What is Skier’s thumb?
Skier’s thumb is an acute condition in which the ligament joining the bones of thumb together are injured or torn. It is also known as sprained thumb or ulnar collateral ligament injury. Ulnar collateral ligament is located on the inside of thumb metacarpo-phalangeal joint and is essential for gripping and pinching. The damaged ligament could destabilise the joint leading to chronic instability. The injury to the ligament could happen repetitively in some sports leading to thinning and stretching of the ulnar collateral ligament before it’s completely torn, called gamekeeper’s thumb.
Skier’s thumb occurs due to a strong force that bends the thumb in the backward and outward direction. It stretches or tears the Ulnar collateral ligament. This happens due to a fall onto an outstretched hand especially when your thumb is gripping something at the same time, also happens while playing basketball, football, rugby, handball , cricket and baseball when the impact happens over the thumb. It is less common in automobile accidents. Skier’s thumb accounts for 8- 10 % of all skiing accidents and accounts for 86% of all injuries that occurs at the base of the thumb.
The injury is divided into following grades-
- Grade 1– the ligament is only stretched not torn, the injury is mild.
- Grade 2- the ligaments have partial tears (<3mm), the injury is moderate and involves some loss of function
- Grade 3-ligaments are completely torn (>3mm) or pulled off from the bone, the injury is severe. Sometimes, a small chip of bone gets removed with the ligament. This is termed as the avulsion fracture.
- Grade 4: Failed immobilization and required surgery as did all of those with a Stener’s lesion
What is Stener’s lesion?
This is a unique lesion that happens in Skier’s thumb, proper recognition of this injury and appropriate management is essential for optimal outcome. Ruptured ligaments usually heal well if they are in close contact, however in Skier’s thumb a situation exists where the torn ends could be separated by a muscle (adductor aponeurosis), preventing the natural healing of the ligament.
What are the symptoms of Skier’s thumb?
Pain, bruising, swelling and tenderness are common symptoms of the skier’s thumb. Pain is felt at the base of the thumb usually in the web space between index finger and thumb. It gets worse when you try to move it in any direction. You will be not able to grasp/pinch things in between your thumb and index finger. The thumb might feel wobbly and you may find it difficult to throw objects.
How is it diagnosed?
It is diagnosed after an assessment of your medical history, your symptoms and careful physical examination. Your surgeon will examine your thumb by moving it in all directions to know the stability of the thumb. If it is unstable, then it shows that the ligaments are completely torn. He may ask you for a X-ray as it can reveal any fracture or avulsion fracture in the thumb. He may also ask you for an ultrasound scan/MRI scan, as it helps to know the severity of the injury.
What happens if nothing is done?
If the Ulnar collateral ligament injury is left neglected or not treated properly, it will lead to chronic laxity, instability of the thumb, chronic pain, weakness and arthritis in the joint.
How is it treated?
The treatment of skier’s thumb depends on the severity of the injury and the attachment of the ligament to the bone. Grade 1 and grade 2 can be treated with conservative methods such as rest, ice packs, painkillers, anti-inflammatory medicines, splint and hand therapy.
Surgery is indicated in
- Acute injury with more than 3mm tears
- Complete tearing of the ligament
- Stener’s lesion
- Avulsion fracture
- Grade 3 & 4 injury
- Chronic injury
What are the non-operative treatments?
Grade 1 and Grade 2 skier’s thumb recover well with conservative treatment. It includes-
- Ice packs- you can apply ice packs at the base of the thumb for 20 minutes for three times a day. This will relieve your pain and will reduce the swelling too.
- Medicines- painkillers like codeine and paracetamol and anti-inflammatory drugs like ibuprofen and aspirin can be taken.
- Splint or cast – your surgeon can instruct you to wear a thumb spica cast/splint for 4 weeks.
- Hand therapy- it is started with gentle exercises for hand and thumb to regain strength and prevent stiffness due to immobilization. It is followed by strengthening and strenuous exercises. It should be done under the guidance of your surgeon and hand therapist based on the healing of ligament repair/reconstruction.
What does the operation involve?
The main aim of the surgery is to reconstruct or reconnect the ligament and restore the stability of the thumb.
- Surgery is usually performed as a day case under general anaesthetic, a cut is made in the skin at the affected site at the base of the thumb.
- The torn ligament is repaired in acute injuries with bone anchor and reconstructed with tendon graft and anchors in chronic injuries.
- If the ligament is avulsed with a piece of bone, depending on the size of the fractured bone fragments, they are reattached with pins or screws or bone anchors.
- The skin is stitched using absorbable sutures and a thumb spica splint or cast is applied. The surgical time is usually 1-2hrs and the majority of the patients go home the same day.
What happens after surgery?
- The local anaesthetic wears off 4-10 hrs after surgery; patients are encouraged to start taking painkillers before the pain starts i.e. on return home and for at least 48 hours from there. This way most of our patients report little or any pain.
- You have to keep your hand and wrist elevated (above the level of your heart) and keep moving your fingers, elbow and shoulder to maintain the flexibility and prevent stiffness of the joints.
- Your thumb is rested in a half cast for 10-14 days followed by splint for another 4 weeks to protect it from injury and allow proper healing. At 2 weeks, the wound is checked before application of splint by the hand therapist.
- You are reviewed again after the period of six weeks for removal of plaster and x-rays, in selected cases the plaster immobilisation could increase by another 4 weeks.
- The wound should be massaged using moisturising cream by the patient 3 times a day for 3 months once the wound is well healed. This reduces the scar sensitivity and scar-related complications (tenderness; helps scar to mature).
- You could start a gentle range of movement (ROM) exercises at 2 weeks and progress to more strenuous activities (swimming, driving, lightweights in gym etc) around 8-10 weeks. This will be guided by your surgeon and is based on radiographic (X-ray) and clinical assessment. The duration may increase or decrease based on the severity & chronicity of injury and method of fixation.
Are there any risks?
- Wound infections < 1%
- Injury to nerves, blood vessels and tendons
- Scar tenderness.
- Chronic pain
- Instability of the joint
- Neuropraxia of the radial nerve
- Failure of repair
- Chronic Regional Pain Syndrome “CRPS”.
- Any surgery can end up with rare complications and leave a patient worse than before surgery and is rare in this surgery
What are the results of the operation?
The results of the surgery are excellent with minimal serious complications (<1%). Most patients regain their normal range of motion and function of the thumb. The outcome is more predictable under the author’s experience.
When can I return to driving and work?
You can get back to work in 2-4 weeks if you have a desk job, however might take upto 3 months if your job involves physical work. Regarding return to contact sports, it usually takes 3 months and depends on the severity of injury. You should be able to resume driving in around 6 weeks. The above time line could vary based on the severity of injury and the treatment modality. Your physician will be able to advise you.
UCL injury and Stener’s lesion
- Sprained thumb with avulsed bone fragment
- ORIF with screws