Exclusion criteria were non-English studies and any study with less than 2 years mean follow-up. Looney AM, Wang DX, Conroy CM, Israel JE, Bodendorfer BM, Fryar CM, Pianka MA, Fackler NP, Ciccotti MG, Chang ES. Baar H, Baar B, Kaplan T, Erol B, Tetik C. Chir Main. 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. Stretching or even a rupture of the graft is also possible. An example of the search strategy used for PubMed was ((((((ulnar[Title/Abstract]) AND collateral[Title/Abstract]) AND ligament[Title/Abstract])) OR ucl[Title/Abstract])) AND thumb[Title/Abstract]. Each abstract was manually reviewed, with potentially relevant full text of studies scrutinized for study inclusion or exclusion. Complication rates after RCL repair (N= 4; 22.2%) were higher than UCL repair (N= 7; 11.3%). Superficial infections tend to settle quickly with oral antibiotics and regular dressings. The ulnar collateral ligament complex is located on the inside of the elbow (pinky or medial side). [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. government site. Sports Health. If the latter was executed only partially, a score of 1 was assigned. A systematic review of multiple medical databases was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines with specific inclusion and exclusion criteria. Pearl: ensure slight adduction of thumb when placing the thumb spica splint for skier's thumb to reduce stress on the UCL. American Society of Anesthesiologist (ASA) status, Wound Class, UCL versus RCL repair, date of surgery), post-operative treatment (immobilization and rehab), complication type (prolonged stiffness/pain, instability, reoperation, salvage arthrodesis of the first MCP joint), complication treatment, and outcome of the complication (e.g. to maintaining your privacy and will not share your personal information without 4. 31. Subject, surgical, and study data were compared using 2-sample and 2-proportion Z-test calculators with alpha 0.05 because of the difference in sample sizes between the compared groups. [41] Abrahamsson et al[42] maintain that a proximally displaced ligament, palpated proximal to the MP joint, is a more specific indication for surgery. doi: 10.1016/j.asmr.2020.12.004. Eventually this abnormal movement will wear out the joint and it will become arthritic. HHS Vulnerability Disclosure, Help Epub 2020 Jun 29. There is currently no consensus on treatment of acute or chronic UCL injuries. I was able to work while wearing the splint. The .gov means its official. Weakened grip or reduced thumb range of motion may occur. Selection bias was presented based on the variance in subject age, gender, hand dominance, injury chronicity, injury location, the presence or absence of bony avulsion, the presence or absence of Stener lesion, and the retrospective nature of most of the studies. Epub 2021 Sep 7. Abrahamsson SO, Sollerman C, Lundborg G, et al.. There is no uniformly agreed on surgical indication for UCL injuries to the MP joint of the thumb. J Hand Surg Am. 415 Ray C Hunt Drive, Suite 3200 Charlottesville, VA 22903 434-982-HAND (4263) In addition, basic science, anatomical/histopathological, imaging, biomechanical, surgical technique, and studies on digits other than the thumb were excluded. Axillary block anesthesia is a technique which can also provide anesthesia to the whole arm. UCLR case series that contained complications data were included. The overall complication rate after primary thumb RCL and UCL repair was 13.8%. When evaluating the relationship between ulnar and radial ligamentous injury and the presence or absence of complication, there was no significant difference, however trends were noted, X. 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%). He too had the internal brace augmentation. Clipboard, Search History, and several other advanced features are temporarily unavailable. Ulnar collateral ligament injuries of the thumb (gamekeeper or skier thumb) are more common than the radial side but both can cause significant disability. No study directly compared the different types of graft for UCL reconstruction. Studies that duplicated patient populations from the same authors were excluded. All techniques improved clinical outcomes, including pain, motion, strength, and stability (Table 5). government site. 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. Your ligament may need to be reattached to the bone using a bone anchor. the splint for protection or at night until twelve weeks after the operation. 