Thumb Ulnar Collateral Ligament Injuries Research Articles

MRI spectrum of injuries to the thumb metacarpophalangeal joint ulnar collateral ligament with a proposed expanded classification of injuries in American football players.

Injuries to the ulnar collateral ligament of the thumb metacarpophalangeal joint are of both historic and modern interest for athletes and non-athletes alike. The thumb metacarpophalangeal joint requires stability in both flexion and extension utilizing a combination of static and dynamic stabilizers. This article reviews the magnetic resonance imaging categorization of thumb ulnar collateral ligament injuries and proposes two additional injury patterns seen in high-level and professional athletes who play American football. In addition to the direct magnetic resonance imaging findings in collateral ligament tears, secondary findings of rotation and subluxation can be seen at the thumb metacarpophalangeal joint due to the altered physiologic forces on the joint. Internal brace augmentation via suture tape of a traditional ulnar collateral ligament repair is a novel surgical technique that provides protection during initial healing and the ensuing remodeling phase following repair or reconstruction, resulting in a faster return to play.

Return to Play After Thumb Ulnar Collateral Ligament Injuries Managed Surgically in Athletes—A Systematic Review

The purpose of this systematic review was to summarize the available data on how surgical management of injuries to the thumb ulnar collateral ligament (UCL) complex affects athletes and their return-to-play (RTP) and postinjury performance metrics in addition to evaluating rehabilitation guidelines. A systematic search was performed on PubMed and Embase databases for articles on outcomes of surgical treatment of thumb UCL injuries in athletes. Articles with expert recommendations on postoperative management and RTP guidelines were also included separately. Study characteristics were recorded, including sport, RTP rates, and data on performance. Recommendations were summarized by sport. The Methodological Index for Non-Randomized Studies (MINORS) criteria was used to assess methodological quality. The authors also present their recommended return-to-sport algorithm. Twenty-three articles were included, including 11 with reports on patients and 12 expert opinions on guiding RTP. The mean MINORS score for the applicable studies was 9.4. In the 311 patients included, RTP was 98.1% in aggregate. No performance detriments were noted in athletes after surgery. Thirty-two (10.3%) patients had postoperative complications. The recommendations on timing to RTP vary by sport and author, but all recommended initial thumb protection when returning to sport. Newer techniques, such as suture tape augmentation, suggest the permission for earlier motion. Return-to-play rates after surgical treatment of thumb UCL injuries are high, with reassuring return to preinjury level of play with few complications. Recommendations for surgical technique have trended toward suture anchors and, now, suture tape augmentation with earlier motion protocols, although rehabilitation guidelines vary by sport and author. Current information on thumb UCL surgery in athletes is limited by the low quality of evidence and expert recommendations. Prognostic IV.

Routine use of ultrasound imaging to diagnose skier’s thumb. Results from a first-aid orthopedic department in an Italian ski resort

Damage to the ulnar collateral ligament (UCL) of the thumb’s metacarpophalangeal joint (TMPJ) can result in severe functional impairment: correct diagnosis is critical to ensure the appropriate treatment to restore full TMPJ function. In an acute phase, clinical findings and X-rays alone are not reliable enough for a precise diagnosis: ultrasound scan (USS) may represent a fast, inexpensive and sensitive technique to improve the diagnosis of thumb trauma in emergency department. The purpose of this study is to assess if the introduction of the routine use of USS in clinical practice to evaluate thumb trauma could aid in diagnosis and treatment of this common injury. During eight winter seasons (2012-19), we dealt with 2553 injuries of the TMCJ at our emergency department. During the first period (2012-2015), the diagnosis of TMCJ injuries relied on clinical examination and X-rays; in the second study period (2016-2019) the diagnosis of all thumb traumas were based on clinical examination, radiographs, and ultrasound. Patients affected by type I and II lesions were conservatively treated by the application of a thumb spica plaster for three weeks, while in type III injuries for a period of one month. Type IV UCL lesions underwent surgery through a phalanx tunneling and anchor fixation technique followed by 5-weeks of immobilization in a thumb spica plaster cast. Both groups were followed up either clinically or as phone consultations for foreign patients. In the period 2012-2015, we classified 27% of TMPJ lesions as type I, 19% as type II, 15% as type III, and 27% as type IV lesions. The remaining 12% represented a fracture variant (type V). USS identified 30% type I, 21% type II, 18% type III, and 19% type IV lesions, the latter with a positive so called tadpole sign (14) (247 pts.); the remaining 12% of patients presented a fracture variant. During the first study period, the diagnosis of TMPJ injuries made exclusively by clinical examination and X-ray studies, lead to a high number of false positive type IV diagnoses that were not confirmed during surgery (13%). The introduction of USS imaging during the second period led to a detection of almost all (> 98%) type IV lesions intra-operatively, thereby avoiding unnecessary surgery, possible complications, rehabilitation, and recovery. Our work demonstrates that the routine use of USS imaging in the study of thumb UCL injuries improves the diagnostic sensitivity of clinical findings in a low cost, quick and feasible manner. USS can lead to a significant decrease in the number of misdiagnoses as previously demonstrated by other studies. USS is likely to improve patient collaboration and could potentially supplant stress-test radiography which can be painful and potentially risky in some patients.

