Sprained thumb
Illustration showing the damage to the ulnar collateral ligament on the inner side of the thumb base

Definition

Sprained thumb, also named skier’s thumb, is the injury to the ulnar collateral ligament (UCL) of the thumb caused by excessive strain.

Anatomy of the thumb including the UCL and the adjacent adductor pollicis aponeurosis often damaged with a thumb sprain

Pathology

The ulnar collateral ligament (UCL) is located on the inner side of the metacarpo-phalangeal (MCP) joint between the metacarpal bone and the proximal phalange of the thumb, facing the index finger. Depending on the strain applied to the thumb, the injury to the UCL may involve damage to the adductor aponeurosis (thumb muscle), the accessory collateral ligament, bony structures, tendons and neurological tissues. The implications of these injuries can be detrimental as the thumb controls grasping, which comprises 50% of the functions of the hand. 

A sprained thumb may be aggravated by the interposition of the aponeurosis (tendon-like tissue connecting the thumb muscle to the phalange) of the adductor pollicis muscle between the ruptured UCL and its site of insertion at the base of the proximal phalange. This is called the Stener lesion. This injury requires surgical treatment to prevent joint instability and loss of function.

Illustration of a Stener lesion. Note the ruptured ulnar collateral ligament

Classification

A thumb sprain is classified depending on the extent of the UCL rupture:

Type I and II UCL injuries for incomplete sprains

Type III UCL injury for a complete rupture of the ligament.

Left: Distal radius intraarticular, displaced fracture; Middle: Older distal radius fracture with callus formation; Right: Distal radius and ulna fracture, extraarticular and displaced

No 2.

Intra-articular fracture extends to the wrist joint (or articulation)

Extra-articular fracture is located outside of the wrist joint

Open fracture when bone fragments perforate the skin

Comminuted fracture when the bone breaks into multiple fragments

Non-displaced when the anatomical alignment of the bone is maintained or displaced when the bone fragments move apart.

Melone’s classification describes the characteristics of intra-articular fractures of the radius:

i    Stable fracture

ii    Unstable "die-punch"

iii   "Spike" fracture

iv Split fracture

v   Explosion injuries

Acetabular fracture of the pelvis

Acetabular fractures

These fractures are divided into:

Anterior pillar (not weight bearing part of joint)

Posterior pillar (often associated with dislocation of the hip including the weight bearing part of joint)

Transverse

Comminuted involving both column type 

Sacral / coccygeal fractures

The sacrum is a triangular-shaped bone formed by 5 fused vertebrae, which provide a posterior wall to the pelvic ring. At each side of the sacrum, the ala structures articulate with the ilium bones forming the sacro-iliac joints. Sacral fractures are usually parallel to the spine and can involve the ala. Less frequently sacral fractures may display an “H” shape, including a transversal fracture uniting both sides of the sacrum. Three zones are described where sacral fractures can occur that are along vertical lines relative to the alignment of the foramina. Sacral fractures may result in sacral instability and require treatment via sacroplasty (injection of bone glue into the fracture). Surgery is necessary in case of associated neurological symptoms.

Fractures of the coccyx involve the tailbone, the terminal portion of the spine situated below the sacrum formed by 3 to 5 fused vertebrae. Coccyx fractures occur when falling on a seated position. They are more common in elderly women and seldom require surgical treatment.

Thumb sprain is also called skier's thumb as the sport is a frequent cause of the pathology

Causes

Thumb sprains are typical sport injuries. They often occur when catching a ball, in downhill skiing or during other physical activities. These injuries are mostly found in active, young sportsmen. A thumb sprain results from the following mechanisms:

Thumb bending backwards under a hyperextension force

Thumb undergoes excessive forward bending with a hyperflexion force

Thumb lateral bending when the force is applied sideways.

Any ball and contact sports like rugby are a risk factor for thumb sprains

Risk factors

Thumb sprains arise often with a fall, when catching a ball and during impacts in contact sports. The main risk factors are:

Basketball, netball

Contact sports such as hockey, football, rugby

Skiing

Falls onto the hand

Martial arts

A bruise around the thumb base is a typical symptom of a UCL sprain

Symptoms

The symptoms arising from a sprained thumb are:

Pain

Increasing pain during thumb/hand activity

Swelling

Bruising

Movement restrictions

Thumb weakness

Thumb flexion is measured by a medical examiner

Diagnosis

During the examination the patient provides medical history including previous hand injuries and mechanisms leading to the current injury to the thumb. The clinical examination is usually sufficient for the diagnosis of a sprained thumb and involves:

Palpation to the region of the ulnar collateral ligament

Monitoring changes in the range of movement of the thumb both passively and actively

The valgus ulnar test of the UCL determines the ligament stability and/or rupture of the sprained versus the normal thumb when applying a 30 degree flexion (normal). The test is positive for UCL rupture if the flexion the thumb leads to excessive laxity of greater than 30 degrees. X-rays, CT scan and MRI are only taken if other injuries are suspected such as wrist sprain/fracture, thumb metacarpal fracture and dislocation/instability of the MCP joint.

 

Treatment

Temporary immobilisation of the thumb with a brace following a sprain injury

Nonoperative treatment

The management of a sprained thumb is normally achieved conservatively if a valgus laxity of MCP joint extension is less than 30°. Conservative treatment includes the immobilisation of the thumb for a week with a spica cast that is replaced with a spica thermoplastic splint for up to 6 weeks.

Additional treatments include:

Ice pads

Administration of NSAIDs

Painkillers

Physiotherapy for thumb exercises whilst the hand is in the cast or splint including flexion/extension and gripping/pinching after 10-12 weeks from injury

X-ray showing the ossification of the proximal thumb phalange following injury

Surgical treatment 

Surgery is required in case of severe or total rupture of the UCL or when a sprained thumb is concomitant to a thumb fracture. Different methods are available for repairing the ligament depending on the type of injury. The procedure aims to reconnect the torn ligament to the bone (proximal phalange) with a suture or a screw. If an avulsion fracture is associated to the sprain of the UCL, it will be repaired with fixation of the bone fragment. A reconstruction of the ligament may be necessary in case of neglected injury with the use of a tissue graft. After surgery a spica cast is applied for at least 4 weeks.

Complications

If a thumb sprain is neglected or treated too late the following complications may arise:

Stiffness of the MCP joint requiring physiotherapy

Arthritis of the MCP joint

During surgery the damage of the sensory nerves located on the posterior side of the thumb may cause local numbness. Infection is an additional complication following surgery.

Thumb opposition is a useful exercise for the recovery following a thumb sprain

Rehabilitation

A physical or occupational therapist will guide the patient to rehabilitation plan to restore flexibility and strength of the thumb with exercises such as thumb opposition, extension and flexion. The therapist will also inform the patient on how to modify activities to avoid recurrent injuries to the UCL. Standard rehabilitative therapy includes:

Massage

Joint mobilisation

Stretch exercises

Electrotherapy

Return to activity plan

Taping

Bracing

Thumb taping is used to stabilise the thumb joints and avoid sprains

Prevention

Preventing thumb sprains is achieved by protecting the thumb during physical activities and reducing the risk of falls. Common strategies are:

Thumb taping

Wearing protective gear during sport training and carpentry work

Modification of physical activities

Exercise to improve muscle strength and flexibility of the thumb