Treatment for acute and chronic thumb ligament injuries

In my previous blog, I briefly talked about skier's thumb, a very commonly missed injury to the ligaments of the thumb.

Skier's thumb is an acute tear to one of the stabilizing ligaments to the metacarpophalangeal joint of the thumb. It usually occurs as a result of falling on an outstretched hand or having a ski pole tug on the base of the thumb when losing balance. While this joint doesn't have a big arc of range of motion, it is very important in providing thumb stability for pinching and grasping.

The stabilizing structures to the thumb are very complex and are mostly ligaments or ligament like structures. Ligaments that stabilize the metacarpophalangeal joint are ulnar collateral ligament (responsible for stabilization so we can pinch and grasp) and radial collateral ligament (responsible for keeping the phalangeal bone aligned on the metacarpal bone, located on the opposite side from the ulnar collateral ligament). Injuries to the ulnar collateral ligament are 10 times more common than the radial collateral.

An injury to the radial collateral ligament can be very frequently missed because the patients can still grip and pinch. They may or may not develop pain and a "wobbly" feeling with certain movements. Over time, a noticeable deformity of the metacarpophalangeal joint will develop as a result of this injury. Many patients may attribute this to developing arthritis.

Early recognition and treatment of these injuries is key to good outcomes.

In cases of an acute complete tear of the ulnar collateral ligament confirmed on clinical exam by a hand surgeon, patients will need an operative intervention to repair this ligament. Most of the time the repair is done through a small incision over the torn ligament using special bone suture anchors to secure the ligament into its normal anatomical position. Following surgery, the thumb has to be immobilized in a cast or a splint for six weeks to allow healing. Occupational therapy may be needed.

In cases of chronic injury to the ulnar collateral ligament (more than 3-4 weeks from injury to surgical repair) "primary" repair (meaning reattaching the ligament back to bone) may not be feasible due to scarring of the tissues. In these cases, a tendon graft is used to recreate the ligament. This means more extensive surgery and more occupational therapy to prevent stiffness and regain normal range of motion.

In certain cases this injury may be recognized several years after the initial tear of the ligament. Most of these patients already developed a significant amount of arthritis within the metacarpophalangeal joint. This is essentially wear and tear of cartilage on the joint surface due to a "wobbly" unstable joint. Joint fusion to alleviate joint pain and regain joint stability may be the only option.

When it comes to thumb injuries, seeking early medical attention is the best thing you can do. For most of my patients, they knew that "something was wrong" with the most subtle changes after the injury.


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