The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 94, Issue 21

Current Concepts Review | November 07, 2012

Management of Thumb Metacarpophalangeal Ulnar Collateral Ligament Injuries

Peter C. Rhee, DO¹; David B. Jones, Jr., MD¹; Sanjeev Kakar, MD, MRCS¹

¹ Division of Hand and Microvascular Surgery, Department of Orthopedic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905. E-mail address for S. Kakar: kakar.sanjeev@mayo.edu

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Investigation performed at the Mayo Clinic, Rochester, Minnesota

J Bone Joint Surg Am, 2012 Nov 07;94(21):2005-2012. doi: 10.2106/JBJS.K.01024

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Abstract

Untreated ulnar collateral ligament (UCL) injury of the thumb metacarpophalangeal joint (MCPJ) can lead to long-term pain and functional limitations.

Detection of a UCL injury involves sequential examination of true and accessory ligaments and comparison with the uninjured side.

Acute partial UCL injuries can be successfully treated nonoperatively.

Acute complete or displaced UCL injuries can be successfully treated with operative repair.

In cases of chronic UCL injury, treatment options include static and dynamic reconstructions.

If painful arthrosis is present with chronic UCL instability, salvage may be performed with MCPJ fusion.

Figures in this Article

Introduction

Rupture of the thumb metacarpophalangeal joint (MCPJ) ulnar collateral ligament (UCL) represents one of the most common ligamentous injuries of the hand. Failure to recognize or appropriately treat these injuries can lead to instability, pain, and weakness of the MCPJ¹. Ligamentous insufficiency can result from either an acute valgus force on the abducted thumb, as commonly seen in skiing accidents (so-called skier's thumb), or from chronic repetitive valgus stress (so-called gamekeeper's thumb)². Effective management of both acute and chronic injuries requires an anatomically based physical examination, judicious use of imaging studies, and proper treatment.

Anatomy

The thumb MCPJ is a diarthrodial ginglymoid joint that allows for motion in all planes, but primarily flexion and extension³. Static stabilizers include the articular surface congruity, the palmar plate with two embedded sesamoid bones, and the collateral ligaments (radial and ulnar). Dynamic stabilizers include the intrinsic muscles (abductor pollicis brevis, flexor pollicis brevis, and adductor pollicis muscles) and extrinsic muscles (extensor pollicis longus, extensor pollicis brevis, and flexor pollicis longus muscles) about the thumb. The adductor pollicis muscle serves as the primary dynamic stabilizer of the MCPJ and resists valgus stress. The muscle inserts broadly onto the lateral tubercle of the proximal phalanx, volar plate, ulnar sesamoid, and the adductor aponeurosis, including the extensor pollicis longus muscle.

The UCL is comprised of two distinct bundles, the proper and accessory UCLs (Fig. 1)³. The proper UCL courses in a distal-palmar direction from the base of the first metacarpal head to the lateral tubercle of the proximal phalanx⁴. The accessory UCL is more superficial and blends into the fibrocartilaginous region of the palmar plate (including the ulnar sesamoid bone)⁵. The primary function of the UCL is to provide support against valgus stress and volar subluxation of the MCPJ^6,7. Strong key or tip pinch of 10 kg can result in nearly 40 to 60 kg of force across the MCPJ⁶. If torn, UCL insufficiency can lead to weakness of both key and tip pinch^1,7-9.

Fig. 1

Figs. 1-A and 1-B. Anatomy of the thumb metacarpophalangeal ulnar collateral ligament. Fig. 1-A In extension, the accessory collateral ligament (2) is taut whereas the proper collateral ligament (1) is lax. Fig. 1-B In flexion, the proper collateral ligament is taut, and the accessory collateral ligament is lax. 3 = first metacarpal head, 4 = proximal phalanx, and 5 = sesamoid bone. In both images, left is proximal and right is distal. Reproduced, with permission of the American Academy of Orthopaedic Surgeons, from Tang P. Collateral ligament injuries of the thumb metacarpophalangeal joint. J Am Acad Orthop Surg. 2011 May;19(5):287-96.

