CLINICAL ORTHOPAEDICS AND RELATED RESEARCH
Number 327, pp 79-04
Bony Skier’s Thumb Injuries
Jeffrey B. Husband, MD; and Scott A. McPherson, MD
Avulsion fractures of the ulnar collateral liga-
ment of the thumb metacarpophalangeal joint
(bony skier’s thumb) may result in chronic in-
stability with pain and weakness of pinch if
improperly treated. Management requires an
understanding of the relevant anatomy and
careful clinical examination including stress
testing. Undisplaced, or minimally displaced
and stable fractures are treated conservatively,
whereas displaced, rotated and unstable frac-
tures require surgical treatment.
Acute injuries of the ulnar collateral liga-
ment of the thumb metacarpophalangeal
joint have received much attention in the lit-
The term skier’s thumb
eratu~e.3.8.9.15.17.20,2~.25
has been coined to describe these injuries
due to their common occurrence in skiing ac-
~idents.6~8~9~13 Injury to the ligament results
from forceful abduction of the thumb and
may also occur from simple falls and from a
variety of sporting activities including foot-
ball, basketball, hockey, wrestling, and cy-
~ling.5,12,17.21.23,25
This paper deals specifically with avulsion
fractures of the ulnar collateral ligament of the
thumb metacarpophalangeal joint. It discusses
anatomy, clinical and radiographic evaluation,
and treatment including the options for surgi-
cal fixation as well as rehabilitation.
From the Park Nicollet Hand Center, St. Louis Park,
MN.
Request for reprints to Jeffrey B. Husband, MD, 6490
Excelsior Boulevard, E 400, St. Louis Park, MN 55426.
79
0 1996 LippincoWRavenPublishers
ANATOMY
The metacarpophalangeal joint of the thumb
is a diarthrodial hinged joint that flexes, ex-
tends, abducts, and adducts. The range of
flexion and extension varies greatly and, to a
lesser extent, so does abduction and adduc-
tion.22This variation is secondary to differ-
ences in metacarpal head configuration and
collateral ligament tightness.
Stability of the metacarpophalangeal joint
is determined by the joint capsule, the volar
plate, and the collateral ligaments. The
proper ulnar collateral ligament originates
from the dorsal ulnar metacarpal head and in-
serts into the volar ulnar base of the proximal
phalanx. It is at this site of attachment where
avulsion fractures most commonly occur.
The accessory collateral ligament runs volar
and parallel to the proper collateral ligament
and inserts into the volar plate (Fig 1). When
stressing the ulnar collateral ligament com-
plex, the proper ulnar collateral ligament is
taut in flexion while the accessory collateral
ligament is relaxed. The reverse is true in ex-
tension. This is of importance in the evalua-
tion of joint stability.
Dynamic stability of the metacarpopha-
langeal joint is provided by the intrinsic
muscles of the thumb, particularly the ad-
ductor pollicis, which resists active abduc-
tion. It has 3 points of insertion: into the ul-
nar base of the proximal phalanx, into the
ulnar sesamoid, and into the extensor expan-
sion via the broad adductor aponeurosis.

