VSMC News

Skier's Thumb

It is a glorious and powdery day, the conditions are pristine, you feel connected and one with your skis. Then unexpectedly you catch an edge, lose your balance and splat! In the time it takes to say “Yikes!” you are headed down the trail face first. After a brief anatomy check you get up and try to resume skiing, but your thumb hurts so much you can hardly grasp the pole. You have just sustained an injury commonly known as Skier’s Thumb. Historians, however, call it “Gamekeeper’s Thumb,” the Scottish term for men who killed and skinned rabbits for a living, and who experience “stretched out “ ligaments in their thumbs because of the repeated motion they performed to skin the rabbits.

Skier’s Thumb is an injury to the ulnar collateral ligament, which is responsible for stabilizing the thumb and hand when you grasp or pinch. It is located at the base of the thumb where it connects to the hand. Any sudden force that pulls the thumb away from the hand, such as falling on an outstretched hand that is holding a ski pole, can damage the ulnar collateral ligament. Skier’s Thumb is the acute injury and Gamekeeper’s Thumb refers to the chronic condition of ligament instability.

The Third Degree
Like any ligament injuries, ulnar collateral injuries are classified as Grade I, II, or III. Grade I is the most common. It involves a tear of the ligament fibers, with no loss of ligament integrity. With Grade II injuries, a greater portion of the fibers tear, but the overall ligament integrity remains intact. The Grade III injury is the most severe. It is a complete disruption of the ligament and thumb stability is totally lost.

The symptoms of the Grade III injury include pain and swelling at the base of the thumb. The thumb feels week when you try to pinch or grasp. The base of the thumb may develop a bruise and often a bump can be felt at the thumb’s base on the palm side. Proper diagnosis of this condition includes a thorough hand examination, including a valgus stress test that determines the overall integrity of the ligament. This test can be painful because it involves placing the thumb in a variety of directions and angles. X-Rays can also help ascertain how unstable the thumb is in a stressed position.

Treatment
If the ulnar collateral ligament is only partially torn, the thumb will be immobilized for a period of four weeks, followed by a gradual weaning from the cast for the next two weeks. During this time, it is important that properly prescribed rehab exercises are performed.

For a Grade III injury the treatment is more involved and usually requires surgery to bring the ligament back to its proper anatomic position. If there is the additional complication of a fracture, the fracture is repaired at the same time the ligament is sutured. Then, the hand is put in a cast for four weeks, followed by two weeks in a custom-fabricated splint. It is during this phase that the patient follow specific hand exercises in order to protect the repair, increase mobility, and build strength for stability. For the next few months, careful adherence to activity modification and continued protection is critical. It is very important to avoid stressful postures and forces for three to four months following surgery to allow the ligament to completely heal.

Without proper diagnosis, this very common injury can result in a chronic and oftentimes disabling condition like what the Scottish Gamekeepers experienced. Because the thumb is so integral to the function of our hand, any joint instability can impact its ability to hold onto objects, pinch and grasp.

If you’re a skier in the midst of a fall, letting go of your poles is the best line of defense. The absence of poles while falling on an outstretched hand can lessen the possibility of disrupting the ligament.

No ski enthusiast wants to give up skiing, even if his/her hand is in a cast. If you are of that mindset and you’ve sustained a thumb injury, consider seeing a hand specialist. A hand therapist can fabricate a custom splint that you can wear comfortably under a ski glove. This type of splint is often made for thumb strains to protect the injury from reoccurring .For the individual who has had a surgical repair, this type of splint is essential.

If you chose to go this route, bring your poles and gloves to the appointment to assure a proper and comfortable fit. Newer generation splinting material can be modified easily by a trained therapist with splinting experience.
Prefabricated thumb splints are commercially available but very often do not provide the essential and custom fit that is so important to position and thumb stabilization. These prefabricated splints often impede normal hand use and alter the hand’s biomechanics, resulting in awkwardness and discomfort.

If you experience Skier’s Thumb, seek early and appropriate medical advice. It’s the best way to prevent long- term complications and disability and keep doing the sport you love. So, next time you fall while skiing, don’t forget to lose your poles!

Deborah G. Hartenstein, OTR, CHT is a licensed occupational and certified hand therapist at Vermont Sports Medicine Center in Rutland. She can be reached at vthand@aol.com or at 802-775-1300.

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