2022 Mar 27;4(3):141-146. doi: 10.1016/j.jhsg.2022.02.008. Exclusion criteria were non-English studies and any study with less than 2 years mean follow-up. This leads to what is know as a positive ulnar variance. Although the natural history of chronically untreated UCL injury eventually leads to pain and loss of function, surgery intervened in the studies present. Fourteen articles were included and analyzed (293 thumbs). 2012 Nov 7;94(21):2005-12. doi: 10.2106/JBJS.K.01024. After failure of nonoperative treatment, at anywhere from 6 months to more than 6 years, nearly all patients can achieve complete pain relief, normal pinch and grip strength, joint stability, and range of motion after surgical reconstruction. Posner MA, Retaillaud JL. There were 6 studies that reported clinical outcomes after acute UCL repair using different techniques.20,2426,28,29 Repair techniques (Table 4) included pullout suture over button with or without Kirschner wire immobilization, suture anchors, soft tissue periosteal suture, and arthroscopic Stener reduction with K-wire. J Hand Surg Glob Online. 2019 Apr;47(5):1103-1110. doi: 10.1177/0363546519831705. Accurate diagnosis of finger injuries can often be difficult, given the complicated soft-tissue anatomy of the hand and the diverse spectrum of injuries that can occur. 18. [23,3638] Kuz et al recommend that most acute avulsion fractures of the thumb UCL be treated nonsurgically, with the exception of displaced fractures with more than 30% articular involvement or bony Stener lesions. The original study using this tool had a mean quality score range of 25% to 96% but had more than half of the studies scoring >75%. Lohman M, Vasenius J, Nieminen O, et al.. MRI follow-up after free tendon graft reconstruction of the thumb. [33] Avulsion fractures of the ulnar base of the proximal phalanx occur 20% to 30% of the time. Frykman G, Johansson O. Surgical repair of rupture of the, 46. #Injury location reported only in 3 studies. gamekeeper's thumb; skier's thumb; stener lesion; ulnar collateral ligament, NOW OVER 19K FOLLOWERS ON TWITTER. Abrahamsson SO, Sollerman C, Lundborg G, et al.. Tommy John surgery; ulnar collateral ligament reconstruction; ulnar nerve transposition; ulnar neuropathy. PLoS Med. Griffith TB, Ahmad CS, Gorroochurn P, D'Angelo J, Ciccotti MG, Dines JS, Altchek DW, Camp CL. There is no uniformly agreed on surgical indication for UCL injuries to the MP joint of the thumb. 5. [32] Ulnar collateral ligament injuries can involve injuries to the dorsal capsule, palmar plate, and adductor aponeurosis. The fixation technique associated with the highest rate of neuropathy was the modified Jobe (16.9%) versus DANE TJ (9.1%), figure-of-8 (9.0%), interference screw (5.0%), docking technique (3.3%), hybrid suture anchor-bone tunnel (2.9%), and modified docking (2.5%). I wore a custom plastic splint that immobilized the MCP joint but allowed me to move the IP joint for 8 weeks total. Bookshelf 8600 Rockville Pike The overall complication rate after primary thumb RCL and UCL repair was 13.8%. Exercises: Gradually progress to competitive throwing and sports . Federal government websites often end in .gov or .mil. This ligament prevents the thumb from pointing too far away from the hand. A broken thumb can also cause numbness or tingling. For all statistical analysis within all studies analyzed, P < 0.05 was deemed significant. Abstract Objectives: Rupture of the ulnar collateral ligament (UCL) is a frequent injury of the hand. For example, it can be removed when performing . Mean subject age was 33.9 years. It is an often-encountered injury and can lead to chronic pain and instability when diagnosed incorrectly. Epub 2014 Dec 30. The ECRL bone-tendon ligamentoplasty for chronic ulnar instability of the metacarpophalangeal joint of the thumb. Wilk KE, Arrigo CA, Dugas JR, Cain EL, Andrews JR. The mean time from reported injury date to surgery was 202.4 days (2-5969). Thirty-two thumbs were treated nonoperatively and 261 operatively. