Skier's thumb
Thumb dislocation often results in instability and pain due to
rupture of the ulnar collateral ligament.
​
Ulnar collateral ligament
(UCL) injuries
The skier's thumb, Gamekeepers thumb and ulnar collateral ligament (UCL) injuries refer to similar pathology on the inside of the thumb.
It often occurs in skiing injuries because the thumb sticks forward from the pole-grip and contacts the snow at speed forcing it backward. It is also a common bike injury when the handlebar forces the thumb backward during a crash. A gamekeeper's thumb refers to a more chronic injury so called as it was common in Scottish gamekeepers who would use their thumb grip to break the neck of trapped rabbits.
The UCL is a stabiliser that stops the thumb dislocating sideways. It is important during normal pinch grip where the thumb acts as a post to grip against. Without a stable thumb, it is difficult to have the strength to grip, twisting and pinch. As well as instability, the injured thumb is often painful to use.
Types of injury
Injury to the thumb ulnar collateral ligament can be graded clinically. This can be performed by your surgeon if you are not too sore.
-
Sprain (painful but stable thumb)
-
Partial tear
-
complete tear (thumb is unstable)
Sometimes the ligament pulls off a small piece of bone. This is called an avulsion fracture and may heal well in some cases.
​
The 'Stener' lesion
When the thumb dislocates sideways a completely torn ligament can become stuck out over 'adductor aponeurosis' - this is like your shirt untucked from your pants when you stretch sideways. It cannot heal back down to bone this way unless it is physically tucked in back under the aponeurosis surgically.
​
Diagnosis of a Stener lesion is often performed by ultrasound; it cannot be seen on x-ray as it is not a bone injury. MRI is another way to see this, but is costly and may have longer waiting periods.
Should I have surgery?
Skiers thumb injuries often heal well with bracing, especially if only a partial tear of the UCL. Most ligament avulsion injuries take 12 weeks for strong healing. Bony injuries may heal in 6 weeks. Initially a wrist spanning brace may be given, followed by short hand-based splint after 6 weeks. The thumb is used constantly in daily activity and it is normal to experience discomfort up to 6 months after injury when gripping or twisting.
​
Surgery may be recommended for:
-
A complete tear, as may heal more strongly
-
A Stener lesion which needs to be surgically tucked in under the aponeurosis.
-
Failure of non-operative treatment may lead to chronic instability that may also required surgical reconstruction. This may be a more complex procedure requiring ligament graft.
​
If the thumb is unstable, or a complete tear is diagnosed you should discuss repair with a surgeon.
UCL stabilisation Surgery
Acute injuries may be surgically treated by direct repair, but sometimes reconstruction or augmentation is required. It is normally performed as a day surgery procedure.
​
A 3cm cut is made on the back of the thumb, the torn ligament is identified and the aponeurosis is split to repair the ligament back down to bone with a suture anchor.
A stronger repair may be augmented with synthetic suture tape to stabilise and protect the repair. This is often indicated in delayed injuries or repeat injuries. Sometimes a more complex procedure using tendon graft may be discussed as an option in difficult cases.
​
After surgery you will have a plaster backslab until your follow-up appointment with the hand therapist. They will remove stitches and provide you with a plastic splint that needs to be used for 6 weeks. You will start tendon glide exercises to prevent stiffness from aponeurosis scarring.
What are the risks of surgery?
This is important but relatively minor surgery. All surgery carries some general risks such as infection, allergic reactions to drugs etc. You will normally have a general anaesthetic and you should discuss this with your anaesthetic doctor prior to surgery.
​
The ligament repair is very small and fine so the repair must be protected until this heals. You must wear your splint for at least 6 weeks. It is very difficult to re-repair a re-torn ligament. Even if you do not re-tear the ligament you can stretch out the repair and the thumb may become less stable and more prone to re-injury.
Thumb stiffness is common due to immobilization and scarring to the aponeurosis. This is partly the nature of establishing important stability. Excessive stiffness may be avoided by early thumb joint exercises whilst wearing your splint. Like many ligament injuries the thumb grip may be uncomfortable for 6 months while it is healing.
​
There is a small chance of infection that is minimised by keeping the wound covered until stitches are removed. It is common to have a small area of numbness on the back of your thumb from nerve retraction during surgery- this normally recovers completely but may take a few months if it occurs. Sometimes patients develop reactive pain after hand surgery called CRPS, this nerve over-activity may occur in up to 1% of patients and is treated by medication and active therapy.
General advice regarding UCL surgery
The information here is general and varies depending on individual factors such as: time to treatment, strength of repair, occupation, age and sporting demands.
Will surgery benefit?
Complete tears, Stener lesions and unstable thumbs.
Immobilisation
Splint for 6 weeks
Driving
No driving for 2 weeks
Aim for surgery
Stabilize the thumb by repair or reconstruction of the UCL
Hospital stay
Day surgery only
Return to Work
-
1 handed duties at 2 weeks
-
Light duties at 6 weeks
-
Full duties at 12 weeks
Investigations
Clinical evaluation
X-ray + Ultrasound/MRI
Therapy
Hand therapy starting at 2 weeks
Return to Sport
-
Non-grip sports in brace
-
Heavy grip sport >6-12 weeks