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Allied with the trapezoidal shape of the thumb metacarpal head, the proper and accessory UCL provide selective stability in flexion and extension, respectively (Fig. 1). With MCPJ flexion, the volar plate glides proximally, relaxing the accessory collateral ligament, while the proper UCL and dorsal capsule tighten¹⁰. The opposite occurs with MCPJ extension. The normal valgus laxity ranges from 6° in extension to 12° to 15° in flexion^11,12. The capsuloligamentous restraints of the MCPJ of the thumb allow an average of 10° to 15° of passive abduction^8,12.

Pathoanatomy

UCL insufficiency results in volar-radial subluxation of the proximal phalanx at the MCPJ. As the origin of the UCL is dorsal to the flexion-extension axis of the MCPJ, dorsal support is afforded to the joint, which may explain the rotatory (supination) deformity that may occur with chronic UCL insufficiency⁷. Similarly, the adductor pollicis muscle courses volar to the axis of rotation, causing volar subluxation at the MCPJ. Kaplan theorized that additional discontinuity in the dorsal joint capsule between the extensor mechanism and the adductor aponeurosis caused radial displacement of the extensor pollicis longus as the deforming force¹³.

Interposition of the adductor aponeurosis between the torn UCL and the MCPJ (the so-called Stener lesion) can impede healing of ligamentous structures¹⁴. The occurrence of a Stener lesion has been reported to occur in 64% and 88% (twenty-five of thirty-nine and fifteen of seventeen thumbs, respectively) of complete ruptures of the UCL^15,16. Although not substantiated, many consider this entity an indication for operative treatment.

Evaluation of UCL Injuries

Physical Examination

In acute injuries, patients often report an abduction or valgus-directed force to the thumb and present with edema, ecchymosis, and tenderness along the MCPJ. The presence of a palpable mass on the ulnar aspect of the proximal phalanx base may be indicative of a Stener lesion. This finding is commonly absent in patients with chronic insufficiency of the UCL of the thumb. A focused examination of the MCPJ of the thumb should include a methodical assessment of valgus laxity. Because of the pain that is associated with stress testing, local anesthesia with intra-articular lidocaine has been advocated to increase the accuracy of detecting UCL instability (correct diagnosis in 28% versus 98% of forty-seven patients with and without intra-articular injection, respectively)¹⁷. Although not routinely performed and not recommended, median and/or ulnar nerve blocks at the wrist have been suggested as a means to provide a reliable examination of the acutely injured thumb due to the effect of intrinsic and extrinsic muscles on the stability of the thumb MCPJ^18-20.

Valgus stress-testing should be performed in both extension and flexion to determine the status of the accessory and proper collateral ligaments, respectively. After isolated division of the proper collateral ligament, Heyman et al.¹⁵ noted significantly more valgus laxity of the thumb when it was positioned in 35° of flexion than when it was positioned in extension (p < 0.01). However, with disruption of the accessory collateral ligament and palmar plate complex, there was nearly equal laxity in both flexion and extension. In this series, all patients who had at least 35° of valgus instability with the thumb positioned in 30° of flexion had confirmed rupture of the proper collateral ligament with at least 15° of additional valgus laxity as compared with that measured in the uninjured thumb. When laxity of at least 35° was present with the thumb in full extension, fifteen of sixteen patients (94%) had complete displacement of both the accessory and proper collateral ligaments with a Stener lesion.

Although normal variations in laxity exist between the left and right thumb per individual, a comparison should be made between the injured and uninjured thumbs²¹. Recently, Malik et al.²² noted a >15° left-to-right difference in twelve (12%) of 100 normal patients when the thumb was positioned in 30° of flexion and in three (3%) of 100 patients when the thumb was positioned in extension. Nonetheless, these studies have been the foundation for the traditional diagnosis of UCL ruptures, with evidence of >35° of valgus laxity in flexion or extension and >15° of difference in valgus laxity as compared with that of the uninjured thumb^11,15,19.

