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Experience with arthrography of the first metacarpophalangeal joint
Experience with A rthrography o f the First Metacarpophalangeal Joint J. Stothard and D. M. Caird
E X P E R I E N C E WITH A R T H R O G R A P H Y OF THE FIRST M E T A C A R P O P H A L A N G E A L JOINT
J. STOTHARD and D. M. CAIRD, Middlesbrough, England SUMMARY
Arthrography o f the first metacarpophalangeal joint at various times after trauma involving suspected rupture o f the joint capsule or collateral ligaments has been performed since 1975 and the first four and a half years experience is reviewed. More variations in arthrogram appearance were f o u n d than previously reported and the appearance recorded elsewhere as being typical o f a Stener lesion was not seen in the forty-one arthrograms examined. The selection o f patients f o r surgery produced satisfactory results subjectively and objectively and the arthrographic appearance agreed with the operative findings up to twenty-one days after injury. Some patients were saved from unnecessary surgery by arthrography.
INTRODUCTION
The problem of long term joint instability leading to weakness of pinch grip after traumatic rupture of the ulnar collateral ligament and dorsi-utnar capsule of the first metacarpophalangeal joint is well recognised. Recommendations have been made that careful clinical examination after this suspected injury might be supplemented by examination under anaesthesia (Kessler, 1963; Mogensen, 1980), stress radiographs (Lamb, 1971; Bowers, 1977; Palmer, 1978) or arthrography (Linscheid, 1974; Resnick, 1976; Bowers, 1977) to aid accurate diagnosis and permit early repair. Early operation had been found to give good results byKessler (1963), Stener (1963a). Frank (1972), and Smith (1977). The injury is probably usually produced by an abduction stress in the extended thumb, and that this may be so has been confirmed by cadaver studies (Neviaser, 1971). However, there has been some discussion as to whether stress radiographs should be performed in extension (Bowers, 1977) or full flexion (Palmer, 1978). Bowers also emphasises the importance of comparing the stress radiograph with that_ of the uninjured side. It was felt that capsular tears were important as well as collateral ligament rupture and arthrography was therefore selected for a trial study as a diagnostic aid as it appeared to have the potential to provide more information than stress radiography. The multi-tissue pathology frequently found at surgery was emphasised by Frank (1972). Arthrography has been performed when such injuries were suspected since October 1975, and the notes and radiographs of forty-two patients who had undergone investigation between then and February 1980 were traced and the patients reviewed in May 1980. J. Stothard, M.D., F.R.C.S., Middlesbrough General Hospital, Ayresome Green Lane, Middlesbrough, Cleveland. Cc) 1981 British Society for Surgery of the Hand The Hand-- Volume 13
No. 3
1981
0072-968X-81-00410257
$02.00 257
Experience with Arthrography o f the First Metacarpophalangeal Joint J. Stothard and D. M. Caird
TECHNIQUE The arthrograms were performed under general anaesthesia and any operation indicated performed under the same anaesthetic. Using aseptic technique the dye (most recently Hypaque 25~ was inserted into the joint from the dorso-radial aspect using a 23G needle. The needle was usually left in position while anteroposterior and lateral radiographs were performed, dye being introduced just before exposure. Surgery consisted of repair of recent ruptures of collateral ligaments with nonabsorbable sutures (usually 4 / 0 Prolene) and positioning of fractures of the base of the proximal phalanx with 3 / 0 stainless steel wire passed obliquely around the bone as described by Frank (1972) except that a pull-out techniques was not used. Palmer pegs (Frykman, 1956) or Kirschner wires (Zilberman, 1965) were not used. Care was taken to repair any capsular tear as well as a ligament rupture or fracture. All surgery was performed through straight longitudinal incisions and the patients were kept in plaster for three weeks after operation. Conservative treatment comprised plaster fixation for three weeks (Seventeen patients). TABLE 1 SUMMARY OF ARTHROGRAM FINDINGS Operation Normal Dorsal leakage of dye only Volar leakage of dye only Ulnar leakage of dye with fracture base P . P . Radial leakage of dye with fracture base P . P . Ulnar leakage of dye without fracture Radial leakage of dye without fracture Films missing Fracture base P . P . on radiographs Technical failure
with or f
without associated dorsal or volar leakage
TOTAL
No Operation
Total
5 2 --
5 6 2
10 8 2
7 2 4 1 2
-1(a) l(b) ---
7 3 5 1 2
2
2
4
25
17
42
(a) See Fig. 3. (b) Interpreted as normal at time.