A Comparison of Acute Versus Chronic Thumb Ulnar Collateral Ligament Surgery Using Primary Suture Anchor Repair and Local Soft Tissue Advancement

PurposeTo assess patient satisfaction and functional outcomes of primary suture anchor repair with local soft tissue advancement for both acute and chronic thumb ulnar collateral ligament (UCL) injuries.MethodsWe retrospectively reviewed patient charts who had undergone operative UCL repair between 2006 and 2013. Patients who had more than 8 weeks between the time of injury and surgery were classified as having chronic injuries. In both acute and chronic cases, a primary suture anchor repair of the ligament was performed with local soft tissue advancement. For each patient, baseline demographics, operative complications, and associated injuries were recorded along with visual analog scale pain scores; Quick Disabilities of the Arm, Shoulder, and Hand scores; and their return to work or sport status. Comparisons of outcomes and complications were made between the groups (acute vs chronic injuries).ResultsAmong the 36 patients who met our inclusion criteria, both the acute (n = 19) and chronic (n = 17) groups were similar with regards to major or minor comorbidities, visual analog scale scores; Quick Disabilities of the Arm, Shoulder, and Hand scores; return to work or sport status; or patient satisfaction.ConclusionsPatients with both acute and chronic thumb UCL injuries have similarly acceptable functional outcomes, postoperative pain, and satisfaction. Primary suture anchor repair without ligament reconstruction appears to be a safe and effective treatment option for patients’ thumb UCL injuries, even in the chronic setting.Type of study/level of evidenceTherapeutic III.

Thumb Metacarpophalangeal Joint Ulnar Collateral Ligament: Early Outcomes of Suture Anchor Repair with Suture Tape Augmentation

Introduction The purpose of this study was to evaluate the early outcomes of thumb metacarpophalangeal (MCP) joint ulnar collateral ligament (UCL) repair using suture anchors with suture tape augmentation.Materials and Methods Six patients underwent thumb UCL repair or reconstruction with suture tape augmentation and six patients underwent thumb UCL repair with intraosseous suture anchors between January 2013 and January 2018. The main outcome measures were range of motion, strength, Disabilities of the Arm, Shoulder, and Hand (DASH) score, and complications.Results At final follow-up for patients who had suture tape augmentation, the average thumb MCP joint and interphalangeal (IP) joint flexion were 65 and 73 degrees, respectively. The average DASH score was 4.3. At final follow-up for patients who had intraosseous suture anchor repair, the average thumb MCP joint and IP joint flexion were 50 and 60 degrees, respectively. The average DASH score was 38. There were no complications or secondary procedures in either group.Conclusion The use of suture anchor repair with suture tape augmentation for thumb UCL injuries is a treatment option that allows for early range of motion with satisfactory early outcomes that are comparable to intraosseous suture anchor repair.Level of Evidence This is a level IV, case series article.