1996;25:527530. Mean subject age was 33.9 years. Outcome of avulsion fractures of the ulnar base of the proximal phalanx of the thumb treated nonsurgically. When untreated, this injury may lead to decreased pinch strength, pain, instability, and osteoarthritis. Nonoperative treatment of acute UCL injury (with or without a Stener lesion) frequently fails, leading to chronic pain, instability, and weakness, eventually prompting surgical intervention. The surgical approach associated with the highest rate of neuropathy was detachment of flexor pronator mass (FPM) (21.9%) versus muscle retraction (15.9%) and muscle splitting (3.9%). A secondary purpose was to compare graft choice and surgical technique for reconstruction. The pathology and treatment of radial subluxation of the thumb with ulnar displacement of the head of the first metacarpal. Comparison of Outcomes Based on Graft Type and Tunnel Configuration for Primary Ulnar Collateral Ligament Reconstruction in Professional Baseball Pitchers. abductor pollicis longus (PIN) proximal, dorsal, and radial force on the shaft fragment. Unable to load your collection due to an error, Unable to load your delegates due to an error. 2014 Dec;33(6):384-9. doi: 10.1016/j.main.2014.10.003. There were 6 studies that reported clinical outcomes after autograft UCL reconstruction.11,18,19,21,22,27 Reconstruction techniques (Table 5) and grafts included palmaris longus via bone tunnels with or without K-wire MP joint fixation, palmaris longus with suture anchor fixation, iliac crest boneperiosteumbone graft with cortical screw fixation, and extensor carpi radialis longus bonetendon ligamentoplasty with titanium screw and suture anchor fixation. 3. No study compared different graft types or fixation techniques. 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. All material on this website is protected by copyright, Copyright 1994-2023 by WebMD LLC. Data range was reported as minimum to maximum absolute values. 19. Positive ulnar variance is used to describe a forearm where the distal ulna is no longer in line with the distal radius, resulting in the ulnar being longer. Get new journal Tables of Contents sent right to your email inbox, Outcomes After Injury to the Thumb Ulnar Collateral LigamentA Systematic Review, Articles in PubMed by Julie Balch Samora, MD, PhD, Articles in Google Scholar by Julie Balch Samora, MD, PhD, Other articles in this journal by Julie Balch Samora, MD, PhD, Ulnar Collateral Ligament Injury of the Thumb Metacarpophalangeal Joint, Weight Training in Youth-Growth, Maturation, and Safety: An Evidence-Based Review, Effectiveness of Shockwave Treatment Combined With Eccentric Training for Patellar Tendinopathy: A Double-Blinded Randomized Study, Core Stability Exercises for Low Back Pain in Athletes: A Systematic Review of the Literature, Diagnosis and Treatment of Triceps Tendon Injuries: A Review of the Literature, Privacy Policy (Updated December 15, 2022). Mean Quality Appraisal Tool score was 13.1 (55% overall rating study methodological quality). Consensus was obtained between the authors on assignment of study quality scores with any score dispute being decided by default assignment of the lower of the 2 disputing scores, as originally reported and recommended in the original study using the Quality Appraisal Tool.16. 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. Surgical techniques and a review of 70 patients. Mechanism of injury to the UCL of the MCP joint of the thumb is sudden, forced, radial deviation (abduction) and extension resulting in partial or complete tear of the ligament. Infection is a rare complication of hand surgery. 1998;23:503506. 7. All techniques improved clinical outcomes, including pain, motion, strength, and stability. The rate of complications after RCL primary repair was higher than UCL repair, however not statistically significant. The overall complication rate after primary thumb RCL and UCL repair was 13.8%. History. Although many injuries can be managed conservatively, some require more invasive interventions to prevent complications and loss of function. Please try after some time. This site needs JavaScript to work properly. Knowledge of the anatomy and accurate physical examination are essential in the evaluation of a patient with skier's thumb. This includes, but not limited to, self-retrograde massage, cold therapy, and extremity elevation. Some broken bones do not heal even when they get the best surgical or nonsurgical treatment. Key, pulp, and tip pinch and grip strength were either equivalent or only mildly weak compared with the contralateral thumb and hand in all subjects. Epub 2015 Sep 22. Although the natural history of chronically untreated UCL injury eventually leads to pain and loss of function, surgery intervened in the studies present. To date, no literat. Methods: Commonly, the joint will be permanently enlarged due to the scarring of the healing process. PMC Acute UCL repair and autograft UCL reconstruction for chronic injury led to excellent clinical outcomes, without a significant difference between the 2 groups. Thumb ulnar collateral ligament (UCL) tears occur commonly in elite athletes. **Stener lesion status reported in 6 studies (145 thumbs). Exercises: Progress to Phase II throwing (once successfully completed Phase I) POST-OPERATIVE WEEK 30-32 . Further detection bias existed in that not all studies used each clinical outcome (eg, Glickel grade) or radiographic measure postoperatively. A sprained thumb is a common injury among athletes. [33] Avulsion fractures of the ulnar base of the proximal phalanx occur 20% to 30% of the time. Please confirm that you would like to log out of Medscape. Patel SS, Hachadorian M, Gordon A, Nydick J, Garcia M. J Hand Microsurg. Only prospective studies can determine this injury course. Chronic post-traumatic radial instability of the metacarpophalangeal joint of the finger. 