RESULTS Arthrographic findings The patients were predominantly male (M:F = 34:8) with an age range of eight to fifty eight years, and gave a history of falling (seventeen) sporting (nine) or other (fifteen) injury from one day to eighteen months before referral and investigation by arthrography. (In one patient the mechanism of injury was not stated). Twenty-one patients had a positive finding on the initial plain radiographs, in seventeen a fracture (two possibly not recent) and in four dorsal dislocation without fracture. These tended to be referred earlier (av. five days, range one to twenty one days) than the other patients (av. fifty days, range two to 548 days). 258
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Twenty-five patients underwent operation immediately after arthrography and the arthrographic findings were confirmed in seventeen cases. Of the remaining eight, two were technical failures, two of the radiographs had been lost, three were false negatives (fifty seven days, fifty eight days and eighteen months after injury) and in one patient a primary arthrodesis was performed (128 days after injury) without any mention in the operation notes o f specific ligament or capsular rupture. The findings are summarised in Table 1. Six patients were found at operation to have a rupture of the ulnar collateral ligament without fracture. Four of these had ulnar leakage of dye on the arthrography performed one, six, sixteen and twenty-one days after injury. One only showed a dorsal leakage of dye (fifty-seven days after injury) and one had a normal arthrogram (fifty-eight days after injury). The relation between the arthrographic and operative findings is shown in Table 2. Although a fracture usually indicated an avulsion injury corresponding to an unstable ligament rupture, this was not always so. In two instances a fracture of the ulnar side of the base of the proximal phalanx was not associated with an appropriate dye leak andthese patients were treated conservatively with good results (Fig. 3). In one patient a fracture of the radial side of the head of the first metacarpal with a normal arthrogram was explored, but no lesion was found. TABLE 2 C O M P A R I S O N OF A R T H R O G R A M A P P E A R A N C E WITH OPERATIVE F I N D I N G S
--
ARTHROGRAM
Ulnar or Radial Leakage of dye
No Ulnar or Radial dye Leak
Technical Failure/ or Lost
1 1 2
3 1
Lesion Not No Confirmed Confirmed Operation
Operation Finding Fracture Ulnar Side Fracture Radial Side Rupture Ulnar Collat. Ligt. or Capsule Rupture Radial Collat. ligt.
7 2 4
l(a) l(b)
1
(a). See Fig. 3. (b) Interpreted at time as normal. When no fracture was present, a leak on the ulnar side still represented a significant lesion, meriting exploration, although careful examination of the arthrogram often outlined the ulnar collateral ligament, even if it was intact (Fig. 2). Perhaps surprisingly, this remained true shortly after a dorsal dislocation of the joint. Four patients had had a dislocation one to three days before arthrography. Three showed only dorsal and volar dye leakage, but one showed an ulnar leakage o f dye and at exploration a rupture of the ulnar collateral ligament was found and repaired. The Hand-- Volume 13
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Experience with Arthrography o f the First Metacarpophatangeal Joint J. Stothard and D. M. Caird
Fig. 1. Anteroposterior and lateral views of arthrogram six days after a fall. At exploration the rupture of the ulnar collateral ligament was level with the articular surface of the first metacarpal The associated tear of the dorsal capsule extended as far as the extensor pollicis brevis tendon, which was intact.
