Thumb UCL / RCL Tear
(Skier's or Gamekeeper's Thumb)
A thumb Ulnar Collateral Ligament (UCL) tear is also known as “skier’s thumb” or “gamekeeper’s thumb.” The UCL is located on the inside of the thumb close to the webspace between the thumb and index finger. It is a strong band of tissue that attaches to the proximal phalanx bone and metacarpal bone in the thumb, functioning to keep the two bones stable when moving the thumb such as during pinching and grasping motions. The Radial Collateral Ligament (RCL) is similar to the UCL, but is on the opposite side of the UCL (on the outside part of the thumb). Most of what is described below pertains to both the UCL and the RCL.
Injury to the ligament occurs when there is a sudden force on the thumb, such as falling or having the thumb pulled away. In fact, the condition is called skier’s thumb because skiers often fall with their hand strapped to the pole, thereby forcibly pushing the thumb away from the hand. Repetitive stress upon the ligament can also result in chronic injury to the ligament. The term “gamekeeper’s thumb” comes from the old Scottish gamekeepers who used to snap the necks of rabbits and other game chronically using their hands, causing secondary injury due to repetitive force upon the ligament.
The ulnar collateral ligament may be torn partially or completely, or a piece of bone may break off with the ligament. Also, the torn end of the ligament can flip out and become trapped by the Adductor muscle, blocking the ligament from the ability to heal back to the bone--this is called a “Stener Lesion."
Patients with a thumb UCL or RCL injury will often experience pain at the thumb area (at the base close to the webspace). If this is an acute injury, there may be swelling and bruising in the area. Your thumb may feel loose, unstable or weak especially with gripping, grasping or pinching activities. In addition, there may be a lump present on the inside of the thumb from the torn ligament.
At your visit, we will evaluate the injury first by physical examination. This will include pressing upon the areas around the hand and thumb to locate the point of pain or tenderness. Provocative stress testing will be performed to determine if there is pain, laxity (looseness of the ligament) or a greater opening of the joint compared to the opposite side. Dr. Steven Lee will usually also order an X-ray in order to rule out the possibility of a fracture or piece of bone pulled off with the ligament or other pathology. Depending on the examination and radiographic findings, he may order an MRI to further evaluate the nature of the injury to the ligament.
The decision between non-operative and surgical treatment of this condition is dependent on the extent of the injury to the ligament. Partial tears or sprain of the ligament may warrant immobilization in a “thumb spica” splint for at least 6 weeks. It is very important to wear this splint consistently, 24/7, including while sleeping. The splint may be removed to wash hands or shower but has to be immediately placed back on afterward. Hand therapy is usually started gradually after splinting in order to regain strength and mobility. There is still a chance that the injury may not heal even after a long period of proper immobilization. Patients may continue to experience instability in the thumb. In these cases, Dr. Steven Lee may consider surgical treatment.
Dr. Steven Lee may recommend surgical treatment, either to repair or to reconstruct the UCL or RCL for those who have a complete rupture, if a piece of bone has been pulled off and significantly displaced or rotated, if the ligament has been displaced such that it cannot heal properly on its own such as in a Stener Lesion, or if the patient has failed non-operative treatment. Delay in treatment may lead to chronic instability, weakness, limited mobility or arthritis.
Surgical treatment of the thumb UCL involves making a small incision over the base of the thumb where the UCL is located and depending on the extent and nature of the tear, Dr. Lee will decide to repair or reconstruct the ligament. The damaged ligament is cleaned and will be anchored to its appropriate place of attachment at the bone so it can heal properly. If the ligament has been beaten up beyond repair, a reconstruction will be performed using a local tendon as a graft. The surgery for RCL tears is more or less the same, but occurs on the outside part of the thumb.
Dr. Steven Lee has revolutionized the treatment of ligament tears and thumb collateral ligament tears specifically with his pioneering of Internal Bracing of the Hand. Internal bracing utilizes an innovative strong suture tape construct with new bone anchors in order to increase the strength of the repair or reconstruction, thereby significantly quickening the rehabilitation process, and allow earlier return to sports and daily function. Please feel free to ask Dr. Lee about his specific expertise with this method. Learn more about Internal Bracing here.
Learn more about scheduling surgery.
Post Operative Care:
Following surgery, patients are usually placed into a splint immediately postoperatively in order to allow for healing to occur. Patients will have use of their other four fingers and wrist for light activity but are advised to refrain from getting the dressings wet, including sweating. Patients usually follow up in office 7-10 days after surgery for a wound check and to see if sutures are ready to be removed. At this visit, a referral for a custom splint is usually given in order to obtain a smaller custom-fit (and more comfortable) splint from a hand therapist. This custom splint is to be worn at all times, usually for 4 weeks, and only to be removed for washing. After the period of immobilization for healing, hand therapy (occupational therapy) is advised for 6 weeks. Hand therapy is important part of the recovery process to help decrease scar tissue and hypersensitivity at the surgical site, as well as to improve range of motion and strength following surgery. Depending on the activity, sport, or type of work, Dr. Lee may be able to return you to these activities as soon as the sutures have been removed, or even earlier.
Learn more about post-operative care.
*It is important to note that all of the information above is not specific to anyone and is subject to change based on many different factors including but not limited to individual patient, diagnosis, and treatment specific variables. It is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopedic advice or assistance should consult Dr. Steven Lee or an orthopedic specialist of your choice.
*Dr. Steven Lee is a board certified orthopedic surgeon and is double fellowship trained in the areas of Hand and Upper Extremity Surgery, and Sports Medicine. He has offices in New York City, Scarsdale, and Westbury Long Island.