Sprained Thumb (Thumb UCL Ligament Tear)
Sprained Thumb (Thumb UCL Ligament Tear) | Denver, Colorado
Whether you prefer to call it a "skier’s thumb” or a “gamekeeper’s thumb',” every winter I commonly see many injuries to the thumb ulnar collateral ligament (UCL).
How does a thumb UCL tear happen?
While it may sound benign from the name, this can be a very serious injury and often requires surgery. Thumb UCL injuries occur after a fall landing directly on the thumb, or any forced ‘abduction’ injury.
For instance, I see this in football quarterbacks who are hit in the hand as they throw the ball.
These impacts cause the ulnar collateral ligament of the thumb to tear when the thumb is forcefully pulled away from the palm (abducted). The likelihood of a full tear increases if the thumb begins in a position of abduction, such as holding a skier’s pole or football.
Skier’s Thumb Symptoms & Diagnosis
Figure 1 - A thumb UCL ligament tear disrupts the ability to use the thumb for pinching, a critical hand function in our daily lives.
Under normal conditions, the thumb UCL gives strength to your pinch. When torn, the thumb becomes unstable with any pinching. The thumb simply gives away with the force.
Notice the location of the thumb UCL ligament and the tear depicted in Figure 1. Now imagine pinching between the thumb and index finger. When the thumb UCL is torn, the thumb just gives away to the force of pinching. This is not compatible with all we need to do with our thumbs in a typical day.
I can typically detect this thumb instability with a basic examination of your hand. X-rays of your thumb are always important to determine whether you have any associated fracture of the thumb. Lastly, if there’s any question on examination about whether your thumb UCL is partially torn versus fully torn, I may order an ultrasound or MRI to confirm the diagnosis.
Skier’s Thumb Treatment
If you’ve had this injury, you understand how disabling, painful, and frustrating it feels. Fortunately, depending on the severity of your injury, there are reliable non-surgical and surgical treatments to get you back to being you.
If your ligament is only partially torn, cast immobilization is an option. This typically involves 4 weeks of wearing a cast, followed by a period of temporary bracing and rehab.
If the ligament is fully torn, the only reliable path to ligament healing is surgery. While there are many methods to surgically fix the thumb UCL, I will typically use a technique known as an InternalBrace (Arthrex - I have no affiliation). The extra strength of the InternalBrace allows you a much faster return to the use of your hand and eliminates the need for casting after surgery.
Additional Information
That does it for my quick overview of skier’s thumb injuries. If you have more specific questions about skier’s thumb, or you just want to learn more, read on below as I answer many of my patients’ most common thumb UCL questions.
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The Basics
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A skier’s thumb (sometimes known as a gamekeeper’s thumb or is a rupture of the thumb’s ulnar collateral ligament (UCL) at the metacarpophalangeal (MCP) joint.
See Figure 1 above for a visual depiction of this injury.
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This injury is caused by a forced ‘abduction’ of the thumb.
Translation: hold out your right hand in front of you as if you were ready to give a ‘high five.’ Now imagine any injury that pulls your thumb away from your palm (to the left if you’re looking at the back of your right hand). This is abduction.
This is why skiers are at such risk. The pole that is held while skiing naturally abducts the thumb. So the thumb is already in this position when the skier lands during a crash. The force of the fall will further abduct the thumb and can tear the thumb ulnar collateral ligament (UCL).
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While it is commonly seen in skiers, anybody is at risk for a skier’s thumb. These injuries can occur after something as simple as a fall on an outstretched hand or as high-energy as a motor vehicle accident.
In general, we tend to see these injuries more often in patients who participate in contact sports or high-impact hobbies.
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As with many traumatic injuries, prevention is difficult. Of course, you could avoid high-impact activities such as skiing or snowboarding.
Over the years, manufacturers have tried various modifications to ski pole designs, including removing the strap, with the intent of decreasing skier’s thumb injuries. Unfortunately, none of these have yet been shown to significantly decrease the rate of skier’s thumb.
Though somewhat less frequent, we also see this injury in snowboarders when they fall on an outstretched hand, particularly on slick turns.