The five patients with normal arthrograms w h o underwent operation deserve explanation. T w o were patients long after injury w h o had obvious lesions clinically, one a rupture o f ulnar collateral ligament and one a rupture o f extensor pollicis brevis. One was a patient who had symptoms since a fall two months before but had had a dislocation nine years previously and required an arthrodesis for degenerative changes. The other two had recent injuries and no rupture was found on exploration, though one showed evidence o f an old tear of the radial collateral ligament (which was overlapped as the joint seemed unstable) and the other had a fracture o f the radial side o f the head o f the first metacarpal which was presumably also old (though ununited). TABLE 3 S U R V E Y OR A R T H R O G R A M P A T I E N T S M A Y 1980
Total No. Average age (range) Male:l,cmalc No. of m o n t h s average follow up {range) No. of days delay before arthrogram (range) Operation: no operation
Attenders
Non-Attenders
28 32 years (8-58) 13:5 27 (3-54) 15 (2-58)* 17-11
14 28 years (15-58) 11:3 32 (4-55) 17 (1-60) 8:6
*Excluding the atypical patient with an eighteen month delay as inclusion biases a simple average. 260
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Fig. 2. Anteroposterior and lateral views of arthrogram sixteen days after a fall. At exploration the extensor pollicis brevis tendon and dorsal capsule were found to be ruptured, extending right round the ulnar side of the joint. The ulnar collateral ligament was intact, as suggested by the arthrographic appearance. Although there is leakage of dye on the ulnar side of the joint from the capsular tear, the position of the ligament can be seen (c/f Fig. 1).
Long term follow-up T h e patients were reviewed in M a y 1980 and twenty-eight o f the forty-two patients (67~ attended. The follow-up was three to fifty-five m o n t h s f r o m the date o f a r t h r o g r a m / o p e r a t i o n . The attenders appeared to be representative o f the g r o u p as a whole (Table 3). In addition the attenders included two o f the three patients with an arthrodesis, two o f the f o u r patients with a dislocation on the initial radiographs, two o f the four patients who had required repair o f a r u p t u r e d extensor pollicis brevis tendon, and one o f the four patients whose a r t h r o g r a m s was a technical failure. The patients were questioned a b o u t the presence or absencelof s y m p t o m s (the actual f o r m o f question was " A t the present time, does y o u r t h u m b trouble you at a l l ? " ) , a n d then asked leading questions a b o u t aches and pains, weakness o f grip, stiffness and instability. If any s y m p t o m was admitted to, the patient was asked if it was considered troublesome or not troublesome. Fifteen patients had s y m p t o m s , but n o n e felt they were in a n y way troublesome. The c o m m o n e s t s y m p t o m was pain, noted by ten patients, (eight operated, two not ope~:ated) sometimes only with a specific activity such as turning valves at work. Six patients (all operated) noticed stiffness, and three (all operated) c o m p l a i n e d o f weakness o f grip: two Of these were y o u n g men with the d o m i n a n t h a n d involved, one o f w h o m had had an arthrodesis for persistent pain after a repair The Hand-- Volume 13
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Fig. 3a. Not all fractures represent a rupture of the collateral stability. Plain radiographs show a fracture of the base of proximal phalanx on the ulnar side. of a rupture of the proximal end of the radial collateral ligament. The other was a lady of fifty-eight who also complained of pain and had obvious degenerative changes radiographically. N o patient complained of instability. Four patients had noticed a patch o f numbness distal to the longitudinal scar. The patients were also questioned about the scar (if present). All were cosmetically acceptable and none acutely painful if accidentally knocked. Examination was performed to compare the range of movement (flexion/extension) with that of the opposite thumb (which varied greatly, as expected), and also to assess any instability. This was carefully tested in both extension and flexion for both abnormal movement a n d any pain, and again compared with the opposite thumb. Palpation for localised tenderness was related to the joint line, any fracture or wire fixation, or to the scar. Pinch grip was measured in both hands (average of three readings each hand) using the smallest bulb of a standard Martin vigorimeter held in a specially made clamp to prevent it rotating when used for pinch grip. Finally each joint was subjected to radiographic examination. The loss of range o f flexion compared to the opposite thumb (measured to the nearest 5 ~ with a flexible finger goniometer) varied f r o m 0-35 ~ (excluding the two 262
