
Surgical Intervention
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.
Maintenance Phase
Rehabilitation Program
Occupational Therapy
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).
Medication
Medications are primarily used to decrease pain and inflammation in cases of skier's thumb. Thus, the most commonly used medications are oral nonsteroidal anti-inflammatory drugs (NSAIDs) in conjunction with the rest of the rehabilitation plan.
Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
Various oral NSAIDs can be used to decrease pain and inflammation for this musculoskeletal condition, and the drug of choice (DOC) is largely a matter of convenience (eg, what is the best dosing frequency to achieve adequate analgesic and anti-inflammatory effects?), the safety profile, and cost.
Ibuprofen (Motrin, Advil, Nuprin, Rufen)
A commonly used NSAID. DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis. Many doses are available without a prescription.
Adult
200-800 mg PO tid/qid
Pediatric
<6 months: Not established
6 months to 12 years: 4-10 mg/kg/dose PO tid/qid
>12 years: Administer as in adults.
May increase sodium and fluid retention and may raise BP with concurrent use of ACE-inhibitors and diuretics; may increase the risk of bleeding (eg, GI) with the concurrent use of alcohol, aspirin, corticosteroids, heparin, and warfarin
Documented hypersensitivity; peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in patients with CHF, hypertension, and decreased renal and hepatic function; caution in the presence of anticoagulation abnormalities or during anticoagulant therapy; caution in those taking systemic corticosteroids; to minimize side effects, avoid the administration of multiple NSAIDs concurrently
Ketoprofen (Orudis, Actron, Oruvail)
For the relief of mild to moderate pain and inflammation.
Small dosages are initially indicated for small and elderly patients and in those with renal or liver disease.
Doses over 75 mg do not increase therapeutic effects. Administer high doses with caution, and closely observe the patient for response.
Adult
25-50 mg PO q6-8h prn; not to exceed 300 mg/d
Pediatric
<3 months: Not established
3 months to 12 years: 0.1-1 mg/kg PO q6-8h
>12 years: Administer as in adults.
Coadministration with aspirin increases the risk of inducing serious NSAID-related side effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and β-blockers; may decrease the diuretic effects of furosemide and thiazides; may increase the risk of methotrexate toxicity; phenytoin levels may be increased with concurrent administration. Monitor prothrombin time closely (instruct patients to watch for signs of bleeding).
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in patients with CHF, hypertension, and decreased renal and hepatic function; caution in the presence of anticoagulation abnormalities or during anticoagulant therapy
Naproxen (Aleve, Naprelan, Anaprox, Naprosyn)
For the relief of mild to moderate pain; inhibits inflammatory reactions and pain by decreasing cyclooxygenase activity, which results in a decrease of prostaglandin synthesis.
Adult
500 mg PO followed by 250 mg q6-8h; not to exceed 1.25 g/d
Pediatric
<2 years: Not established
>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d
Coadministration with aspirin increases the risk of inducing serious NSAID-related side effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and β-blockers; may decrease the diuretic effects of furosemide and thiazides; may increase the risk of methotrexate toxicity; may increase phenytoin levels with concurrent administration. Monitor prothrombin time closely (instruct patients to watch for signs of bleeding).
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and levels usually return to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of the drug.
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 |
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References
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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. 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].
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].
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].
O'Callaghan BI, Kohut G, Hoogewoud HM. Gamekeeper thumb: identification of the Stener lesion with US. Radiology. Aug 1994;192(2):477-80. [Medline].
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
