Dr. Santosh Batajoo Resident (Orthopaedic Surgery)

Skier’s Thumb

Injury to the metacarpophalangeal joint ulnar collateral ligament of the thumb.

A tear or avulsion of the ligament may occur at the site of insertion into the phalanx of the thumb.

Skier’s thumb- acute condition

Gamekeeper’s thumb – chronic condition – as a result of repeated episodes.

introduction

C S Campbell, an orthopedic surgeon originally coined the term gamekeeper’s thumb in 1955, after he observed this condition in a series of Scottish gamekeepers.

history

Gamekeeper’s – who kill small animals by forcefully extending the neck.

Skiers- who fall onto the extended thumb, hyperabduction.

athletes

The capsule is thickened medially and laterally to form the ulnar and radial collateral ligaments which are static stabilizer of MCP joint.

Ligament- proper and accessory ulnar collateral ligament

The capsule is thin over its dorsolateral aspect between EPB and abductor pollicis. dorsomedial aspect between the EPB and the adductor

pollicis.

anatomy

Rupture of ulnar collateral ligament caused by forcible abduction.

Fall onto an outstretched hand.

Gamekeeper’s fracture – an avulsion fracture

mechanism

A. Partial rupture – only the ligament proper is torn. Thumb is unstable in flexion.

B. Complete rupture – Thumb is unstable in all the positions.

types

The stener lesion – Interposition of the adductor pollicis aponeurosis between the ends of the torn ligament.

Prevent healing of the ligament.

Chronic instability.

Present in about 80% of complete ruptures.

type injury treatment

1

2

3

4

5

6

Fracture undisplaced

Fracture displaced

Ligamentous tear, stable

Ligamentous tear, unstable

Volar lip fracture

Ulnovolar fracture and ligamentous tear.

Conservative

Surgical

Conservative

Surgical

Conservative

surgical

Classification (palmer & louis)

Swelling and tenderness over the ulnar side of the thumb metacarpophalangeal joint.

Bruise like discoloration around the joint.

Interference in pinching activity, grasp.

Laxity of the joint

Lump (stener lesion).

Clinical features

Abduction stress testing Joint in full extension and 30 degrees of flexion.

Should be compared with the uninjured thumb.

Stress test in extension with abduction more than 40 degree indicates a complete injury. Compared to other side- difference of more than 15 degree.

X-ray – To exclude a fracture. avulsion fracture: fragment from the base of the proximal phalanx. Subluxation Stress view examination Minimally displaced (<2mm) avulsion fracture – complete avulsion without Stener lesion.

Ultrasonography MRI

investigations

Chronic instability

Arthritic changes in the MCP joint.

Weak pinch grasp.

Stiffness of the MCP and IP joints.

Neurapraxia of the radial sensory nerve.

complications

Partial tear- Immobilization in a splint for 4-6 weeks followed by

movement. Thumb spica cast or brace.

Complete tear- Operative repair. Immobilized postoperatively for 6

weeks. Flexion extension can be started early. Interphalangeal joint should be left free. Unrestricted usage is allowed at 3 months.

treatment

Delayed diagnosis – dissecting out the ligament from within the fibrotic mass and reattaching it.

Late diagnosed complete tear (several months) - Repair of the capsulo-ligamentous complex with a

palmaris longus free tendon graft or MP joint fusion.

If arthritis is present, arthrodesis of the MCP joint.

Early diagnosis is the important determinant of functional outcome.

Complete ruptures that are surgically treated within 3 weeks have good result.

The prognosis for repairs undertaken longer than 6 weeks is poor.

Physical therapy after surgery.

Outcome and prognosis

Thank you…