80 Husband and McPherson
Ic
Fig 1. Ulnar collateral ligament complex of the
thumb metacarpophalangeal joint. (A) Proper
collateral ligament (taut in flexion); (B) acces-
sory collateral ligament (lax in flexion); (C) volar
plate; and (D) area of avulsion fracture.
CLINICAL AND RADIOGRAPHIC
EVALUATION
The mechanism of injury is forced abduction
of the thumb. Patients present with pain,
swelling, and tenderness on the ulnar side of
the metacarpophalangeal joint.
Before performing stress testing, antero-
posterior, oblique, and lateral radiographs of
the thumb are obtained. Collateral ligament
avulsion fractures vary in location, size, dis-
placement, rotation, and the presence or ab-
sence of comminution. Rarely, the avulsion
will be from the metacarpal head. Louis et
allx have described an avulsion fracture of
the volar plate, which should be distin-
guished from ulnar collateral ligament avul-
sion fractures, because it is a stable injury
and 1 that should be treated conservatively.
Skeletally immature patients may have a
Salter-Harris Type I11 fracture.10
When the degree of fracture displacement
or rotation or both requires surgical treatment,
stress testing is unnecessary. When there is a
question of instability, stress testing should be
performed. A median and radial nerve block
at the wrist helps eliminate pain and allows
for a more accurate examination. It has been
reported that small, minimally displaced frag-
ments may be detached from the ligament
with instability, and consequently stress test-
Clinical Orthopaedics
and Related Research
ing has been recommended for these frac-
tures.13 This is, however, controversial and
may carry with it the risk of converting a sta-
ble fracture into an unstable 1.
Given that the proper collateral ligament
is taut in flexion and lax in extension, the au-
thors perform stress testing at 30" metacar-
pophalangeal flexion. If the metacarpopha-
langeal joint angulates 35" or more with the
radially applied stress, or 15" greater than
the opposite side, then it is considered unsta-
ble and surgery is recommended.12.22
Properly performed stress testing has elim-
inated the need for stress radiographs in the
majority of patients. Ultrasound11 and mag-
netic resonance imaging (MRI) have been
used to evaluate ligamentous injuries, but are
not indicated for bony skier's thumb injuries.
CONSERVATIVE TREATMENT
Undisplaced or minimally displaced fractures
with no joint instability are managed nonoper-
atively (Fig 2). Previous reports, however,
have failed to define clearly what represents
significant displacement or rotation. Gener-
ally, displacement of 1 mm or less, joint sta-
bility, and the absence of articular incongruity
are indications for conservative treatment.
After the initial swelling subsides, the pa-
tient is fitted either with a short arm thumb
spica cast or a custom made forearm based
thumb spica splint with the interphalangeal
joint included. Active range of motion
(ROM) exercises can be started in most
cases approximately 3 weeks after injury
with discontinuation of all splinting 3 to 4
weeks later. The patient continues with ROM
and is instructed in strengthening exercises.
Formal hand therapy usually is unnecessary.
A return to unrestricted activities often is
possible as early as 6 weeks after injury.
Radiographically, most patients demon-
strate progressive fracture healing, although
some will have a persistent, but stable and
pain free, fibrous nonunion. Those patients
who develop instability or arthritis may ulti-
mately require surgical reconstruction.
Number 327
June, 1996 Bony Skier’sThumb Injuries 81

Stener lesion occasionally may be identified

at the proximal edge of the adductor aponeu-
rosis. The ulnar side of the joint is exposed by
taking down the adductor aponeurosis, taking
a small margin of the extensor pollicis longus
to allow for easier repair (Fig 4).
If a capsular tear is not present, adequate
visualization of the joint is obtained by incis-
ing the capsule longitudinally dorsal to the
ulnar collateral ligament. The joint and frac-
ture site are inspected and cleared of
hematoma. The choice of fracture fixation
technique depends on several factors, includ-
ing the size of the fragment, the presence of
comminution, and the experience and prefer-
ence of the surgeon. For a large, single frag-
ment, the authors prefer to use a 1.5-mm
minifragment screw (Fig 5). This technique
is technically demanding because the joint
and fracture line cannot be visualized once

Fig 2. Minimally displaced avulsion fracture-

treated conservatively.

SURGICAL TREATMENT
Inappropriate treatment of bony skier’s
thumb injuries has been reported to result in
chronic painful instability, weakness of
pinch, and arthritis.7J7,*0.23Therefore, surgi-
cal treatment is recommended for those frac-
tures with 2 mm or more of displacement, or
significant articular involvement with incon-
gruency or rotation. The goal of surgery is
restoration of anatomy with stable fixation.
Ideally, surgery should be performed within
2 weeks of injury.21
The authors prefer to use a chevron inci-
sion with its apex at the volar ulnar aspect of
the metacarpophalangeal joint. This incision
allows for adequate exposure-volarly where
the fracture is located and dorsally where a
constant nerveto the thumb must be Fig 3. Surgical incision indicated by solid line.
identified and protected (Fig 3). After com- Course of sensory nerve indicated by inter-
pletion of the superficial dissection, a bony rupted line.