Skier’s Thumb UCL Tear Symptoms & Diagnosis
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The symptoms of a skier’s thumb, sometimes referred to as a thumb sprain or gamekeeper’s thumb, include swelling, pain, bruising, or a sense of instability.
All of these symptoms are typically made worse when trying to pinch, grab, or twist with the thumb.
Because the thumb ulnar collateral ligament provides stability when we use our thumb to pinch, a tear of this ligament will lead to painful instability with use of the thumb.
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If you have fallen on your thumb, or otherwise significantly injured your thumb, you should see a hand surgeon right away.
Outcomes after repair of the thumb UCL ligament in a skier’s thumb injury are most successful when repaired within 3-4 weeks after the injury. Beyond that, the chances of a successful repair decrease over time.
Do not delay in seeking care if you have had a significant thumb injury.
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I can typically detect a skier’s thumb injury with a basic examination of your hand. There will be a feeling of instability in your thumb with gentle stretching of the ligament, particularly when compared to your uninjured side.
If there is any doubt as to the nature of your injury, whether it’s partial or complete, or if I detect additional abnormalities, I will typically order an ultrasound or MRI to confirm the diagnosis. This is critical given that different injury patterns (partial tear versus complete tear) result in different treatment needs.
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An MRI is not necessary in all cases. If you have an associated fracture with your UCL tear, or if you have obvious asymmetric instability of your thumb on my examination relative to the uninjured thumb, an MRI is unnecessary to confirm the diagnosis
Skier’s Thumb UCL Treatment
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This is where the details really matter.
Partial ruptures of the ligament that are seen and treated immediately can be successfully treated without surgery in a cast. Typically, you can expect about 4-6 weeks in a cast, followed by a transition period with a brace.
I restrict heavy thumb activity for up to 3 months. Even with perfect non-surgical treatment, most patients note an aching sensation in the thumb for 6-12 months in this situation.
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If you have sustained an injury to your thumb, there are several at-home treatments to start right away before you can get in to see a doctor. Let’s walk through how to treat your thumb (or any injury) with what is commonly known as R.I.C.E. therapy.
R - Rest. If your thumb hurts following an injury, try to stop using it as much as possible. Even better, obtain a standard velcro ’thumb spica’ brace from your local pharmacy or a friend. This will immobilize the joints of your thumb and allow your injury to rest. While this may not be enough to definitively treat your injury, this will help with the initial stages of pain and inflammation.
I - Ice. It can be very helpful to use ice on the injured thumb. Be sure you have a protective layer between the ice and your skin (eg, dish towel, clothing). Do not ice the area for more than 20 minutes at a time. I typically recommend icing in a “20 minutes on, 20 minutes off” pattern.
C - Compression. Of all the stages of R.I.C.E., be the most careful with compression. Some find that some gentle compression feels good after an injury for extra stabilization. In general, we would recommend accomplishing this by using an elastic wrap bandage (Brand example: ACE wrap). However, it is crucial that you don’t stretch the elastic wrap bandage while you wrap. This will provide too much compression, and if your thumb swells, you can develop a painful or even permanently damaging condition. If you are interested in using compression, be sure to gently apply the bandage and re-evaluate frequently to ensure it is not becoming too tight with your thumb swelling. Never apply compression before going to sleep for the night.
E - Elevation. This is the most important one. I wish this were first in the mnemonic, but then it would spell E-R-I-C. Anyways, elevate, elevate, elevate. The higher the better. When you can, keep the thumb above the level of the heart. When that’s not possible, keep your hand above your elbow. Gravity is your friend! The more you elevate your injured thumb, the less swelling you will experience. The less swelling you experience, the less pain you will have. This is particularly crucial in the first few days after an injury.
Skier’s Thumb UCL Surgery
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The surgery to repair a skier’s thumb involves re-attaching the ulnar collateral ligament to the bony surface from which it tore.
This ligament can actually tear off different anatomic areas, but it most commonly pulls off the bone ‘distally’ (at the end nearer to your fingertip rather than nearer to your wrist). In some cases, it will even pull off a small piece of bone that we term an ‘avulsion fracture.’