Rupture Site Location of Surgically Treated Thumb Metacarpophalangeal Ulnar and Radial Collateral Ligaments

PurposeThumb metacarpophalangeal collateral ligament injuries occur in 50 per 100,000 people. The most frequent rupture site locations that are often cited are the thumb ulnar collateral ligament (UCL) occurring distally from the proximal phalanx and the radial collateral ligament (RCL) occurring proximally from the metacarpal head.2,16 In this study, we report the frequency of the rupture site location of both thumb UCL and RCL injuries.MethodsA retrospective analysis of 1,004 consecutive finger collateral ligament surgeries performed at a single academic institution over 17 years was conducted. The inclusion criteria were any patient who underwent either a thumb UCL or RCL surgical repair. Patients were excluded if the rupture etiology was secondary to a laceration or a congenital or chronic deformity. Descriptive statistics were presented.ResultsThree hundred forty-seven patients were included in this study, including 288 thumb UCL injuries and 59 thumb RCL injuries. The rupture site location for the thumb UCL was proximal in 5.9% (n = 17) of the cases, distal in 92.7% (n = 267), and midsubstance in 1.4% (n = 4). Fifty-three (18.4%) Stener lesions were noted. The rupture site location for the thumb RCL was proximal in 69.5% (n = 41) of the cases, distal in 25.4% (n = 15), and midsubstance in 5.1% (n = 3).ConclusionsIn thumb UCL ruptures, the rupture site occurred most often at the proximal phalanx, whereas RCL injuries occurred most often at the metacarpal head. Overall, there was greater heterogeneity of RCL rupture site location frequency. Careful surgical exposure should be performed when repairing either the UCL or RCL. Further studies will determine if differences in rupture site location portend a difference in prognosis.Type of study/level of evidencePrognostic III.

Diagnostic accuracy of ultrasound and magnetic resonance imaging in detecting Stener lesions of the thumb: systematic review and meta-analysis.

This study assesses the diagnostic accuracy of ultrasound and magnetic resonance imaging (MRI) in diagnosing Stener lesions of the thumb. MEDLINE, PubMed, Embase and Cochrane CENTRAL were searched for studies using ultrasound or MRI to detect Stener lesions following suspected thumb ulnar collateral ligament injuries. The reference standard was surgical exploration or clinical joint stability. Risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies tool. A random-effects bivariate meta-analysis was used to estimate pooled sensitivity and specificity. Forest plots were generated. Nine ultrasound (315 thumbs) and six MRI (107 thumbs) studies were included in meta-analysis (all high risk of bias). Pooled sensitivity and specificity for ultrasound were 95% and 94%, and for MRI were 93% and 98%. Both ultrasound and MRI demonstrate high diagnostic accuracy in detecting Stener lesions. Ultrasound is an appropriate first-line imaging modality.

Accuracy of Ultrasound Compared to Magnetic Resonance Imaging in the Diagnosis of Thumb Ulnar Collateral Ligament Injuries: A Prospective Case Series.

This prospective case series compared the accuracy of ultrasound (US) to magnetic resonance imaging (MRI) in differentiating complete displaced (CD) thumb ulnar collateral ligament (UCL) tears from nondisplaced injuries in 10 patients with suspected traumatic thumb UCL injuries. Ultrasound identified 100% (2 of 2) of MRI-documented CD tears, both of which were further confirmed during surgical repair. Ultrasound identified the absence of CD tears in the remaining 8 patients. Although MRI is the reference standard imaging modality for characterizing thumb UCL injuries, ultrasound should be considered an accurate, cost-effective, and alternative imaging modality to differentiate surgical versus nonsurgical thumb UCL injuries.

Motorcyclist's thumb: carpometacarpal injuries of the thumb sustained in motorcycle crashes.