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). and transmitted securely. ||Injury chronicity not always defined, but we used ,3 weeks for acute injury and .3 weeks for chronic injury. Ulnar collateral ligament (UCL) injuries occur 10 times more frequently than radial collateral ligament (RCL) injuries. Nonoperative treatment led to high patient satisfaction for acute thumb UCL injury in 2 studies.23,29 Thirty-two subjects were treated with thumb-spica immobilization (30 were proximal phalanx avulsion fractures). A systematic review of the literature was completed using the MEDLINE, PubMed, and Ovid databases. Both purely ligamentous and bony avulsion injuries were included. [32] The most common region of rupture of the UCL is at the distal insertion or in the distal aspect of the ligament, leaving the proximal stump intact. Management of thumb metacarpophalangeal ulnar collateral ligament injuries. Symptoms of the UCL injury include pain, instability of the MCP joint of the thumb, and weakness in prehension and the chronicity of the injury. All but 2 were level IV evidence. Potentially inclusive articles were manually reviewed, discussed among the authors, and a decision was made regarding inclusion or exclusion. Detection bias was present in the inconsistent use of an invalidated outcomes tool (Glickel grading system), visual measurement of range of motion, different tools for strength and stability measurement, and the subjective nature of reporting weakness and stability. Ritting et al[30] assert that operative management of acute injuries is indicated when the thumb is without an endpoint to valgus stress testing. If it is appropriate, then surgical consent probably happened before the surgery. [41] Abrahamsson et al[42] maintain that a proximally displaced ligament, palpated proximal to the MP joint, is a more specific indication for surgery. The evidence regarding operative and nonoperative treatments of acute and chronic thumb UCL insufficiency is primarily limited to level IV retrospective case series and level V expert opinion. These exercises may be directed by a physical or occupational therapist. Chir Main. 32. Ulnar collateral ligament (UCL) rupture is often seen in patients practicing sports activities, particularly in ski falls. This damage may lead to temporary or permanent numbness or weakness. RESULTS The mean follow-up time was 22.2 months (range 6-54 months). Metacarpophalangeal joint instability was either not observed or mild (up to 9 degrees). The authors report no funding or conflicts of interest. PMC ECRL, extensor carpi radialis longus; IP, interphalangeal; MRI, magnetic resonance imaging; NR, not reported. Muscles. 31. This is the first study to compare complication rates between radial and ulnar collateral ligament injuries of the thumb. Patients who fail nonoperative management have persistent thumb pain, decreased pinch strength, decreased grip strength, limited activities of daily living (especially opening jars and turning keys), continued instability, and early arthrosis.15,39 It is not entirely clear why patients fail nonoperative treatment, but some authors contend that failure may be because of irreducible displacement of the ruptured ligament.15 In patients who had failed nonoperative treatment, who were subsequently taken to surgery, it was found that many of the small avulsion fractures had rotated with the fragment's articular surface rotated out of the plane, precluding fracture healing.15. Ulnar neuropathy was defined as any symptoms or objective sensory and/or motor deficit(s) after surgery, including resolved transient symptoms. Danilkowicz RM, O'Connell RS, Satalich J, O'Donnell JA, Flamant E, Vap AR. Complications after surgical treatment of UCL injury are rare. Breek JC, Tan AM, van Thiel TP, et al.. Free tendon grafting to repair the metacarpophalangeal joint of the thumb. 26. Usually it is pulled off of the bone (proximal phalanx) on the nail side of the joint. 