A torn ulnar collateral ligament makes pinching, gripping, and turning a key painful — sometimes impossible. Complete UCL tears require surgery. Partial tears get stress-tested first. Dr. Graham repairs acute UCL injuries with Internal Brace augmentation and reconstructs chronic tears with tendon graft — with full pinch and grip strength returning in most patients.
Timing matters. A Stener lesion will not heal in a splint — delaying surgery makes reconstruction (not repair) more likely. Early evaluation is worth it.
Understanding the Injury
The ulnar collateral ligament (UCL) of the thumb runs along the inner — ulnar — side of the metacarpophalangeal (MCP) joint, providing the stability needed for pinch and grip. When the thumb is forcibly pushed away from the hand — radially deviated against resistance — this ligament is put under sudden, extreme tension and can partially or completely tear.
Two names describe the same injury in different contexts. Skier's thumb refers to the acute injury that occurs when a falling skier catches a ski pole, levering the thumb away from the hand. Gamekeeper's thumb historically described a chronic attenuation of the UCL from repetitive stress — but today both terms are used interchangeably to describe the UCL tear itself.
The UCL is essential for the most fundamental hand function: pinch. Picking up a cup, turning a key, writing with a pen, opening a jar — all require a stable thumb MCP joint. Patients with a complete UCL tear feel instability, weakness, and pain with any of these activities. Left untreated, a complete tear leads to progressive MCP joint instability, articular cartilage damage, and eventual post-traumatic arthritis.
In Dr. Graham's experience, the most important diagnostic question is whether the UCL is completely torn and — if so — whether a Stener lesion is present. These two factors determine whether the thumb will heal in a splint or whether surgery is required.
The UCL (green) runs along the ulnar border of the thumb MCP joint. A radially-directed force — catching a ski pole, a fall on an outstretched hand — stretches and tears this ligament.
The radial collateral ligament (RCL, dashed) on the opposite side is less commonly injured. UCL tears account for the vast majority of collateral ligament injuries at the thumb MCP joint.
The Critical Concept
When the UCL tears completely, it often retracts and displaces — folding back on itself underneath the adductor pollicis aponeurosis, a thin but strong fibrous layer overlying the MCP joint. This displaced position is called a Stener lesion.
The Stener lesion is the anatomical reason a complete UCL tear will not heal with splinting alone. The adductor aponeurosis now lies between the two torn ends of the ligament — acting as a physical barrier that prevents the healing process from reconnecting them. No matter how long the thumb is immobilized, these torn ends cannot find each other across this barrier.
Surgery is required to move the aponeurosis out of the way, reappose the torn ligament ends, and secure them back to the proximal phalanx. In Dr. Graham's experience, the sooner this is done after the injury, the better — fresh tissue repairs more reliably than scarred, retracted tissue.
MRI is Dr. Graham's preferred imaging to confirm the presence of a Stener lesion and characterize the tear prior to surgery. It provides the best soft tissue detail and guides surgical planning.
Treatment Framework
The treatment decision depends on three factors: completeness of the tear, stability on stress testing, and time since injury.
Partial UCL tears that demonstrate stability on stress testing heal reliably with splinting alone. Dr. Graham uses a removable thumb spica splint worn for 4 to 6 weeks, with gradual return to activity as stability is confirmed.
Who qualifies:
All complete UCL tears are operated on. Dr. Graham repairs the torn ligament back to its insertion on the proximal phalanx using a suture anchor, then augments the repair with an Internal Brace — a strong synthetic tape that provides immediate mechanical stability while the ligament heals.
Who qualifies:
When the UCL tear is chronic — typically several months to years old — the native ligament has retracted, scarred, and can no longer be reapproximated for repair. In these cases, Dr. Graham reconstructs the ligament using a tendon graft, recreating the UCL from scratch and securing it anatomically at both its origin and insertion.
Reconstruction is also used when prior repair has failed and the native tissue is too attenuated for re-repair. The result is a durable, reconstructed ligament that restores MCP stability and allows full return of pinch and grip strength in most patients.