The purpose of this study was to investigate motorcycle crash thumb injury patterns. We hypothesized that ulnar collateral ligament injuries at the thumb metacarpophalangeal joint would be most common and there would be a side predilection due to the clutch and brake positions. Motorcyclist admissions following injury between 2002 and 2013 were reviewed, and phalangeal and metacarpal injuries treated acutely identified. Demographics, injury, and treatment characteristics were recorded. Association between laterality and injury type was assessed. Of 128 patients, 59 underwent acute treatment for thumb injuries. Eleven patients sustained thumb ulnar collateral ligament injuries; 27 sustained thumb carpometacarpal injuries. Most carpometacarpal injuries were fracture-dislocations (19/27). Thumb carpometacarpal injuries had no overall side predilection; ulnar collateral ligament injuries occurred more on the right. Carpometacarpal fractures and dislocations are the most frequent motorcycle crash thumb injury, probably due to the mechanics of gripping handlebars and the high-energy force directed into the palm and against the metacarpal base. Level IV.

Long-Term Outcomes of Primary Repair of Chronic Thumb Ulnar Collateral Ligament Injuries.

Background: The purpose of this study is to evaluate long-term outcomes of ligamentous repair rather than reconstruction for chronic thumb ulnar collateral ligament (UCL) injuries. Methods: Patients at least 15-years status-post repair of a chronic (greater than 6 weeks) UCL tear were contacted for clinical evaluation, radiographs, and postoperative outcome questionnaires, including the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, visual analog scale (VAS) pain scale, and study-specific questions. Twelve of 21 (57%) living patients were available for long-term, greater than 15-year follow-up (average 24.5 years, range 16.9-35.6). Results: Eighty-eight percent of patients had some degree of osteoarthritis. Increased age at the time of injury and higher DASH scores were correlated with increased grades of the thumb metacarpophalangeal osteoarthritis. Delay to treatment and VAS pain scores had no correlation with radiographic findings. Conclusions: Repair of a chronic UCL injury with available local tissue appears to be a reasonable alternative to ligament reconstruction, resulting in durable long-term outcomes despite the majority of patients progressing to osteoarthritis.

Return to Football and Long-Term Clinical Outcomes After Thumb Ulnar Collateral Ligament Suture Anchor Repair in Collegiate Athletes

To evaluate return to play after complete thumb ulnar collateral ligament (UCL) injury treated with suture anchor repair for both skill position and non-skill position collegiate football athletes and report minimum 2-year clinical outcomes in this population. For this retrospective study, inclusion criteria were complete rupture of the thumb UCL and suture anchor repair in a collegiate football athlete performed by a single surgeon who used an identical technique for all patients. Data collection included chart review, determination of return to play, and Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) outcomes. A total of 18 collegiate football athletes were identified, all of whom were evaluated for follow-up by telephone, e-mail, or regular mail at an average 6-year follow-up. Nine were skill position players; the remaining 9 played in nonskill positions. All players returned to at least the same level of play. The average QuickDASH score for the entire cohort was 1 out of 100; QuickDASH work score, 0 out of 100; and sport score, 1 out of 100. Average time to surgery for skill position players was 12 days compared with 43 for non-skill position players. Average return to play for skill position players was 7 weeks postoperatively compared with 4 weeks for non-skill position players. There was no difference in average QuickDASH overall scores or subgroup scores between cohorts. Collegiate football athletes treated for thumb UCL injuries with suture anchor repair had quick return to play, reliable return to the same level of activity, and excellent long-term clinical outcomes. Skill position players had surgery sooner after injury and returned to play later than non-skill position players, with no differences in final level of play or clinical outcomes. Management of thumb UCL injuries in collegiate football athletes can be safely and effectively tailored according to the demands of the player's football position. Therapeutic IV.

Return to Play and Long-Term Clinical Outcomes after Suture Anchor Repair of Thumb Ulnar Collateral Ligament Injuries in Collegiate Football Athletes