Regardless, in the majority of cases, we use a small device known as a suture anchor. This anchor is essentially a plastic screw through which sutures are threaded. This screw is placed into your bone, and the sutures are then tied through your ligament.
When the knot is secured, this ties the ligament back down to the bone where it can heal over the ensuing 1-2 months.
Depending on the severity of the surrounding damage, I will often secure the repair with a second suture anchor (InternalBrace) to protect the ligament from external stresses while it heals.
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Therapy after a skier’s thumb surgery is crucial. This is typically completed with a ‘certified hand therapist (CHT),’ most often by way of occupational therapy (rather than physical therapy).
Fortunately, we employ many CHTs in our practice, so you will have ready access to this service following surgery. This therapy is critical to regaining the appropriate flexibility and strength in your thumb after skier’s thumb surgery.
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Remember that ‘recovery’ is a subjective term. Below is the typical outline of healing following this surgery in which I use the InternalBrace method outlined above:
Surgery - 2 weeks: Wear a post-operative splint full-time, no thumb use or motion
Begin 2 weeks: Removable splint made by hand therapy, begin to work on gentle thumb range of motion exercises. No physical use of the thumb.
Begin 6 weeks: Initiate light pinching activities with thumb, continue to work on range of motion. Wean out of brace for light activities.
Begin 8 weeks: Progress strengthening of thumb and continue to use the brace less and less
3-4 months: Return to heavy activities and/or impact sports. Most patients feel 90% of their former selves by this point. Occasional aches and pains, or a bad day here or there are still expected.
9 months - 1 year: “Full” recovery, where you may have to stop and think to remember which thumb you had injured.
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Typically, in my practice, you will not need a cast after skier’s thumb surgery. Most patients wear the post-operative splint (put on in the operating room) for the first 2 weeks and then transition to a removable splint made by your hand therapist.
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All surgeries have risks, many of which are generic to surgery itself. I go over these in detail with you before surgery as part of the informed consent process. Examples include bleeding, infection, damage to surrounding nerves/vessels, anesthesia risks, or failure of the procedure.
There are a couple of risks specific to skier’s thumb ulnar collateral ligament repair that are worth highlighting.
The first is stiffness. All repaired thumbs will feel very stiff when beginning work with therapy. This is why therapy is so important.
However, some loss of range of motion in the thumb, compared to pre-injury, can be expected. The average motion at the thumb metacarpophalangeal joint (MCP joint) after surgery to repair the ulnar collateral ligament is 80-90% of the uninjured thumb.
This is well-tolerated due to the fact that we can easily move our thumb up and down through the other joints in the thumb. Patients who achieve this 80-90% of motion rarely notice any deficiencies, even in high-level athletics.
The most common risk of skier’s thumb repair surgery is what we call a ‘neuropraxia.’ This is when a nerve ‘goes to sleep’ after surgery.
There is a sensory nerve branch that crosses directly over where I work to repair the thumb UCL. In surgery, we have to carefully retract that nerve out of the way in order to repair the ligament. Sometimes, even just this light touch of retracting the nerve aside will cause the nerve to ‘panic’ and shut down for a period of time.
If this happens to you, you will notice an area of numbness or tingling over the back of your thumb towards your fingertip. This nerve is not involved in any of the movement, strength, or function of your thumb. The nerve will typically ‘wake up’ over a period of a few weeks to a few months after surgery.
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Surgical repair of a complete tear of the thumb UCL is crucial to restore basic functions to your thumb.
As described above, if your thumb UCL is completely torn, you will have an unstable thumb any time you pinch or grip. This is true even for the simplest functions of daily life such as turning a key, opening a jar, or lifting an object.
Following surgical repair, the vast majority of patients regain their pinch strength to within 5-10% of the uninjured side. This is a very thin margin that most people are unable to sense without directly measuring the difference. Even a return to high-level athletics is routine at about the 3-4 month mark after surgery.
Another key metric to a patient’s outcome is range of motion. For a full discussion of this, please see the above section on ‘risks’ of surgery for a thumb UCL repair.