Although no classification scheme has been formally validated, tenderness along the UCL with symmetric laxity compared with that of the contralateral thumb (i.e., a sprain) is generally classified as a grade-I injury. An increase in laxity of <10° to 15° relative to the contralateral thumb and with a firm end point (i.e., a partial rupture) is defined as a grade-II injury. An increase in laxity of >15° without a firm end point (i.e., a complete rupture) is classified as a grade-III injury²³.

Imaging Studies

Radiographs should be made in the evaluation of patients with a thumb injury to assess for osseous injury and volar subluxation, especially prior to making stress radiographs, as small fractures at the base of the proximal phalanx have been noted in as many as twenty-five (40%) of sixty-three UCL injuries²⁴. The use of stress radiographs has been described for UCL injuries with >35° of abduction or 10° to 15° of increased abduction relative to that of the contralateral thumb for the purpose of diagnosing a UCL injury^8,15. They are also helpful in detecting fractures at the base of the proximal phalanx, as these fractures may not represent a true avulsion injury of the UCL. Hintermann et al.²⁴ noted two fracture patterns in twenty-five patients with skier's thumb: 32% sustained a true avulsion fracture of the UCL, and 68% had an isolated fracture that was not attached to the ligament. The authors advocated the use of stress radiographs because the fracture may not be an osseous avulsion but, instead, a fragment of the volar aspect of the proximal phalanx associated with a complete disruption of the UCL. Nonetheless, the making of stress radiographs can be limited by patient-guarding, can cause discomfort for the patient, and have demonstrated a fairly high rate of false negative results, up to 25% in a series of twelve UCL injuries²⁵. Therefore, stress radiographs are most useful in the evaluation of patients with equivocal laxity and are not necessary when the diagnosis (based on patient history and clinical examination) is clear. Alternatively, fluoroscopy is an efficient method of evaluating an osseous injury and obtaining a real-time radiographic stress examination.

Ultrasound has also been advocated in the evaluation of thumb ligamentous injuries. Hergan and Mittler²⁶ used ultrasound to evaluate thirty-nine patients with suspected UCL injuries prior to operative intervention and correctly diagnosed the injuries of thirty-six of the thirty-nine patients, as confirmed intraoperatively. Shinohara et al.²⁷ evaluated UCL injuries in fourteen patients who subsequently underwent operative treatment; those authors were able to accurately differentiate patients who did or did not have a Stener lesion and they also reported that ultrasonic evaluation could be useful in surgical decision-making. Conversely, Susic et al.²⁸ evaluated fourteen patients for the presence of UCL injuries prior to operation and identified only two of five Stener lesions. In addition, they misidentified the location of the ligament rupture in seven of the fourteen patients. Jones et al.²⁹ reported that the positive predictive value of ultrasound in the diagnosis of UCL rupture was higher (94%) than with clinical examination alone (80%) in a series of sixty patients with UCL injury. A recent review of the literature on ultrasound diagnosis of UCL rupture demonstrated a collective sensitivity of 76%, specificity of 81%, accuracy of 81%, positive predictive value of 74%, and negative predictive value of 87%³⁰. While ultrasound is less expensive than magnetic resonance imaging (MRI) or magnetic resonance (MR) arthrography and is noninvasive, the variability of these series highlights the main drawback of ultrasonic evaluation, which is that the results tend to be dependent on operator experience. Therefore, ultrasound is useful if there is uncertainty regarding the diagnosis and an experienced musculoskeletal ultrasonographer is available.

A number of level-III evidence and cadaveric studies have evaluated the accuracy of MRI in detecting UCL injuries (Fig. 2)^25,31,32. MRI has demonstrated excellent diagnostic accuracy, ranging from 89% to 100%, with improved results when combined with MR arthrogram^25,31,32. Hergan et al.³² compared MRI with ultrasound and demonstrated 100% sensitivity and specificity of MRI (as compared with 88% sensitivity and 83% specificity of ultrasound) in the evaluation of seventeen patients with UCL tears and twenty-one normal volunteers. The cost-effectiveness of routine MRI in the evaluation of UCL injuries has not been established, and the role of imaging studies in the evaluation of patients with thumb injuries continues to evolve. Currently, MRI or ultrasound is generally recommended if there is uncertainty of the diagnosis on the basis of the clinical examination or to rule out a suspected Stener lesion.