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Experience with A rthrography o f the First Metacarpophalangeal Joint J. Stothard and D. M. Caird
Fig. 3b. Arthrography showed only a small dorso-radial leak of dye and the patient was treated conservatively. When reviewed eighteen months later he had an excellent result, being asymptomatic and having full movement and good grip strength. The fracture appeared to have united. patients with an arthrodesis). We appreciate that Coonrad and Goldner (1968) recorded significant side to side variations in uninjured thumbs. The loss was mainly o f full flexion rather than extension. The average loss was 15 ~ in the operated group (fourteen patients) and 7 ~ in the non-operated group (twelve patients). With each measurement only accurate to (at best) 5 ~ o f arc, these figures are not significantly different. Only one patient had obvious ulnar instability, measured to be about 45 ~ in extension (when it was most marked). Curiously, this was a patient who had had a normal arthrogram but had had overlapping of his r a d i a l collateral ligament fortyone months previously. No patient had radial instability. Nine patients had some localised tenderness, usually related to the joint line, though in one case caused by a broken end of Pulvertaft wire on the far side of the proximal phalanx. The pinch grip strength was best expressed as a percentage of that in the opposite hand. When the dominant hand was involved (seventeen patients) the average figure was 97% with a range from 73-117%. In the operated group the average strength was 100% (ten patients) and in the non-operated group 93% (seven patients). When the non-dominant hand was involved (eleven patients) the average figure was 78% with a range from 59-105%. in the operated group the average figure was 79~ (six patients) and in the non-operated group 78% (five patients). Neither of these operated vs. non-operated comparisons was significantly different. The three patients who had noticed weakness of grip had strengths of 81% The [[and-- Volume 13
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Experience with Arthrography o f the First Metacarpophalangeal Joint J. Stothard and D. M. Caird
Fig. 4. The reported appearance of an antero-posterior view of an arthrogram of the first metacarpophalangeal joint with a displaced ruptured ulnar collateral ligament (Stener lesion). 1 represents the adductor aponeurosis and 2 the displaced ulnar collateral ligament.
(dominant hand after repair of fracture ulnar side base of proximal phalanx), 96% (arthrodesed dominant hand), and 62% (fifty-eight year old lady, degenerative changes, non-dominant hand). The patient who clinically exhibited instability (though his only symptom was a patch of numbness distal to his dorso-radial scar) had a grip strength of 62% in his non-dominant hand. Eleven of the twenty-six patients subjected to radiography (the two patients with an arthodesis were excluded) had had fractures, of which all but two had had operative fixation. Three of the operated ones (all on the ulnar side of the base of the proximal phalanx) appeared not to have united four, eight and twenty-seven months after operation. These three patients still had localised tenderness at the fracture site. DISCUSSION Although tile mechanisms of injury described by our patients was in similar proportions to that found by Lamb (1971), the variety of lesions is much greater. Lamb (1971) performed thirty operations, but only one patient had a fracture whereas twenty-two had a ruptured collateral ligament. The present paper includes data on twenty-five patients who underwent operation and thirteen of these required fixation of a fracture of the base of the proximal phalanx. Six patients h a d a rupture of the ulnar collateral ligament, and one the radial collateral ligament. Four patients required repair of a ruptured extensor pollicis brevis tendon in addition to an extensive capsular tear (two of these patients also had a ruptured ulnar collateral ligament) and two underwent a primary arthrodesis for degenerative changes. With 264
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Experience with Arthrography o f the First Metacarpophalangeal Joint J. Stothard and D. M. Caird
