The development of an opposed thumb is what drove the human race to create tools and to develop into the beings we are today. Thumbs allow us to do everyday tasks like write, open a door, tie our shoes, eat a burger, swing a bat and open a jar of peanut butter. We grip and pinch because of all that a thumb can do. When loss of range of motion and/or chronic pain make using a thumb complicated, then everyday life becomes hard. Independence can be limited or lost.
Jeffery Kutsikovich, M.D. is a board-certified orthopedic surgeon specializing in the hand, wrist, elbow and shoulder at Bone and Joint Institute of Tennessee. He spends much of his time helping his patients get back full use of their thumb after disease or injury limits mobility. Kutsikovich graduated from Ohio State University College of Medicine in 2010, and completed his residency at Campbell Clinic in Memphis through the University of Tennessee Health Science Center. He continued his training by receiving a subspecialty certification in surgery of the hand through a fellowship at the Indiana Hand to Shoulder Center. He has written several scientific papers, is a member of both the American Society for Surgery of the Hand and the American Academy of Orthopaedic Surgeons, and serves as team physician for Independence High School.
Williamson Source: You have spent a lot of time studying the hand, one part of that being ligament injuries to the thumb. What are some possible injuries to the thumb’s ligaments?
Dr. Kutsikovich: The base of the thumb is very delicate. The MCP (metacarpophalangeal) joint, or second knuckle, gets caught a lot when someone falls, and it gets twisted away from the hand. This can cause a simple sprain, or it can be a more radical tear. When a tear is complete, it will not heal well, so surgery is needed more often in this case.
WS: What causes injuries to the thumb’s ligaments?
Dr. Kutsikovich: The majority of thumb injuries come from a simple fall. When trying to catch ourselves, the thumb gets pulled away from the hand and rotates.
Sports are another leading cause of thumb injury. The thumb may get caught on a piece of equipment or a uniform and jerked roughly, again pulling it from the hand and twisting. One injury is commonly called Skier’s Thumb. It is an acute injury to the thumb that is commonly caused by gripping a ski pole when it may strike something and cause an acute, partial or complete rupture of the UCL (ulnar collateral ligament) of the thumb’s MCP joint due to hyperabduction trauma. Acute Skier’s Thumb can cause instability and limit normal motion of the thumb from side to side, inflammation, and eventually lead to arthritis in the joint.
There is also Gamekeeper’s Thumb. It is a more chronic condition. The name comes from a repetitive action employed by gamekeepers, especially of ducks and chickens, on old Scottish estates. They had a particular way that they would kill the game by strangling them that would put stress on the inside ligament of the thumb. Over time it would put enough stress on the ligament that it would become lax. We still call chronic thumb ligament issues by that name.
WS: We’ve all jammed a thumb or fallen and twisted it a bit, but I think most of us just tough it out. When is it time to get a hurt thumb looked at?
Dr. Kutsikovich: A jam is a sprain. If it doesn’t get well over a week or two and there is significant pain, then it is time to get your thumb looked at. With new technology, it is not a huge rush to get in for a lower grade separation or tear. Of course, if you think it is dislocated or fractured, then you should come in right away. Signs of dislocation include severe bruising and swelling around the joint; your finger looks crooked, oddly shaped or a bone is sticking out; or you are unable to move your finger.
WS: What tools do you use to diagnose ligament injuries of the thumb?
Dr. Kutsikovich: My two main tools are x-rays and physical examinations. X-rays tell us a lot. We can see subluxation, which is typically found when there is thumb osteoarthritis. And we can see some tears. But my biggest tool is a physical examination of the thumb. Every person’s thumb is different with different strengths and subtle instabilities. With a physical examination, I can put the thumb through a number of tests for range of motion, stability, palpitation, and nerve assessment.
An MRI is less useful because the thumb joints are so small. Different MRI machines read differently, so sometimes ligament damage can go undetected. I use MRI less, and find a physical exam to actually be my greatest tool.
WS: What non-surgical treatments are available?
Dr. Kutsikovich: There are three grades of thumb injury. A low-grade injury like a sprain is gradel I. The ligament fibers are strained, but there is no tearing or separation from the bone. In spite of the strain, the joint is very stable. It may take two months or so for the ligament to totally heal. This is the type of injury people might let heal on its own.
A grade II injury means that there is a slight separation, a tear or partial detachment. This level of injury needs more caution. I put patients into a molded brace for four to six weeks, and for those who are active in sports, this might be two or three more weeks in a brace. After the injury heals, the patient will go through hand therapy to get back full mobility and lessen tightness of the ligament.
Ulnar collateral ligament tears or separations always need surgery, as complications can develop. They are rated as grade III injuries. If the ligament becomes incarcerated, caught between the muscle and the thumb bone, then there is no chance of healing. The ligament will simply give away and there will be no stability and persistent pain.
WS: What happens during thumb ligament surgery?
Dr. Kutsikovich: With surgery, we go in and repair or rebuild the joint. How we do it depends on the health of the bone and the extent of the damage. The damage predominantly happens at the UCL, between the metacarpal and the phalanx bones. We go in, reattach the ligament to the bones and put in a brace to provide stability while the ligament heals.
If there are broken bones, they are damaged by arthritis, or the ligament has to be reconstructed, then the surgery is more intensive, but ultimately the use of bracing is the same.
We implant the bracing into the bone, reattach the ligament, and then put the patient into a molded thermoplastic brace instead of a cast. This new bracing technology gives the damaged area more stability and immediate mobility, as well as flexibility. The thermoplastic brace is molded to the individual patient’s hand. Once swelling goes down after some healing takes place, the brace can be heated and remolded to the hand. This provides much greater stability as the patient heals.
This new technology has been a real game changer! Previous to the development of this technology, all I could do was use a small caliber suture when repairing the joint, which was not very strong, and then I supported the suture with a pin which was removed after healing. The patient was not able to move their thumb at all during recovery, and there was a lot of stiffness after. Once the thumb was healed, then the pin was removed through the skin, but this could lead to infection.
Now, the brace acts like the pin, but it is not removed. As the ligament recovers, the brace becomes less necessary, and the ligament takes over all action. Also, the patient can move their thumb almost immediately, so after surgery there is less stiffness to be addressed in physical therapy.
WS: There is also bone fusing. When is this used?
Dr. Kutsikovich: Bone fusing is a final resort. This is only done for patients who are older with severe arthritis or there is significant bone damage or cartilage loss in the area. While in some places in the body bone fusing causes severe mobility issues, the thumb is a bit different. In this case, fusing will actually restore mobility after a patient has been suffering from lack of thumb stability, pain and inflammation.
We call this a final surgery because the new technology is allowing us to restore full mobility in the thumb in most cases. The bracing technology was originally used in the elbow, but it can also be used in the wrist and foot. Anywhere.
WS: Any final words?
Dr. Kutsikovich: Thumb injuries can be complex problems that often go untreated. If you have stability issues in the thumb or chronic pain, get evaluated. New technology has revolutionized thumb ligament repair and healing, allowing us to give back near total mobility with faster healing times and fewer complications.
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