Fig. 2

Coronal T2-weighted magnetic resonance image of a disrupted thumb ulnar collateral ligament (UCL). Indicator arrow demonstrates the displaced UCL, which is avulsed from the proximal phalanx.

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Treatment of Acute UCL Injuries

Treatment of acute UCL injuries is generally successful if the diagnosis is made and treatment initiated without delay. While there is no consensus on the time frame in which acute repair is recommended, a delay beyond three to six weeks may result in retraction and scarring of the ligament, thereby complicating primary repair^7,33. The decision between operative and nonoperative treatment is made on the basis of the degree of instability, with most authors recommending nonoperative treatment for grade-I or II injuries (sprains and partial ruptures) and operative treatment of grade-III injuries (complete ruptures), especially if associated with a Stener lesion (Fig. 3).

Fig. 3

The authors' proposed algorithm for evaluation and treatment of acute ulnar collateral ligament (UCL) rupture. MRI = magnetic resonance imaging.

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Nonoperative Treatment

Nonoperative treatment of partial UCL ruptures (grades I and II) generally results in uneventful healing without residual disability^7,8,34,35. Sollerman et al.³⁵ immobilized forty nondisplaced UCL injuries with use of a plaster thumb spica cast (n = 21) or a functional hinged splint (n = 19) for five to eight weeks. Active and passive range-of-motion exercises were initiated after immobilization, with avoidance of radial-directed forces at the MCPJ. Strengthening exercises (grip and pinch) were started at six weeks. At an average follow-up period of fifteen months, there were no differences detected in range of motion, pinch strength, or return to work between the groups.

While operative treatment is generally advised for complete or displaced UCL ruptures (grade III), nonoperative treatment of these injuries has also been described. Landsman et al.³⁶ noted that thirty-four (85%) of forty ruptures treated with a thumb spica splint healed without residual instability, pain, or stiffness, while the remaining six ruptures were associated with persistent pain and instability at twelve weeks and subsequently underwent ligament reconstruction with uneventful healing. Pichora et al.³⁷ reported on three of thirty-two patients with complete UCL ruptures that were initially treated nonsurgically but which continued to cause persistent symptoms after subsequent operative reconstruction. The authors advised caution when pursuing nonoperative treatment in patients with complete or displaced UCL injuries.

Kuz et al.³⁸ reported on the outcomes of thirty patients with avulsion fractures associated with UCL instability who were treated nonoperatively. Twenty patients were immobilized in a thumb spica cast and ten were treated with a splint for four to six weeks³⁸. At an average of 3.1 years, five of the twenty patients had a nonunion and three had persistent instability. Despite this, all patients reported satisfaction with their function and there was no difference in pinch strength as compared with that of the contralateral thumb. Dinowitz et al.³⁹ reported on nine patients who had minimally displaced (less than 2 mm) UCL avulsion fractures that were initially managed with immobilization. By four months, all patients had persistent pain and instability that required operative repair. Similar poor results were noted by Bowers and Hurst⁸ in eight of nine patients with associated avulsion fractures (unspecified size, displacement, or degree of instability) that were treated nonoperatively. Therefore, the recommendation for nonoperative management is limited to partial ligament ruptures without associated displaced or rotated avulsion fractures³.