27. J Bone Joint Surg Am. A blunt self-retainer is used to retract the musculature, and a small periosteal elevator can be used to clean any remaining muscle fibers from the UCL. 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). Delma S, Ozdag Y, Baylor JL, Grandizio LC, Klena JC. When the thumb is straight, the collateral ligaments are tight and stabilize the joint against valgus force. Rehabilitation and Return-to-Play Criteria Following Ulnar Collateral Ligament Reconstruction. A Stener lesion is difficult to diagnose but leads to poor healing and usually indicates operative management. In some cases, certain risk factors make it more likely that a bone will fail to heal. There were 200 acute injuries and 93 chronic injuries. Click the topic below to receive emails when new articles are available. These tears often occur as a result of a radially directed force on an extended thumb. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. 1989;71:383387. Ritting et al[30] assert that operative management of acute injuries is indicated when the thumb is without an endpoint to valgus stress testing. Levels IIV evidence (according to the Oxford Centre for Evidence Based Medicine used by the American version of the Journal of Bone and Joint Surgery)14 were reviewed for inclusion in this review. Sports injuries accounted for most of the remaining injuries, with only 2.4% acquired as a result of skiing injuries. Moher D, Liberati A, Tetzlaff J, et al.. Gamekeeper's thumb: a quantitative evaluation of acute surgical repair. When untreated, this injury may lead to decreased pinch strength, pain, instability, and osteoarthritis. A score of 0 was assigned if the item was either omitted or not performed. PLoS Med. There is currently no consensus on treatment of acute or chronic UCL injuries. Therefore, these patients were included in the surgical group for analysis, as they did have more than 2 years minimum clinical follow-up after surgical treatment. Bethesda, MD 20894, Web Policies Instability of the metacarpophalangeal joint of the thumb. and twist using your thumb. 14 It is important to diagnose complete tears early because . When a broken bone fails to heal it is called a "nonunion." A "delayed union" is when a fracture takes longer than usual to heal. 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. Continuous variable data were reported as mean SDs from the mean. 2013;23(4):247-254. Usually it is pulled off of the bone (proximal phalanx) on the nail side of the joint. Some error has occurred while processing your request. Quantitative outcome of surgical repair. Am J Sports Med. Your thumb will be immobilized in a splint and should not be moved until follow up. Despite a perception that UCLR has minimal morbidity, a review of all published literature revealed that 12.0% of UCLR surgeries result in postoperative ulnar nerve complications. Complications after surgical treatment of UCL injury are rare. The major arc of motion of the thumb MP joint is flexion and extension, although there is some abduction, adduction, and rotation.30 The stability of the MP joint derives from joint congruity, the true and accessory collateral ligaments, the volar plate, and the surrounding intrinsic muscles.31 The adductor pollicis supplies active support on the ulnar aspect, whereas the abductor pollicis brevis and flexor pollicis brevis provide dynamic stability on the radial border. [16] Despite these study limitations, this systematic review is strong in that it analyzes the largest number of studies and subjects in the literature managed with both nonoperative and operative means for acute and chronic UCL injury. The search was performed on November 17, 2011, using PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines.13 There were no limits placed on study publication date. There are many ways to manage both acute and chronic thumb UCL deficiency, and controversy persists as to the best treatment options. TREATMENT: Treatment consists of either a period of splintage or if completely torn,a repair of the ligament with an operation. There is also significant performance bias, as there are multiple different methods of treatment, providers, graft, suture, and fixation types, as well as methods and duration of immobilization. Most times, they won't know until they're in the surgery if the internal brace is appropriate. 