the aid of arthrography, it was decided not to operate on many patients (17), and only one patient was explored and no lesion found. The results o f this conservative approach seemed to have been soundly based from reviewing the patients an average o f twenty-seven months later, when there were no detectable subjective or objective differences in the function of the operated and non-operated thumbs. It seems unlikely that ruptures of the important ulnar side structures have therefore been missed by this investigation. The operated patients would be expected to include the more serious injuries and this group accounted for most of the residual minor problems. Typical arthrographic appearances found are shown in Figs. 1 to 3. In no case was the appearance depicted diagrammatically in Fig. 4 observed. Displacement of the ruptured ulnar collateral ligament outwith the adductor aponeurosis was reported by Stener (1962), who found it in twenty-five of thirty-nine consecutive cases. Bowers and Hurst (1977) found this lesion in three of the eight patients they operated on and Mogensen and Mattsson (1980) found it in sixteen (25%) of their cases. However, Smith (1977) in his large series o f sixty-nine patients, operated on twenty one patients for :ulnar instability without associated fracture within twentyone days of injury and found a Stener lesion in only three. The arthrographic appearance shown in Fig. 2 was interpreted by Bowers and Hurst (1977) as an undisplaced rupture, but in the example explored by us the ligament was intact. In the present study, four of the patients who had had repair of a ruptured ulnar collateral ligament attended for review. Two had had a repair six and sixteen days after injury and both had residual symptoms (pain in both and weakness of grip in one). Two had had an extensor indicis dynamic repair fifty-seven and fiftyeight days after injury. One had some pain but the only symptom of the other was that his index finger involuntarily flexed when he flexed his thumb. Frank (1972) studied forty one patients of whom thirty two had fractures and Smith (1977) found fractures in twenty four of his eighty-six patient's. More recently, Mogensen (1980) found avulsion fractures in ten out of sixty-six patients. It therefore seems surprising that in his major review Stener (1963b) could only find seven unstable injured thumbs with associated fractures. Other studies have deliberately excluded patients with fractures (e.g. Bowers, 1977). In our experience they form a large proportion of these injuries and do well with early operation, although some may take a long time to unite. Only one o f our patients required a secondary procedure (arthrodesis). The incidence of a patch Of numbness distal to the scar (four patients out of seventeen operated reviewed patients) was disturbing, especially as straight longitudinal incisions had been used and not the V shaped incision described by Mogensen (1980). None of the patients considered the numbness to the troublesome, but with due operative care and awareness of this possible complication we shall take steps to avoid this in the future. It is evident that there is still considerable delay in these patients coming to Orthopaedic attention in this country (averaging fifty days in our patients without fractures) and much of the published work is reported from Scandinavian and American centres. More emphasis should perhaps be given to the importance of these injuries in the hand injury training of general practitioners and casualty officers. The H a n ~
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Experience with Arthrography o f the First Metacarpophalangeal Joint J. Stothard and D. M. Caird
CONCLUSION
We feel that early surgery is indicated for many injuries of the first metacarpophalangeal joint and that arthrography is helpful in demonstrating extensive capsular tears where stress radiography would probably be normal because of the presence of intact collateral ligaments (Resnick, 1976). Good results have been obtained using clinical evaluation supplemented by arthrography to determine which patients should be treated conservatively. Without arthrography some patients (for example Fig. 3) would have undergone an unnecessary operation. REFERENCES BOWERS, W. H. and HURST, L. C. (1977) Gamekeeper's Thumb. Evaluation by Arthrography and Stress Roentgenography. The Journal of Bone and Joint Surgery, 59A: 519-524. COONRAD, R. W. and GOLDNER, J. L. (1968) A Study of the Pathological Findings and Treatment in Soft-Tissue Injury of the Thumb Metacarpophalangeal Joint with a Clinical Study of the Normal Range of Motion in One Thousand Thumbs and a Study of Post Mortem Findings of Ligamentous Structures in /Relation to Function. The Journal of Bone and Joint Surgery, 50A: 439-451. FRANK, W. E. ~ind DOBYNS, J. (1972) Surgical Pathology of Collateral Ligamentous Injuries of the Thumb. Clinical Orthopaedics and Related Research, 83:102-114. FRYKMAN, G. and JOHANSSON, O. (1956) Surgical