Operative Treatment

Operative repair of acute, complete UCL ruptures has consistently demonstrated satisfactory clinical outcomes with excellent pain relief and restoration of stability and pinch strength^{7,15,33,40-43}. Early reports of primary repair of acute ruptures, which most commonly occur at the UCL insertion on the proximal phalanx, describe primary suture repair to the periosteal tissue at the base of the proximal phalanx or pull-out suture repair of the UCL tied over a bone tunnel^5,7,40,44. More recently, various operative techniques have been described including arthroscopically assisted ligament repair⁴⁵, interference docking-screw technique⁴⁶, and condylar shaving⁴⁷ to facilitate primary repair and ligament-to-bone healing.

Most recent reports of acute operative treatment describe the use of suture anchor fixation of the ruptured ligament to the base of the proximal phalanx (Fig. 4)^33,41-43,48. Kozin reported on the treatment of seven patients with acute UCL ruptures treated with suture anchor fixation who had no residual instability and nearly symmetric range of motion (93%) and pinch strength (97%)⁴². Similarly, Weiland et al.⁴³, who reported on thirty patients followed for an average of eleven months after repair of acute UCL rupture, demonstrated no difference in stress test measurements compared with the contralateral side, with satisfaction rated good or excellent in all but one patient. Zeman et al.⁴⁸ reported on fifty-eight patients whose acute UCL ruptures were treated with suture anchor fixation. Of the patients available for follow-up, forty-four (98%) had no instability and were satisfied with their surgical outcome.

Fig. 4-A

Acute disruption of the ulnar collateral ligament (UCL). Forceps holding the distal stump of the ruptured and displaced UCL.

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Fig. 4-B

Primary ulnar collateral ligament (UCL) repair with suture anchor. Indicator arrow demonstrates UCL repaired to its insertion on the proximal phalanx with a suture anchor (not visible, deep to UCL).

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Katolik et al.³³ retrospectively reviewed sixty patients who had complete UCL ruptures; thirty were treated with pullout sutures and thirty were treated with suture anchors. The patients who received pullout sutures were treated with a cast for six weeks followed by removable splint immobilization, while the patients who received suture anchors were treated with a splint for two weeks followed by removable splint immobilization and supervised therapy. After an average follow-up of twenty-nine months, the authors compared the results between the injured and uninjured sides and found that the suture anchor group had significantly greater range of motion (97% versus 86%), greater pinch strength (101% versus 95%), and shorter tourniquet time (twenty-eight minutes versus forty-three minutes) than the pullout suture group did. Despite this, both groups demonstrated high rates of patient satisfaction (4.9 and 4.5 on a five-point scale). The benefits noted in the suture anchor group may also reflect the difference in postoperative immobilization and rehabilitation.

Several recent studies have demonstrated the safety and benefit of earlier motion following acute UCL repair. Firoozbakhsh et al.⁴⁹ reported the results of a biomechanical study of UCL repair with a suture anchor in which they demonstrated decreased load to failure and joint rigidity of repaired ligaments compared with intact ligaments. They noted, however, that repaired ligaments should be able to tolerate forces generated with moderate range of motion as long as pinch forces are eliminated from early postoperative rehabilitation. A similar biomechanical, cadaveric study demonstrated that maximum load to failure was greater than three times the forces encountered in active thumb motion⁵⁰. Sollerman et al.³⁵ demonstrated no complications in patients treated operatively who were immobilized postoperatively in a functional splint that allowed MCPJ flexion and extension while preventing radial or ulnar deviation. Given these findings, there is a trend toward earlier mobilization to prevent thumb stiffness as compared with the traditional practice of immobilization of the MCPJ for four to six weeks followed by an additional six weeks of protected or supervised therapy after UCL repair.

Treatment of Chronic UCL Injuries

Primary anatomic repair of a chronic UCL injury often leads to suboptimal results⁷. The ligament can be attenuated, contracted, and difficult to mobilize to its anatomical osseous insertion^1,51. Both dynamic (tendon transfers) and static (UCL reconstruction) stabilization procedures have been described.

Primary Repair

Smith⁷ reported the results on the treatment of thirty-one patients with a chronic UCL injury. Two patients underwent primary repair that failed, and those patients subsequently underwent tendon transfer of the extensor indicis proprius to the extensor pollicis longus. Similarly, Arnold et al.¹ performed primary repair in two patients with chronic injuries and achieved one “good” and one “fair” outcome, leading the authors to conclude that reconstruction is preferential over late primary repair if the UCL injury is more than six weeks old.