82 Husband and McPherson
Fig 4. Arrow indicates incision of adductor
aponeurosis taking a slip of extensor pollicis
longus.
the fracture is reduced. Therefore the starting
point and direction of screw insertion must
be chosen carefully. The proximal fragment
is overdrilled to allow for interfragmentary
compression. Due to the relatively small size
of the fracture, the surgeon typically has only
1 chance to place the screw. On occasion, the
fragment will break into 2 or more pieces
making fixation even more difficult. This sit-
uation can be salvaged by using a pullout
wire, or, as the authors prefer, a small suture
anchor. The fragments are excised, 1 or 2 su-
ture anchors are placed in the base of the
fracture in the proximal phalanx and the ulnar
collateral ligament is advanced into the de-
fect and secured there (Fig 6).
Tension band wiringlOJ4.16 is particularly
appropriate for those fractures that are too
small for screw fixation. The initial dissec-
Clinical Orthopaedics
and Related Research
tion and reduction are the same as for screw
fixation. Additional dissection is carried
onto the proximal phalanx where a hole is
drilled in a dorsal to volar direction 1 cm dis-
tal to the joint. In a figure of 8 configuration,
a 26-gauge wire is passed through the drill
hole and then through the collateral ligament
using a 20-gauge needle as a guide. If frag-
ment size permits, a small Kirschner wire (K
wire) may be used to stabilize the fracture,
otherwise the fragment is held reduced with
a forceps while the figure of 8 wire is tight-
ened (Fig 7).
For smaller or comminuted fractures,
screw and tension band fixation often are in-
appropriate. These injuries can be treated suc-
cessfully using a conventional pullout wire6,25
or small bone anchors as described above.
On rare occasions, a combined injury
with ligament avulsion from the fracture
fragment may exist.13 In this situation the
authors have combined fracture fixation
and ligament repair using a pullout wire.
Smaller fragments may be excised and the
ligament advanced and secured in the defect
using suture anchors.
The capsule and the adductor aponeurosis
are repaired with 4-0 nonabsorbable suture.
A bulky thumb spica plaster dressing, in-
cluding the interphalangeal joint, is applied
with the thumb slightly adducted. The au-
Fig 5A-B. (A) Large, displaced and
rotated avulsion fracture. (B) After fix-
ation with I .5-mm compression
screw.
Number 327
June, 1996
Fig 6. Collateral ligament advancement and re-
pair using suture anchor. The fracture had frag-
mented while screw fixation was attempted.
thors do not stabilize the metacarpopha-
langeal joint with a temporary K wire.
Assuming that stable fixation has been
achieved, the initial splint is removed within
Fig 7A-6. (A) Small displaced frac-
ture with more than 90" rotation. (B)
After fixation using a tension band
and K wire.
Bony Skier's Thumb Injuries 83
1 week of surgery, a forearm based thumb
spica splint is fabricated, and the patient be-
gins flexion and extension exercises. If a
pullout suture or suture anchors are used for
the repair, immobilization is continued for 6
weeks. At 6 weeks after surgery, the fracture
has usually healed, strengthening is started,
and splinting is discontinued.
DISCUSSION
Injuries to the ulnar collateral ligament have
for many years been referred to as game-
keeper's thumb. Campbell2 described this in-
jury in Scottish gamekeepers in whom ulnar
collateral instability developed due to chronic
stress and attrition of the ligament. The ma-
jority of ulnar collateral ligament ruptures,
however, occur with an acute abduction in-
jury to the thumb. This injury commonly has
been referred to as a skier's thumb reflecting
the preponderance of this injury in downhill
and cross country skiing accidents.'.4.9~19
Avulsion fractures of the ulnar collateral lig-
ament account for approximately 'h of skier's
thumb injuries,4.9.13.19,23and the authors think
the term bony skier's thumb more accurately
reflects the acute nature of this condition.
Radiographs must be evaluated to deter-
mine fragment size, displacement, and rota-
tion. One must differentiate volar plate avul-
sion fractures from ulnar collateral ligament

84 Husband and McPherson
avulsions, as the former can be satisfactorily
treated nonoperatively.18
The following points concerning evalua-
tion and management of bony skier’s thumb
deserve emphasis: (1) If there is any doubt
about joint stability, stress testing should be
performed under a median and radial nerve
wrist block with the thumb at 30” metacar-
pophalangeal joint flexion. If the joint opens
35” or more with radial deviation stress, then
surgery is indicated. (2) Undisplaced, stable
fractures are managed with 3 to 4 weeks of
immobilization and early ROM exercises. A
custom made thumb spica splint is recom-
mended in compliant patients for conve-
nience and to allow early motion. (3) Dis-
placed and rotated fractures require open
reduction and internal fixation to prevent
chronic instability with pain and weakness.
(4) The choice of fracture fixation depends
on the size of the fracture fragment along
with surgeon experience and preference. For
larger fractures, it is preferable to use 1.5-
mm minifragment screws with interfragmen-
tary compression. Tension band wiring is a
useful technique for those fragments not
large enough to support a screw, whereas the
use of suture anchors is recommended for
the smaller and comminuted fractures. The
goal of surgery is stable fixation permitting
early motion.
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