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. It is an often-encountered injury and can lead to chronic pain and instability when diagnosed incorrectly. Before 2021 Mar 10;9(3):2325967121990052. doi: 10.1177/2325967121990052. J Hand Surg Glob Online. These exercises may be directed by a physical or occupational therapist. The mean time from reported injury date to surgery was 202.4 days (2-5969). This review has demonstrated excellent clinical outcomes after surgical treatment of both acute and chronic UCL injury, without any significant difference between repair and reconstruction for acute and chronic injury, respectively. [32] Ulnar collateral ligament injuries can involve injuries to the dorsal capsule, palmar plate, and adductor aponeurosis. J Hand Surg Am. A secondary purpose was to compare graft choice and surgical technique for reconstruction. Unable to load your collection due to an error, Unable to load your delegates due to an error. your express consent. However, thumb UCL reconstruction was hypothesized to be significantly better than repair for chronic UCL injury. Muscles. [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. Thumb sidedness reported in 3 studies (51 thumbs). Basic knowledge of the anatomy of the finger and a thorough evaluation of the patient can ensure proper diagnosis and treatment. An anatomic basis for treatment. Data is temporarily unavailable. Thirty-two thumbs were treated nonoperatively and 261 operatively. Selection bias was presented based on the variance in subject age, gender, hand dominance, injury chronicity, injury location, the presence or absence of bony avulsion, the presence or absence of Stener lesion, and the retrospective nature of most of the studies. 2005;24:217221. There was no significant difference in patient-specific and injury-specific parameters (subject age, gender, hand dominance, time to treatment, or length of follow-up) between patients with successful and failed nonsurgical treatment (P > 0.05 for each of the compared independent and dependent variables). Sports Med Arthrosc Rev. If the tear is diagnosed later a ligament reconstruction might be a better option. To address the purposes of this systematic review, the authors conducted a search of the following medical databases: PubMed, SPORTDiscus, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Cochrane Central Register of Controlled Trials. Only 1 study reported significant loss of either MP and interphalangeal joint motion (P < 0.005).25 Except for 2 patients with significant postoperative weakness, full or near-full strength (key pinch and grip) was restored in all studies. Highlight selected keywords in the article text. Dinowitz M, Trumble T, Hanel D, et al.. Failure of cast immobilization for thumb. This is a strong ligament that supports the thumb when pinching or gripping and if it is damaged may lead to a chronic instability of the thumb which causes problems with function. Seventeen articles (n = 1518 cases) met the inclusion criteria, all retrospective cohort studies. Fusetti C, Papaloizos M, Meyer H, et al.. Please use this form to submit your questions or comments on how to make this article more useful to clinicians. The rate of complications after RCL primary repair was higher than UCL repair, however not statistically significant. Our primary purpose was to compare nonoperative treatment with surgical repair and surgical reconstruction of thumb UCL injuries. Please enter a Recipient Address and/or check the Send me a copy checkbox. Transfer bias was present in the difference of length of follow-up, despite a minimum of 2 years, and the proportion of subjects who enrolled and completed that which was actually followed up. eCollection 2022 Jan. Gnanasekaran D, Raveendranath V, Karupusamy A. J Hand Microsurg. Symptoms are dependent on the cause and severity of injury to the UCL. Re-rupture occurred in 1 patient, chronic subluxation occurred in 1 patient, and chronic pain/stiffness occurred in 5 patients. The authors report no funding or conflicts of interest. After significant delay to treatment or even failed nonoperative treatment, excellent clinical outcomes can be achieved, without a difference between initially treating the injury surgically. Mean Quality Appraisal Tool score was 13.1 (55% overall rating study methodological quality). MeSH 2020 Apr 28;14(1):25-30. doi: 10.1055/s-0040-1710154. 14. One study15 reported outcomes of 9 patients who had failed nonoperative treatment and underwent subsequent surgical repair. Thumb sprain may cause bruising, tenderness, and swelling around the base of the thumb. 6, 9-14 For high-demand overhead athletes, surgical management is often recommended . [31] The adductor pollicis supplies active support on the ulnar aspect, whereas the abductor pollicis brevis and flexor pollicis brevis provide dynamic stability on the radial border.