Thumb fractures

Monday, November 21, 2011

The Chicago Bear’s Jay Cutler may have the most famous thumb since Little Jack Horner. Having hurt it making a tackle and subsequently revealing that th thumb needed to be repaired by surgery, the press has decided that the fate of his team has been decided by one opposable digit. The thumb makes all the difference when it comes to grip strength and it is a tiny ligament at the base of the thumb where that strength lies.

Anatomically, the ulnar collateral ligament (UCL) attaches the 1st metacarpal to the proximal phalanx of the thumb along the ulnar borers of the bones. In regular English, there is a tight band of tissue that attaches the base of the thumb to the rest of the hand along the 1st web space between the thumb and index finger. Its job is to keep the thumb taught and in place when grabbing something like a jar or can or football. When it is loose, it’s tough for the thumb to remain stable and it tends to give way when the grasping motion is made.

A torn ligament is called a sprain and a sprained UCL has an interesting past. It’s also known as gamekeeper’s thumb and was described by a physician who studied Scottish gameskeepers who sacrificed wounded small animals by breaking their necks between their thumbs, index fingers and the ground. Over time, this motion would weaken and loosen the UCL. The sprained ligament was also known as skiers thumb because in the act of falling, the ski pole grip would tear the thumb away from the rest of the hand. While the injured part is the same, Gamekeepers thumb often refers to a chronic overuse injury while skier’s thumb refers to an acute event.

Making the diagnosis of an ulnar collateral ligament sprain of the thumb starts with understanding the mechanism of injury, knowing the anatomy and realizing that there is tenderness along the course of the ligament. As with any other sprain, it’s important to know whether there the ligament is stable and the thumb can be stressed to see if there is a stop to the motion of pulling thumb away from the rest of the hand or whether there is give and it feels like the thumb is going to keep going. X-ray is important because the ligament may be stronger than the bone where it attaches, and the force of injury can tear off a chunk of bone.

Treatment of the UCL sprain depends upon if the joint is stable and whether there is a significant fracture. Sometimes it can be treated in a thumb spica splint or cast, protecting the thumb from moving and allowing the ligament to heal, just like any other sprain. Sometimes, an operation is needed to pin the bone or ligament back where it belongs. A splint or cast is still needed to protect the operation site and prevent the pins from moving.

The hand is a complex machine and each small part is important to allow it to function as a while. It’s amazing that a small band of tissue less than an inch long can be so debilitating but it’s also amazing that a pro quarterback could continue to play and completer the game with a painful hand that prevented the ability to fully grasp the ball and throw it. A strong body needs a strong mind to perform and it seems that Mr. Cutler led his team to a win pulling out a plumb, Jack Horner style

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