Reconstruction is indicated when:
The earlier a complete UCL tear is evaluated, the more likely a primary repair — rather than reconstruction — is possible. Repair is faster, simpler, and has a lower donor-site burden than reconstruction. Don't wait if your thumb feels unstable after an injury.
Surgical Technique
The Internal Brace technique augments the UCL repair with a strong, flexible synthetic tape — secured at both the proximal phalanx and the metacarpal head — that shares the load with the healing ligament from the moment of surgery. This is the same principle used in ankle ligament repair and provides immediate mechanical stability that the repaired ligament alone cannot offer in the early weeks of healing.
The practical benefits are meaningful. The Internal Brace allows the post-operative immobilization protocol to be abbreviated relative to repair alone, and gives the repair a mechanical safety net during the rehabilitation phase. In Dr. Graham's experience, patients repaired with Internal Brace augmentation tend to recover strength faster and more completely than those treated with repair alone.
The procedure is performed as an outpatient under regional anesthesia, with or without light sedation. Operative time is typically under an hour. Patients go home the same day.
The repaired UCL needs time to heal — typically 6–8 weeks before it can bear load independently. The Internal Brace acts as a biological scaffold during this window, preventing re-tear while the ligament consolidates. It is not removed after healing — it remains permanently and continues to provide secondary support to the repaired ligament.
Regional block — wrist or more proximal. Sedation available. Outpatient procedure at Baptist Beaches Hospital or Horizon Surgery Center.
Curved incision over the ulnar MCP joint. The adductor pollicis aponeurosis is carefully reflected to expose the torn UCL and confirm the Stener lesion.
The UCL is reapproximated and secured to the proximal phalanx using a suture anchor at its anatomic footprint. Tissue quality is assessed intraoperatively.
A FiberTape Internal Brace is secured with anchors at the proximal phalanx and metacarpal head — spanning the MCP joint and providing immediate stability independent of the healing ligament.
The aponeurosis is repaired, the wound closed, and a post-operative splint applied. Worn for 2 weeks, then transitioned to custom-molded thumb spica orthosis for 4 more weeks.
Recovery Timeline
Six weeks of thumb protection, then progressive strengthening. Full pinch and grip return in most patients.
Post-operative splint in place. Wound healing. Fingers remain free — only the thumb MCP joint is immobilized. Sutures removed at 2-week visit.
Custom-molded removable thumb spica orthosis worn for 4 weeks. Allows hygiene and skin care. Thumb IP joint motion encouraged — only MCP is protected.
Orthosis discontinued at 6 weeks. Formal hand therapy begins — range of motion, progressive pinch and grip strengthening, activity-specific rehabilitation.
Most patients return to full activity — including sports, manual labor, and fine motor tasks — between 3 and 4 months after surgery. Pinch and grip strength at or near baseline.
"Dr. Graham called me multiple times to check in and made sure I understood every step of the process. My thumb is stronger than it's ever been. He's a surgeon who actually cares about the outcome."
Biologic Treatment Option
Complete UCL tears with a Stener lesion require surgical repair — the ligament has been physically displaced and cannot heal without reattachment. But partial UCL tears without a Stener lesion, and stable partial tears managed conservatively in a thumb spica splint, represent a genuine opportunity for biologic augmentation. PRP delivered to a partial UCL tear may stimulate the ligament's healing response, supporting more complete and durable recovery than immobilization alone.
The UCL is a ligamentous structure with a relatively limited blood supply in some regions — the same biology that makes ligament healing slow and incomplete in general. Concentrated platelet growth factors injected precisely at the tear site provide a biological stimulus that the ligament's own repair machinery may not generate adequately on its own. For patients with confirmed partial tears on MRI who are being managed conservatively, PRP is a well-reasoned adjunct to thumb spica immobilization.
Dr. Graham is happy to discuss whether PRP makes sense for your specific UCL injury pattern. For complete information on the procedure, see the PRP treatment page.
Common Questions
What patients ask most often about skier's thumb and gamekeeper's thumb.