Hitch hiking

Wednesday, March 3, 2010

The hand is just like basketball. It’s pretty simple on the surface, but peel away the skin and there’s lots of stuff happening underneath. It takes a basketball star like Shaq to show us how complicated the hand can be. A sprained thumb ends up needing an operation and throws a wrench into a team’s championship aspirations.

A sprain means that a ligament has been stretched or torn and most people have experienced a sprained joint sometime in their life. Usually RICE (rest, ice, compression and elevation) allows the body to heal itself in a couple of weeks. But some sprains need more aggressive care and the ulnar collateral ligament of the thumb also need to be fixed so that the thumb can do what it’s supposed to do. It’s the ligament that attaches the proximal phalanx (a bone of the thumb) to the first metacarpal (a bone in the hand). Without it, the power of the thumb to grasp and the hand to hold is lost.

The injury is known as a skier’s thumb. When a downhill skier falls forward, the ski pole can force the thumb away from the rest of the hand and sprain the ulnar collateral ligament. The other name for the injury is gamekeeper’s thumb, a historical reference to Scottish gamekeepers who would stretch the ligament while holding down small game animals like rabbits to break their neck.

Sprains are graded based on the severity of injury. First degree signifies a stretched ligament; second degree, a partially torn ligament; third degree, a completely torn ligament. On occasion, the ligament is stronger than the bone where it attaches and a fleck of bone is pulled off, instead of the ligament tearing.

The diagnosis is made by history and understanding the mechanism of injury. Physical exam will find swelling and tenderness at the site of the ligament and the ligament is often stressed. If the ligament is intact (either a first or second degree sprain), a stop will be felt when the thumb is pulled away from the hand. If it’s completely torn, the thumb keeps going.

Usually an orthopedic or hand surgeon will operate to repair the ligament and then it’s rehab time. As with most ligament repairs, prolonged immobilization in a cast is required to allow the ligament to heal. The downside to not moving a joint is stiffness. Rehabilitation needs to get the thumb moving and return range of motion back to where it was.

The ulnar collateral ligament is a tiny structure but has large function. Without it, the thumb becomes less than helpful in daily activities and it becomes a liability to any basketball player who has to grasp, shoot and throw. But it’s also a big deal for a carpenter who can’t grasp a hammer or a pianist who can’t reach for the minor 9th. Shaq’s injury is a reminder that even the most simple appearing things in the body can be rather complicated…and this is but one joint and one ligament.

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