Repair of Rupture of the Ulnar Collate?al Ligament of the Metacarpo-Phalangeal Joint of the Thumb. Acta Chirurgica Scandinavica, 112: 58-64. KESSLER, 1. (1963) Complete Avulsion of the Ulnar Collateral Ligament of the Metacarpophatangeal Joint of the Thumb. Clinical Orthopaedics and Related Research, 29: 196-200. LAMB, D. W., ABERNETHY, P. J. and FRAGIADAKIS, E. (1971) Injuries of the Metacarpophalangeal Joint of the Thumb. The Hand, 3: 164-168. L INSCHEID, R. L. (1974) Arthrography of the Metacarpophalangeal Joint. Clinical Orthopaedics and Related Resarch, 103: 91. MOGENSEN, B. A. and MATTSSON, H. S. (1980) Post-traumatic Instability of the Metacarpophalangeal Joint of the Thumb. The Hand, 12: 85-90. NEV1ASER, R~ J., WILSON, J. N. and LIEVANO, A. (1971) Rupture of the Ulnar Collateral Ligament of the Thumb. (Gamekeeper's Thumb). Correction by Dynamic Repair. The Journal of Bone and Joint Surgery, 53A: 1357-1364. PALMER, A. K. and LOUIS, D. S. (1978) Assessing ulnar instability of the metacarpophalangeal joint of the thumb. The Journal of Hand Surgery, 3: 542-546. RESNICK, R. and DANZIG, L. A. (1976) Arthrographic Evaluation of Injuries of the First Metacarpophalangeal Joint: Gamekeeper's Thumb. American Journal of Roentgenology, 126: 1046-1052. SMITH, R. J. (1977) Post-Traumatic Instability of the Metacarpophalangeal Joint of the Thumb. The Journal of Bone and Joint Surgery, 59A: 14-21. STENER, B. (1962) Displacement of the Ruptured Ulnar Collateral Ligament of the Metacaropphalangeal Joint of the Thumb. A Clinical and Anatomical Study. The Journal of Bone and Joint Surgery, 44B: 869-879. STENER, B. (1963a) Hyperextension Injuries of the Metacarpophalangeal Joint of the Thumb. Rupture of Ligaments, Fracture of Sesamoid Bones, Rupture of Flexor Pollicis Brevis. An Anatomical and Clinical Study. Acta Chirurgica Scaudinavica, 125: 275-293. STENER, B. (1963b) Skeletal Injuries Associated with Rupture of the Ulnar Collateral Ligament of the Metacarpophalangeal Joint of the Thumb. A Clinical and Anatomical Study. Acta Chirurglca Scandinavica, 125: 583-586. ZILBERMAN, Z., ROTSCH1LD, E. and KRAUSS, L. (1965) Rupture of the Ulnar Collateral Ligament of the Thumb. The Journal of Trauma, 5: 477-481.
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E X P E R I E N C E WITH A R T H R O G R A P H Y OF THE FIRST M E T A C A R P O P H A L A N G E A L JOINT
J. STOTHARD and D. M. CAIRD, Middlesbrough, England SUMMARY
Arthrography o f the first metacarpophalangeal joint at various times after trauma involving suspected rupture o f the joint capsule or collateral ligaments has been performed since 1975 and the first four and a half years experience is reviewed. More variations in arthrogram appearance were f o u n d than previously reported and the appearance recorded elsewhere as being typical o f a Stener lesion was not seen in the forty-one arthrograms examined. The selection o f patients f o r surgery produced satisfactory results subjectively and objectively and the arthrographic appearance agreed with the operative findings up to twenty-one days after injury. Some patients were saved from unnecessary surgery by arthrography.
INTRODUCTION
The problem of long term joint instability leading to weakness of pinch grip after traumatic rupture of the ulnar collateral ligament and dorsi-utnar capsule of the first metacarpophalangeal joint is well recognised. Recommendations have been made that careful clinical examination after this suspected injury might be supplemented by examination under anaesthesia (Kessler, 1963; Mogensen, 1980), stress radiographs (Lamb, 1971; Bowers, 1977; Palmer, 1978) or arthrography (Linscheid, 1974; Resnick, 1976; Bowers, 1977) to aid accurate diagnosis and permit early repair. Early operation had been found to give good results byKessler (1963), Stener (1963a). Frank (1972), and Smith (1977). The injury is probably usually produced by an abduction stress in the extended thumb, and that this may be so has been confirmed by cadaver studies (Neviaser, 1971). However, there has been some discussion as to whether stress radiographs should be performed in extension (Bowers, 1977) or full flexion (Palmer, 1978). Bowers also emphasises the importance of comparing the stress radiograph with that_ of the uninjured side. It was felt that capsular tears were important as well as collateral ligament rupture and arthrography was therefore selected for a trial study as a diagnostic aid as it appeared to have the potential to provide more information than stress radiography. The multi-tissue pathology frequently found at surgery was emphasised by Frank (1972). Arthrography has been performed when such injuries were suspected since October 1975, and the notes and radiographs of forty-two patients who had undergone investigation between then and February 1980 were traced and the patients reviewed in May 1980. J. Stothard, M.D., F.R.C.S., Middlesbrough General Hospital, Ayresome Green Lane, Middlesbrough, Cleveland. Cc) 1981 British Society for Surgery of the Hand The Hand-- Volume 13