1993;21:800804. eCollection 2021 Apr. 3. Furthermore, it is interesting that our study quality results using the Quality Appraisal Tool were as low as they were (mean 54% with a range of 33%-79%). Most times, they won't know until they're in the surgery if the internal brace is appropriate. It essentially forms a soft-tissue sling that keeps the radial head in place on the humerus. The mechanism of UCL injury is a forced abduction or rotation and hyperextension injury of the thumb at the MP joint.32 The most common region of rupture of the UCL is at the distal insertion or in the distal aspect of the ligament, leaving the proximal stump intact.32 Ulnar collateral ligament injuries can involve injuries to the dorsal capsule, palmar plate, and adductor aponeurosis.33 Avulsion fractures of the ulnar base of the proximal phalanx occur 20% to 30% of the time.17,34 Anywhere from 14% to 64% of UCL injuries have associated Stener lesions, which occur when the adductor aponeurosis is interposed between the ruptured end of the UCL and its site of proximal phalanx attachment.32, Nonsurgical treatment has been advocated for nondisplaced, or minimally displaced avulsion fractures of the UCL either with functional bracing35 or via thumb spica casting or splinting.23,3638 Kuz et al recommend that most acute avulsion fractures of the thumb UCL be treated nonsurgically, with the exception of displaced fractures with more than 30% articular involvement or bony Stener lesions. Orthop Clin North Am. Other than 1 postoperative palmaris longus graft rupture requiring MP joint arthrodesis, no significant complications such as neurovascular injury or superficial or deep infection occurred. 2022 Jul;50(8):2324-2338. doi: 10.1177/03635465211023952. In these patients, after failure of nonoperative treatment at anywhere from 1 month to more than 6 years, nearly all patients can achieve complete pain relief, normal pinch and grip strength, joint stability, and range of motion after surgical reconstruction. MCP fusion was performed on 36.3% (4/11) of patients with RCL (N=1) and UCL (N=3) tears. 1962;124:396411. Ulnar collateral ligament (UCL) injuries have significantly increased over the past few decades, especially in young throwing athletes. abduction-adduction motion. A score of 2 was assigned if the item was completely and accurately performed and reported. Part I: anatomy and diagnosis. 1999;24:275282. Sollerman C, Abrahamsson SO, Lundborg G, et al.. Functional splinting versus plaster cast for ruptures of the, 41. Early and late postoperative complications were recorded. Eighty patients were included in the study [N=62 (UCL), N=18 (RCL)]. The .gov means its official. However, thumb UCL reconstruction was hypothesized to be significantly better than repair for chronic UCL injury. When untreated, this injury may lead to decreased pinch strength, pain, instability, and osteoarthritis. 1. Furthermore, the lack of patient-specific data precluded advanced statistical calculations, and weighted means from individual studies were the basis for comparison. Corresponding Author Hisham M. Awan, MD, The Ohio State University Hand and Upper Extremity Center, 915 Olentangy River Rd, Suite 3200, Columbus, OH 43212 (hisham.awan@osumc.edu). Unilateral injuries: 291 and bilateral injury: 1. Clipboard, Search History, and several other advanced features are temporarily unavailable. The rate of complications after RCL primary repair was higher than UCL repair, however not statistically significant. Surgically Treated Chronically UCL-Deficient Patients Who Had Failed Previous Management, Clinical Outcomes After Primary Repair of Acute UCL Injury, Clinical Outcomes After Autograft Reconstruction for Chronic UCL Injury. 1976;58:106112. Disclaimer. FOIA 1,5,9,10 In acute cases of complete tears involving high-level . Careers. Complication rates after RCL repair (N= 4; 22.2%) were higher than UCL repair (N= 7; 11.3%). It usually occurs secondary to chronic metacarpophalangeal instability and degenerative osteoarthritis of the thumb. Furthermore, there was no donor site morbidity from autograft harvest sites across all studies. **Stener lesion status reported in 6 studies (145 thumbs). Jupiter JB, Sheppard JE. This systematic review has demonstrated excellent clinical outcomes (pain, strength, motion, and stability) after surgical treatment (repair and autograft reconstruction) of both acute and chronic UCL injury, without any significant difference between repair and reconstruction for acute and chronic injury, respectively. Delma S, Ozdag Y, Baylor JL, Grandizio LC, Klena JC. Return-to-Play Outcomes in Professional Baseball Players After Medial Ulnar Collateral Ligament Injuries: Comparison of Operative Versus Nonoperative Treatment Based on Magnetic Resonance Imaging Findings. Evidence-based use of clinical examination, ultrasonography, and MRI for diagnosing ulnar collateral ligament tears of the metacarpophalangeal joint of the thumb: systematic review and meta-analysis. Background:Thumb ulnar collateral ligament (UCL) tears are common in competitive athletes. Accessibility Inclusion criteria included English language studies after nonoperative or operative treatment of thumb UCL injuries with a minimum of 2 years mean follow-up. Am J Orthop (Belle Mead NJ). 