Dynamic Stabilization (Tendon Transfers)

Kaplan¹³ described transfer of the extensor indicis proprius tendon to the extensor pollicis longus with repair of the dorsal capsule, resulting in complete functional recovery of the thumb without additional UCL repair in one patient with a chronic UCL injury. Neviaser et al.¹⁸ advocated MCPJ capsulorrhaphy and adductor aponeurosis advancement to the base of the proximal phalanx, followed by four weeks of external immobilization; they reported painless, stable, and mobile thumbs in six of eight patients at the time of the one-year follow-up. The remaining two patients had either a stable yet painful (arthritic) thumb requiring MCP arthrodesis or recurrence of MCP instability without any need for additional treatment. McCue et al.⁵² performed UCL ligament reattachment or advancement combined with adductor advancement in twenty-five athletes with UCL injuries that had been sustained more than four weeks before surgical treatment; those authors reported that all of the patients were able to return to athletic competition. Sakellarides and DeWeese⁵¹ transferred a split or full extensor pollicis brevis tendon to the proximal phalanx in fourteen patients with chronic UCL insufficiency whose thumbs were immobilized for five to seven weeks after surgery. All patients reported satisfactory results without recurrence of instability or disabling pain.

Static Stabilization (Tendon Graft Reconstruction)

Frykman and Johansson described the technique of UCL reconstruction with a slip of the abductor pollicis longus⁹. In one patient, treatment of a chronic UCL injury resulted in decreased range of motion at the MCPJ, slight abduction instability, and preservation of pinch strength at the time of the two-year follow-up.

The extensor pollicis brevis has been utilized to reconstruct the UCL in a variety of configurations. Strandell¹⁴ reconstructed the UCL with use of a split extensor pollicis brevis in two of fourteen patients with a chronic UCL injury, resulting in slightly decreased motion, decreased pinch strength, laxity compared with the uninjured side, and pain with heavy loading in one patient and a so-called normal thumb in the other patient. In contrast, five of eight patients who underwent free tendon graft (palmaris longus) reconstruction had a so-called normal thumb at the time of follow-up. Fairhurst and Hansen⁵³ used a modification of this technique with the full extensor pollicis brevis tendon in two patients in whom the injury was sustained at a mean of eight weeks before surgery, with the results of operation being a stable MCPJ without loss of function at a minimum postoperative follow-up time of six months.

Smith⁷ reported on thirty-eight patients who underwent reconstruction of a chronically disrupted collateral ligament with use of a free palmaris longus autograft (Fig. 5). Patients were treated with a thumb spica cast for four weeks and a removable splint for an additional five weeks. There were two UCL reconstruction failures salvaged with MCPJ arthrodesis. The remaining patients returned to full activities within three months after surgery. Breek et al.⁵⁴, who used a modification of the technique described by Strandell¹⁴, utilized a free palmaris longus graft for UCL reconstruction in thirty-seven UCL-injured patients, after which the thumb was immobilized for four weeks. After a mean follow-up period of thirty-six months, 92% (forty-seven of fifty-one patients who were available for review, including patients with volar-plate, UCL, and radial collateral ligament injuries) had subjective satisfactory results and 94% (forty-eight of fifty-one) had equal pinch strength in both thumbs. Alternatively, bone-soft tissue-bone (wrist second extensor compartment retinaculum)⁵⁵ and bone-periosteum-bone (iliac crest)⁵⁶ autografts have been reported.

Fig. 5-A

Chronic ulnar collateral ligament (UCL) rupture. Forceps holding the proximal stump of the UCL. Black indicator arrow demonstrating the capsule of the metacarpophalangeal joint.

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Fig. 5-B

Ulnar collateral ligament reconstruction with a palmaris longus allograft. Forceps holding the reflected joint capsule. Black indicator arrow demonstrates the tendon graft secured to the metacarpal head with an interference screw.

