Skier’s thumb/ Gamekeeper’s thumb.
Skier's thumb is an acute partial or complete rupture of the ulnar collateral ligament (UCL) of the thumb’s metacarpophalangeal joint (MCPJ) due to a hyperabduction trauma of the thumb.
There is an extreme valgus stress force applied to the thumb in abduction and extension.
It is called skier’s thumb but can also occur in football, handball, basketball, rugby, soccer, and even a handshake.
If the cause of the injury is associated with a chronic injury to the UCL in which became attenuated through repetitive stress, the term Gamekeeper’s thumb is used interchangeably.
Chronic injury may have a serious risk of disabling instability, pinch strength, and pain-free motion if not treated adequately.
when the adductor aponeurosis becomes interposed between the ruptured UCL and its site of insertion at the base of the proximal phalanx, it leads to a Stener lesion.
Can occur to anyone where there is an extreme valgus stress force applied to the thumb in abduction and extension
An acute UCL injury occurs following a sudden, hyperabduction and hyperextension forces at the MCP joint
With regards to skiing, the injury often occurs when a person lands on an outstretched hand while holding a ski pole, which causes forced abduction of the thumb with extension.
If the injury to the UCL is not treated properly this can lead to chronic laxity, joint instability, pain, weakness, and arthritis in the MCPJ.
Pain at the base of the thumb in the webspace between thumb and index finger.
Swelling of your thumb.
Tenderness to the touch along the index finger side of your thumb.
Blue or black discoloration of the skin over the thumb.
Thumb pain that worsens with movement in any or all directions.
Pain in the wrist (which may be referred pain from your thumb).
Complications of Skier’s thumb
If the UCL is ruptured there is a possibility that the distal end may become interposed by the adductor aponeurosis, which is referred to as a Stener lesion.
A Stener lesion is difficult to diagnose but leads to poor healing and usually indicates operative management. If left untreated, a torn UCL can lead to joint instability and a weak pinch grip.
Associated bony avulsion fractures are seen in 20%–30% of UCL ruptures. The position of an avulsed bony fragment usually indicates the position of the distal end of the UCL.
Treatment is affected by the following:
Timing of presentation (acute or chronic)
Grade (severity of injury)
Displacement (Stener lesion), and it is important for treatment to distinguish between displaced and non‐displaced UCL tears
Location of tear (mid-substance or peripheral) Associated or concomitant surrounding tissue injury (bone, volar plate, etc.) Patient-related factors (occupational demands, etc.)
Physical therapy management
The treatment of skier’s thumb is different for partial and complete ruptures.
The literature however shows that if the MCP joint is stable during testing and there is no dislocation of the fragment, this injury can be treated conservatively without reason for concern.
Partial ruptures are treated conservatively.
The MCP joint is immobilized, with the MCP fixed and the IP joint remaining free to prevent unnecessary stiffness.
A navicular cast or brace is usually used.
Swelling can be controlled with elevation while supine and the use of cold compresses as needed.
Partial UCL injuries like ligament strains, partial tears, low-demand patients, and poor-operative candidates, including patients with degenerative MCP joint disease are effectively treated conservatively.
The primary goal of rehabilitation is enhancing the patients' function and reducing the time of functional recovery.
Immobilization can be done by:
A short-arm thumb spica cast
Thermoplastic splint: allows for the patient to begin the movement of the interphalangeal joint.
A hand-based removable thumb spica orthosis. The MCP is fixed and the IP joints are free to prevent unnecessary stiffness
The patient should begin supervised hand therapy during the period of immobilization.
Gentle flexion and extension range of motion exercises can begin after about four weeks, with the patient continuing to wear the splint between therapy sessions.
After 8 weeks progressive strengthening exercises may begin, but unrestricted activity is not allowed until after 12 weeks.
Gripping and pinching activities should not start until 10-12 weeks and should be advanced as tolerated; forceful gripping activities are typically not tolerated until about week 12.
Surgical treatment is carried if the injury is grade 1 or 2 associated with Stener lesion, displaced avulsion fracture exists, grossly, acute unstable joint and cases of volar subluxation seen on radiographs. There are multiple methods of repair, which can be categorized into dynamic or static
Post surgical immobilization (functional splint) should be for 6 weeks
Mobility and strengthening exercises to be initiated for wrist and fingers
Athletes whose injuries require surgery can usually return to play in about three to four months
Grip strengthening exercises are crucial.
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