As winter arrives and skiing enthusiasts eagerly take to the slopes, the risk of thumb injuries, notably Skier's Thumb, increases significantly. This specific injury comprises 5-10% of all skiing-related injuries and is notably the most common upper extremity injury among skiers. Skier's thumb describes an injury of the soft tissue that connects the bones of your thumb together. In medical terms, this soft tissue is called a ligament.
The hand consists of numerous bones, muscles, and ligaments that allow for the dexterity and movement of our hands. Veins, arteries, and nerves provide blood flow and sensation to the fingers and hands. Any one of these parts of the hand can become injured, and it’s important to address any injury as soon as possible.
Skier's thumb, also known as “gamekeeper’s thumb” involves an injury to the ligament on the inside of your thumb - the ulnar collateral ligament (UCL) of the metacarpophalangeal joint. This injury can involve a sprain - in which case the ligament stretches or partially tears - or a complete tear leading to significant pain, weakness and instability of the thumb.
Understanding the anatomy of the thumb is crucial to comprehending how certain injuries occur, especially those affecting the metacarpal phalangeal (MP) joint, the second joint of the thumb. A key player in the stability of this joint is the ulnar collateral ligament (UCL). This ligament acts as a primary stabilizer, originating at the distal portion of the thumb metacarpal bone on the ulnar or index side and inserting on the inside of the proximal phalanx bone, crossing over the MP joint. Its primary function is to provide stability against radially directed or valgus forces, such as those pushing the thumb from the index side.
Causes and Risk Factors
The term "Skier’s thumb" is often used to describe an acute injury to the UCL, setting it apart from "Gamekeeper’s thumb," which results from repetitive stress to the ligament. Despite the similarity in the tearing or rupture of the UCL, the mechanism of injury is what differentiates the two conditions.
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Skier’s thumb typically occurs when a skier falls on an open or abducted thumb or when a ski pole is forcibly removed from the hand, causing sudden trauma to the UCL of the thumb MP joint. A fall on the hand or sudden force to the thumb can overstretch the ulnar collateral ligament (UCL) located at the base of the thumb. Often called skier’s thumb or gamekeeper’s thumb, this injury most often occurs during falls while performing activities like skiing or bicycling. Any injury in which the thumb is abnormally bent backward or to the side can cause skier's thumb.
Skiing accidents are the most common cause of skier's thumb. A fall on an outstretched hand with a ski pole in the palm of your hand creates the force necessary to stress the thumb and stretch or tear the ligament. A simple fall on an outstretched hand with an empty palm usually does not create this same force. However, your thumb can also be injured if it jams into packed snow at high velocity. Another less common cause of this injury is an automobile crash when the driver has the thumb alone draped over the steering wheel.
The injury occurs most commonly from an acute traumatic event leading to hyperextension of the thumb. Trauma causing hyperextension of thumb is commonly related to falls, especially while holding something in the hand such as a ski pole. Chronic instability may arise from repetitive injuries.
Anyone can get a sprained thumb at any age, but people who ski or who play sports that involve a ball and using your hands, such as baseball, basketball, volleyball and football, are more likely to get a sprained thumb. People who are at a higher risk of falling are also more likely to get a sprained thumb. Thumb sprains are a fairly common injury.
Symptoms of Skier's Thumb
The spectrum of UCL injuries ranges from partial tearing of some fibers to a complete rupture of the entire ligament. Such injuries usually manifest as swelling and pain at the MP joint. These symptoms may occur minutes to hours after the fall that created the injury:
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- Pain at the base of the thumb in the web space between thumb and index finger
- Swelling of your thumb
- Inability to grasp or weakness of grasp between your thumb and index finger
- 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)
Symptoms of skier’s thumb include swelling, bruising, redness, and pain. You may notice these symptoms mostly in your thumb. However, they could spread to the rest of the hand, depending on the severity of the injury. It will also be difficult or painful for you to grasp or hold objects. Weakness with pinching/gripping and instability to the thumb are also common.