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Alldred⁵⁷ described a figure-of-eight weave with a fourth-toe extensor autograft for UCL reconstruction in three patients, all of whom had full function and a stable MCPJ after reconstruction. Sennwald et al.⁵⁸ noted two failures in twenty-five patients treated with figure-of-eight free tendon graft reconstruction. The remaining patients had limitation of flexion (mean loss of 19° at the MCPJ) without influence on mean pinch strength. Osterman et al.²⁰ noted hyperextension laxity in two of nine patients with a figure-of-eight palmaris longus graft reconstruction. However, this did not occur with a “rectangular” (parallel-limb) configuration. Maneaud and Littler⁵⁹ introduced a triangular configuration of free tendon graft reconstruction with the apex of the triangle at the metacarpal neck (proximal) to restore normal anatomy. Glickel et al.⁶⁰ reported stable and pain-free MCPJs in twenty-four of twenty-six patients, with excellent results in twenty patients with this configuration. However, mean loss of motion was 20% at the MCPJ. The reverse (apex distal) was proposed by Fairhurst and Hansen⁵³, with stable reconstructions in follow-up, as noted earlier.

Hsieh et al.⁶¹ compared the traditional figure-of-eight configuration^14,57,58 to a so-called anatomic reconstruction of the proper and accessory UCLs with a free tendon graft. Neither restored full stability to volar translation and abnormal supination at the MCPJ. Lee et al.⁶² biomechanically compared the results of triangular, figure-of-eight, and rectangular free tendon graft reconstructions and noted that all methods resulted in a stable MCPJ. However, only the apex proximal triangular configuration restored motion similar to that of a normal MCPJ. Mitsionis et al.⁶³ reported full stability at the MCPJ in fourteen of twenty patients after free tendon graft reconstruction with suture anchors. Baskies et al.⁶⁴ observed no biomechanical difference between free tendon graft figure-of-eight configuration through bone tunnel compared with fixation with biotenodesis screws.

Arthrodesis

Neviaser et al.¹⁸ performed an arthrodesis on seven of fifteen patients who had a chronically injured UCL with painful arthrosis. At the time of the one-year follow-up, four of the seven patients had deficits in flexion-adduction with loss of the ability to touch the small finger tip. All patients had diminished dexterity, but none believed that this was a significant disability. Hagan and Hastings⁶⁵ reported on ten patients who had thumb MCPJ arthritis due to chronic UCL insufficiency, treated with arthrodesis via Kirschner wires or tension-band wiring without any bone-grafting. They noted a 100% fusion rate and significantly improved pinch strength after arthrodesis (p < 0.02). Arnold et al.¹ performed an MCP arthrodesis in eleven of thirty-three patients who had chronic UCL insufficiency. No long-term results were reported for these patients, but the authors anecdotally proposed that the limitations in function associated with arthrodesis should be reserved as a salvage procedure. Although no statistical analysis was performed, they correlated abnormal preoperative radiographs as predictors of a poor outcome.

Overview

Injury to the thumb MCPJ UCL can present challenges in establishing the diagnosis and determining the optimal treatment. Early diagnosis is essential because acute treatment can result in improved function and decreased pain. In cases of complete rupture and instability, acute repair provides a more predictable and reliable outcome compared with the treatment of chronic injuries. For patients with chronic UCL injuries, a number of static and dynamic stabilization procedures can be used to treat a nonarthritic joint. For joints in which arthrosis is present, MCP arthrodesis is the recommended treatment for chronic UCL insufficiency.

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Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Topics

pain ; reconstructive surgical procedures ; rupture ; thumb ; ulnar collateral ligament

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Peter C. Rhee, David B. Jones, Jr., Sanjeev Kakar; Management of Thumb Metacarpophalangeal Ulnar Collateral Ligament Injuries. The Journal of Bone & Joint Surgery. 2012 Nov;94(21):2005-2012.

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