27. SYMPTOMS: The thumb may be swollen, bruised and painful. Further detection bias existed in that not all studies used each clinical outcome (eg, Glickel grade) or radiographic measure postoperatively. *The Ohio State University Hand and Upper Extremity Center, Columbus, Ohio; Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois; and. better/same/worse than preoperative status). Hand Clin. Our primary purpose was to compare nonoperative treatment with surgical repair and surgical reconstruction of thumb UCL injuries. 1996;25:474477. The procedure involves a synthetic tape that is about a millimeter in width but exceedingly strong. Continuous variable data were reported as mean SDs from the mean. Ulnar collateral ligament injuries of the thumb (gamekeeper or skier thumb) are more common than the radial side but both can cause significant disability. When untreated, this injury may lead to decreased pinch strength, pain, instability, and osteoarthritis. It was hypothesized that surgical management results in equivalent outcomes for both acute and chronic UCL injury. Data collected on each patient included patient demographics, imaging (x-rays and MRI), perioperative data (e.g. Alejandro Badia Orthopedic Hand Surgeon Hands, Elbow, Shoulder and Wrist - Badia Hand to Shoulder Ce. Additional Information: After surgery, you should expect some pain, swelling, and stiffness. Chronic post-traumatic radial instability of the metacarpophalangeal joint of the finger. If the force is too strong, the ligaments can tear. unstable when the thumb is used. Long-term results of ligament reconstruction. 4. Weakened grip or reduced thumb range of motion may occur. Roy J, MacDermid J, Woodhouse L. Measuring shoulder function: a systematic review of four questionnaires. FOIA Ulnar Collateral Ligament Reconstruction: Anatomy, Indications, Techniques, and Outcomes. Here's Advice, Emergency Birth on a Plane: Two Doctors Earn Their Wings, Brachial Plexus Injury in Sports Medicine, Cervical Spine Acute Bony Injuries in Sports Medicine. Causes. Please enable it to take advantage of the complete set of features! The overall complication rate was 13.8% (11/80). [6] Treatment [ edit] A post-operative photo of repair of a complete rupture of the ulnar collateral ligament. Pearl: ensure slight adduction of thumb when placing the thumb spica splint for skier's thumb to reduce stress on the UCL. J Hand Surg Am. There is currently no consensus on treatment of acute or chronic UCL injuries. Some injuries can be associated with a Stener lesion, which is displacement of the ruptured ligament proximal to the adductor aponeurosis, effectively precluding healing without operative treatment.6, Acute injuries can be treated with immobilization or surgically with direct repair using bone anchors, direct repair using bone tunnels and pullout sutures, or tension band fixation of bony avulsions.79 If an injury is chronic, there are several operative treatment options, including ligament reconstruction with tendinous autograft or allograft, bonesoft tissuebone autograft, or even fusion of the MP joint.1012. All but 2 studies were level IV evidence (there was one level II prospective cohort19 and one level III evidence retrospective comparative study20). Erickson BJ, Harris JD, Chalmers PN, Bach BR Jr, Verma NN, Bush-Joseph CA, Romeo AA. The rate of complications after RCL primary repair was higher than UCL repair, however not statistically significant. When the thumb is straight, the collateral ligaments are tight and stabilize the joint against valgus force. After three to four weeks, the joint should heal enough to remove the splint and begin strengthening exercises. One study15 reported outcomes of 9 patients who had failed nonoperative treatment and underwent subsequent surgical repair. Skier's thumb is a partial or complete rupture of the ulnar collateral ligament of the metacarpophalangeal joint of the thumb. Your