Both a broken (fractured) thumb and a sprained thumb can cause pain, swelling and bruising, but there are some differences to look for. A broken thumb usually causes more intense pain, and your thumb may look deformed or misshapen. A broken thumb can also cause numbness or tingling. If you’re experiencing pain, bruising and swelling in your thumb after an accident such as a fall, be sure to contact your healthcare provider.
A thumb sprain involves overstretched or torn ligaments, which are tissues that connect bones at a joint. A thumb strain involves an injury to a muscle or a tendon, which is a tissue that connects muscle to bone. Both thumb sprains and thumb strains usually cause pain.
Healthcare professionals use a grading system to classify the severity of sprains. The three different grades include:
- Grade 1: A grade 1 thumb sprain is a mild sprain. The affected ligament is overstretched but not torn.
- Grade 2: A grade 2 thumb sprain is a moderate sprain. The affected ligament is partially torn.
- Grade 3: A grade 3 thumb sprain is a severe sprain. The affected ligament is completely torn or separated from its attachment to your bone. Severe sprains require medical and/or surgical care. If the ligament takes a small piece of bone with it, it’s called an avulsion fracture.
Diagnosis of Skier's Thumb
To properly diagnose skier’s thumb, schedule an appointment with a health care provider or hand specialist. If you experience any of the symptoms of skier's thumb following an injury, call your doctor as soon as possible. Follow your doctor's instructions about special home care considerations and find out when your thumb can be checked. If you determine that skier's thumb is possible, considering the way your accident happened, then you should be taken by car to a hospital's emergency department. There is no need to go by ambulance unless that is your only means of transportation or there is another more serious injury associated with the accident.
An alternative to the emergency department would be an office visit to an orthopedic surgeon (bone specialist) or hand surgeon's clinic. If an orthopedic surgeon is available to see you on the day of your injury, it is more efficient to go see the surgeon directly instead of from the emergency department's referral.
The medical professional will take a complete medical history, discuss how the injury occurred, and complete a physical exam. The doctor will ask you how the injury happened. Be prepared to answer these questions:
- At what time did your injury take place?
- What was the exact positioning of your hand and thumb during the injury?
- How soon after the injury did the pain and swelling begin?
- Did it feel as if your thumb was stressed beyond its normal range of motion?
The doctor will also ask about your past medical history. Be prepared to answer these questions:
- Have you ever suffered from a similar injury before?
- Have you ever had any type of surgery in your hand or wrist?
- Are you allergic to any pain medications?
- Have you ever fractured any bones in your wrist or hand?
- Are you right-handed or left-handed?
- What is your primary occupation?
The doctor will then perform a physical examination and include the following tests:
- A comparison of the movement of the injured thumb with that of the uninjured thumb looking for looseness of the ligament
- An assessment of how well the major nerves in your hand function
- A check for fractures, including an X-ray of your hand to make sure no bones are broken
- An examination of the rest of your arm for any associated injuries to your wrist, forearm, elbow, and shoulder
In most cases, x-rays are obtained to ensure there is no fracture to the thumb. Most of the time, the diagnosis can then be made clinically based on your exam and symptoms. Occasionally, advanced imaging such as an MRI will be obtained to evaluate the extent of the tear and help determine treatment options.
If a UCL injury is suspected, the first step is to palpate the ligament to check for tenderness. Applying gentle valgus stress-by pulling the proximal phalanx of the thumb away from the hand-can further assess the injury. This should be done while supporting the thumb metacarpal, both with the metacarpophalangeal (MP) joint in full extension and at approximately 30 degrees of flexion. Pain during palpation or when stress is applied may indicate skier's thumb.
A complete rupture of the UCL, characterized by more than 15 degrees of laxity when stress is applied to the joint, typically requires surgical intervention.
Treatment Options
While you can treat your injuries at home with rest and ice, sometimes treatment from a medical professional is necessary.
If you suspect that you may have a skier's thumb, then home care should address the pain and swelling of your thumb. Take the following steps to reduce your pain and swelling.