Objectives:Thumb ulnar collateral ligament injuries (UCL, gamekeeper’s thumb), their surgical treatment and the potential need for prolonged immobilization can significantly damage the careers of collegiate football athletes. Suture anchor fixation may allow quicker return to play with good clinical outcomes but has not been previously studied in this population. The goal of this study is to evaluate return to play and minimum two-year clinical outcomes in collegiate football athletes treated for thumb UCL injuries with suture anchor repair.Methods:Retrospective study. Inclusion criteria were 1) complete rupture of the thumb MCP joint UCL 2) suture anchor repair of UCL 3) collegiate football athlete 4) minimum 2 years postoperative. Data collection included chart review, return to play, and QuickDASH (including work and sport module) outcomes.Skill position players were scheduled for surgery immediately, while non-skilled position players were typically casted until the end of the season and then underwent repair. A single surgeon performed all procedures. Surgical technique was the same for all patients, which included absorbable suture anchor repair of the UCL to the thumb proximal phalanx utilizing two suture anchors. Patients were then immobilized in a thumb spica. Non-skilled position players were cleared for return to play in a cast after sutures were removed. Skilled position players were not cleared until after the cast was removed.Results:A cohort of 18 collegiate football athletes treated with suture anchor thumb UCL repair at minimum 2 years post-procedure was identified. All 18 patients (100%) were available for evaluation at average 6.0 years follow-up (range, 2.5-9.5 yrs). Nine players were skill position players (WR, TE, RB) while the remaining 9 were non-skill positions (OL, DL, LB.) Average age was 19.7 yrs (range, 18-22 yrs). Average time from injury until surgery was 27 days (range 2-105 days). Average return to play for the entire cohort was 5.4 weeks postoperatively (range, 1.5-12.0 weeks). All players returned to at least the same level of play as preoperatively (collegiate). Seven players eventually continued to play professional football. The average QuickDASH score for the entire cohort was 1.2/100 (95% CI 0.40-2.26). Average QuickDASH Work Score was 0.0/100 (95% CI 0.0-0.0) and average QuickDASH Sport Score was 0.7/100 (95% CI 0.0-1.85). Average time to surgery for skill position (n=9) players was 12 days (range 2-26 days) compared to 43 days (range 10-105) in non-skilled (n=9) position players (p = 0.025). Average return to play for skill position players was 7.0 weeks postoperatively (range 4-12 weeks) compared to 3.8 weeks (range 1.5-8.0 weeks) postoperatively in the non-skilled cohort (p = 0.027). There was no difference in average QuickDASH overall score, work score or sport score between the cohorts (Table I).Conclusion:Collegiate football athletes treated for thumb UCL injuries with dual suture anchor repair have quick return to play, reliable return to the same level of play and excellent long-term clinical outcomes. Using the described treatment protocol, skill position players have surgery earlier after injury and return to play later than non-skill position players, without any differences in final level of play or clinical outcomes. Thus, thumb ulnar collateral ligament injuries can be safely and effectively managed by football position demands.

Outcomes After Injury to the Thumb Ulnar Collateral Ligament—A Systematic Review

Rupture of the ulnar collateral ligament (UCL) is a frequent injury of the hand. When untreated, this injury may lead to decreased pinch strength, pain, instability, and osteoarthritis. There is currently no consensus on treatment of acute or chronic UCL injuries. Our primary purpose was to compare nonoperative treatment with surgical repair and surgical reconstruction of thumb UCL injuries. A secondary purpose was to compare graft choice and surgical technique for reconstruction. 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. Clinical outcome studies after nonoperative or operative treatment of thumb UCL injuries, with a minimum of 2 years mean follow-up, were included. Pain, range of motion, key-pinch strength, and stability testing were used as outcome measures. Fourteen articles were included and analyzed (293 thumbs). All but 2 were level IV evidence. Mean Quality Appraisal Tool score was 13.1 (55% overall rating study methodological quality). Thirty-two thumbs were treated nonoperatively and 261 operatively. Mean subject age was 33.9 years. There were 200 acute injuries and 93 chronic injuries. Mean study follow-up was 42.8 months. Nonoperative treatment often failed, necessitating surgery. Acute UCL repair and autograft UCL reconstruction for chronic injury led to excellent clinical outcomes, without a significant difference between the 2 groups. 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. Complications after surgery were rare. 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.