message has been successfully sent to your colleague. Rupture of the ulnar collateral ligament (UCL) is a frequent injury of the hand. MCP collateral ligament sprain is most commonly an acute injury related to trauma. Range of motion returns much sooner, too. Does Weightlifting Improve Cardiovascular Mortality Risk for Older Aged Adults? Surgical treatment has been advocated for all avulsion fractures of the UCL, as the area of articular cartilage is always greater than the fragment size.41 Abrahamsson et al42 maintain that a proximally displaced ligament, palpated proximal to the MP joint, is a more specific indication for surgery. Basic knowledge of the anatomy of the finger and a thorough evaluation of the patient can ensure proper diagnosis and treatment. official website and that any information you provide is encrypted Gamekeepers thumb: a prospective study of functional bracing. 1989;71:383387. The goal of Fusion Arthroplasty of the CMC joint is to fuse the bones together in the thumb so that they do not rub on each other and cause pain. government site. Neurological Complications Following Arthroscopic and Related Sports Surgery: Prevention, Work-up, and Treatment. We sought to address a gap in the literature by comparing thumb metacarpophalangeal (MCP) joint angle measurements and biomechanical strength before complete, acute UCL tear and after . Epub 2019 Mar 21. Fourteen articles were included and analyzed (293 thumbs). Rupture of the ulnar collateral ligament (UCL) is a frequent injury of the hand. Obremskey W, Pappas N, Attallah-Wasif E, et al.. Levels of evidence in Orthopaedic Journals. Unable to load your collection due to an error, Unable to load your delegates due to an error. Results You will be limited for the first 6 weeks with pain, weakness, and stiffness in the hand and thumb. Surgery has been recommended for fracture displacement, significant articular involvement, clinical instability, or fragment rotation.38 Chuter et al40 contend that surgical repair of acute UCL ruptures is the gold standard of treatment in the presence of gross instability, Stener lesions, or displaced avulsion fractures. Please confirm that you would like to log out of Medscape. Seventeen articles (n = 1518 cases) met the inclusion criteria, all retrospective cohort studies. Proximal interphalangeal joint injuries of the hand. Clinical Journal of Sport Medicine23(4):247-254, July 2013. Thumb ulnar collateral ligament (UCL) tears occur commonly in elite athletes. This site needs JavaScript to work properly. Mean subject age was 33.9 years. Morphometric Evaluation of Collateral Ligaments of the First Metacarpophalangeal Joint. Table 1. Increase in Use of Medial Ulnar Collateral Ligament Repair of the Elbow: A Large Database Analysis. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. A secondary purpose was to compare graft choice and surgical technique for reconstruction. Part I of this two-part article focuses on common tendon and . A p-value of 0.05 was considered statistically significant. All authors independently performed the search. After application of all inclusion and exclusion criteria, 14 studies were identified for further analysis and review. eCollection 2021 Nov. Yu JS, Carr JB 2nd, Thomas J, Kostas J, Wang Z, Khilnani T, Liu K, Dines JS. If any instability of the metacarpo-phalangeal joint is detected on the radial side of the joint with lateral stress and ulnar deviation than repair or reconstruction of the radial . Possible complications include: - Objectives: A Novel Surgical Reconstruction Technique in the Management of Chronic Ulnar Collateral Ligament Tears with Volar Subluxation. Of the 262 potentially relevant studies, 14 studies were identified for review11,15,1829 (Figure 1). Injury. Complications after this procedure may include nerve or blood vessel damage. Stener B. Skeletal injuries associated with rupture of the. In the event of disagreement among authors for study inclusion, the final decision was made by the senior author (HMA). 1,6,15 The mechanism of injury is a radially directed force on an extended thumb, which can occur when an athlete falls onto an abducted thumb, slides into a baseball base, or attempts to catch a ball. The range of motion of the MP joint of the thumb following operative repair of the.