- Apply ice to the thumb for 35 minutes at a time, up to 4 times per day. Do not apply ice directly to your skin. Continue to use ice until the pain stops. (You should see your doctor as soon as possible after the injury and then follow a doctor's directions for ice therapy.)
- Avoid movement of the thumb as much as possible. The loose application of an ACE wrap or commercially available wrist brace in the neutral position will help immobilize the thumb. This will help lessen your pain.
- Take acetaminophen for pain relief or ibuprofen for anti-inflammatory action. Avoid both of these over-the-counter drugs if you have stomach problems and cannot tolerate them.
The most important aspect of home care is to ensure that the injury is fully evaluated by an emergency doctor, orthopedic surgeon, or your primary care physician in the first few days.
Treatment depends on the extent of injury to the ligament. In most cases, UCL injuries are treated nonsurgically with immobilization, often by casting and then transitioning to a removable brace. In general, it may take up to three months to fully recover and return to normal activity after a sprain/partial tear of the ulnar collateral ligament.
On the other hand, a partial tear or sprain, where there's pain during stress or palpation but no obvious laxity, often benefits from conservative management. Immobilization with an orthosis can provide the necessary support to the MP joint, preventing any stress on the UCL while the fibers heal.
If the doctor determines that you have a skier's thumb, then referral to an orthopedic or hand surgeon will be the next step. The orthopedic surgeon will determine when your thumb needs to be reexamined. At that time, your options for surgical versus nonsurgical therapy will be discussed.
Typically, partial injuries to the ligament are immobilized for several weeks, while complete rupture of the ligament usually requires surgical repair.
Thumb sprain painful UCL ligament injury
If you elect to have surgery, then operative exploration and ligament repair using something called a "suture anchor" will most likely be performed. After the operation, your hand may be placed in a lightweight cast to hold your thumb still while your ligament heals. You will have to remain in this cast for some time based on your orthopedic surgeon's preferences, although some surgeons now advocate early gentle motion.
Complete tears may be treated surgically or nonsurgically depending on the pattern of tear and patient goals. A hand surgeon can perform a repair to restore the ligament's function.
If you have an associated fracture with your skier's thumb, then it may be treated with a modified cast. Surgical stabilization of the fracture might be needed if a piece of bone has broken off.
Your orthopedic surgeon will see you after surgical repair or after a period of immobilization in a cast. Your thumb will be reexamined. The doctor will decide if you need to continue to immobilize your thumb or if you need physical therapy to regain movement in it. The remainder of your rehabilitation and the management of any chronic problems that may arise from your injury will be addressed by your orthopedic or hand surgeon.
Prevention
While you can’t prevent all accidents, you can train yourself to throw your ski poles away from you when falling to help eliminate a true skier’s thumb.
Skiers should be taught to consciously discard the ski pole during all falls. Falling onto an outstretched hand while skiing without the ski pole in hand should minimize the chance of injury. Skiers should also be encouraged to use poles with finger-groove grips without any restraining devices such as a wrist strap or closed grip.
You can prevent skier's thumb during a car accident by keeping your thumbs on the outside of the steering wheel along with your fingers. This new routine will require a conscious effort because most drivers are taught to grip the steering wheel in a fashion similar to a ski pole.
If your injured thumb doesn’t heal properly, you have a higher chance of experiencing skier’s thumb again in the future. It can also become a long-term or chronic condition, resulting in long-lasting pain, instability, or weakness in the thumb and possibly surrounding fingers, hand, and wrist.
If you suspect you have skier’s thumb, or any other injury to the thumb, fingers, hand, or wrist, you can schedule a consultation at the Hand and Wrist Institute. We are one of the leading practices specializing in injuries to the hand and wrist, using the most current technologies and research. Dr. Dr. Knight is a renowned hand, wrist and upper extremity surgeon with over 25 years of experience. Dr. Knight is a Board Certified Orthopedic Surgeon and Fellowship trained.