Skier's Thumb Treatment & Management

Updated: Sep 15, 2019
  • Author: Patrick M Foye, MD; Chief Editor: Sherwin SW Ho, MD  more...
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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 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, 20]

Ruptured ulnar collateral ligament. Ruptured ulnar collateral ligament.
Completed repair using suture anchors for fixation Completed repair using suture anchors for fixation.

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. [21] 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. [21]

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

  • Grade 3 classification [11]

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. [22]

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. [23]

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.

In addition to ligament reconstruction, thumb-MCP arthrodesis has been shown to produce good outcomes in pain scores and tip-pinch strength. Similarly, patients post-arthrodesis had similar disability scores as patients who underwent primary repair.  [24]

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

Grades 1 and 2 skier's thumbs and incomplete UCL ruptures can be treated conservatively (nonsurgically) with proper immobilization. [11] 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. Anterior view of a hand in a thumb spica splint.
Lateral 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.

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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.

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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).

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