Opinions Regarding the Management of Hand and Wrist Injuries in Elite Athletes

Injuries to the hand and wrist are commonly encountered in athletes. Decisions regarding the most appropriate treatment, the timing of treatment, and return to play are made while balancing desires to resume athletic activities and sound orthopedic principles. Little recognition in the literature exists regarding the need for a different approach when treating these injuries in elite athletes and the timing to return to play. This study explored the complexities of treating hand and wrist injuries in the elite athlete. Thirty-seven consultant hand surgeons for teams in the National Football League, National Basketball Association, and Major League Baseball completed a brief electronic survey about the management of 10 common hand injuries. Notable variability existed in responses for initial management, return to protected play, and return to unprotected play for all injuries, aside from near consensus agreement (94%) that elite athletes with stable proximal interphalangeal dislocations could immediately return to protected play. Basketball surgeons were less likely to recommend early return to protected play than non-basketball surgeons. Baseball surgeons were more likely to recommend early unprotected play after scaphoid fixation. Football surgeons were more likely to recommend earlier return to protected play after thumb ulnar collateral ligament injuries, whereas basketball surgeons were less likely to recommend earlier return to protected play. This study demonstrated wide variability in how consultant hand surgeons approach the treatment of hand and wrist injuries. The findings emphasize the need to individually tailor treatment decisions to the patient's desires and demands, particularly in high-performance athletes.

Ulnar collateral ligament injuries of the thumb: 10 years of surgical experience

Over 10 years in our unit, 127 patients underwent surgical repair of an acute thumb ulnar collateral ligament (UCL) rupture for clinically unstable injuries or displaced avulsion fractures. Ultrasound was used when clinical diagnosis was uncertain. The male/female ratio was 3:2, with a mean age of 40 years (range: 12–81 years). Most of them (≥66%) were hyper-extension/abduction injuries. The most common cause was a fall (49%), followed by sports injuries; skiing accounted for only 2.4%. Ultrasound was 92% sensitive for UCL ruptures (positive predictive value (PPV) 99%). Over 99% of patients had a UCL rupture confirmed at surgery. Other findings included avulsion fractures (21%), dorsal capsular tears (57%) and dorsal capsule infolding (29%). The most common surgical complication was neurapraxia (6.5%). In our population, thumb UCL injuries are rarely caused by skiing. Ultrasound is a useful, sensitive adjunct in acute diagnosis. Dorsal capsular tears and joint interposition are common. Surgery provides excellent results with few long-term complications.

Repair of Acute Ulnar Collateral Ligament Injuries of the Thumb Metacarpophalangeal Joint: A Retrospective Comparison of Pull-Out Sutures and Bone Anchor Techniques

The use of intraosseous suture anchors in the treatment of ruptures of the ulnar collateral ligament of the thumb metacarpophalangeal joint has previously been described. However, no direct comparisons exist of ulnar collateral ligament repair with bone anchor versus repair with a pull-out button and immobilization. Two cohorts of patients with complete rupture of the ulnar collateral ligament of the thumb metacarpophalangeal joint were compared. Thirty patients in each cohort underwent repair of the ulnar collateral ligament with either an intraosseous suture anchor followed by early mobilization or a pull-out suture tied over a button with cast immobilization. Average follow-up was 29 months. At follow-up, range of motion at the metacarpophalangeal and interphalangeal joints for the anchor group averaged 97 percent of that of the contralateral side compared with 86 percent and 87 percent, respectively, for the button group. For the anchor group, pinch strength averaged 101 percent that of the contralateral side compared with 95 percent for the button group. No significant difference was noted between the groups for grip strength. Average tourniquet time for the anchor group was 28 minutes compared with 43 minutes for the button group. Soft-tissue complications were present in 27 percent of patients (eight of 30) in the pull-out button group compared with 7 percent (two of 30) in the anchor group. Cost analysis demonstrates an approximately $140-per-patient savings when using the suture anchor. Both repair methods are safe and effective for treating thumb ulnar collateral ligament injuries. Suture anchors allow for an accelerated rehabilitation protocol, which may account for the improved range of motion and pinch strength at follow-up.

Rupture of the collateral ligament of the metacarpo-phalangeal joint of the thumb.

Rupture of the collateral ligament of the metacarpo-phalangeal joint of the thumb.