No. 3
1981
0072-968X-81-00410257
$02.00 257
Experience with Arthrography o f the First Metacarpophalangeal Joint J. Stothard and D. M. Caird
TECHNIQUE The arthrograms were performed under general anaesthesia and any operation indicated performed under the same anaesthetic. Using aseptic technique the dye (most recently Hypaque 25~ was inserted into the joint from the dorso-radial aspect using a 23G needle. The needle was usually left in position while anteroposterior and lateral radiographs were performed, dye being introduced just before exposure. Surgery consisted of repair of recent ruptures of collateral ligaments with nonabsorbable sutures (usually 4 / 0 Prolene) and positioning of fractures of the base of the proximal phalanx with 3 / 0 stainless steel wire passed obliquely around the bone as described by Frank (1972) except that a pull-out techniques was not used. Palmer pegs (Frykman, 1956) or Kirschner wires (Zilberman, 1965) were not used. Care was taken to repair any capsular tear as well as a ligament rupture or fracture. All surgery was performed through straight longitudinal incisions and the patients were kept in plaster for three weeks after operation. Conservative treatment comprised plaster fixation for three weeks (Seventeen patients). TABLE 1 SUMMARY OF ARTHROGRAM FINDINGS Operation Normal Dorsal leakage of dye only Volar leakage of dye only Ulnar leakage of dye with fracture base P . P . Radial leakage of dye with fracture base P . P . Ulnar leakage of dye without fracture Radial leakage of dye without fracture Films missing Fracture base P . P . on radiographs Technical failure
with or f
without associated dorsal or volar leakage
TOTAL
No Operation
Total
5 2 --
5 6 2
10 8 2
7 2 4 1 2
-1(a) l(b) ---
7 3 5 1 2
2
2
4
25
17
42
(a) See Fig. 3. (b) Interpreted as normal at time.
RESULTS Arthrographic findings The patients were predominantly male (M:F = 34:8) with an age range of eight to fifty eight years, and gave a history of falling (seventeen) sporting (nine) or other (fifteen) injury from one day to eighteen months before referral and investigation by arthrography. (In one patient the mechanism of injury was not stated). Twenty-one patients had a positive finding on the initial plain radiographs, in seventeen a fracture (two possibly not recent) and in four dorsal dislocation without fracture. These tended to be referred earlier (av. five days, range one to twenty one days) than the other patients (av. fifty days, range two to 548 days). 258
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Twenty-five patients underwent operation immediately after arthrography and the arthrographic findings were confirmed in seventeen cases. Of the remaining eight, two were technical failures, two of the radiographs had been lost, three were false negatives (fifty seven days, fifty eight days and eighteen months after injury) and in one patient a primary arthrodesis was performed (128 days after injury) without any mention in the operation notes o f specific ligament or capsular rupture. The findings are summarised in Table 1. Six patients were found at operation to have a rupture of the ulnar collateral ligament without fracture. Four of these had ulnar leakage of dye on the arthrography performed one, six, sixteen and twenty-one days after injury. One only showed a dorsal leakage of dye (fifty-seven days after injury) and one had a normal arthrogram (fifty-eight days after injury). The relation between the arthrographic and operative findings is shown in Table 2. Although a fracture usually indicated an avulsion injury corresponding to an unstable ligament rupture, this was not always so. In two instances a fracture of the ulnar side of the base of the proximal phalanx was not associated with an appropriate dye leak andthese patients were treated conservatively with good results (Fig. 3). In one patient a fracture of the radial side of the head of the first metacarpal with a normal arthrogram was explored, but no lesion was found. TABLE 2 C O M P A R I S O N OF A R T H R O G R A M A P P E A R A N C E WITH OPERATIVE F I N D I N G S
--
ARTHROGRAM
Ulnar or Radial Leakage of dye
No Ulnar or Radial dye Leak
Technical Failure/ or Lost
1 1 2
3 1
Lesion Not No Confirmed Confirmed Operation
Operation Finding Fracture Ulnar Side Fracture Radial Side Rupture Ulnar Collat. Ligt. or Capsule Rupture Radial Collat. ligt.
7 2 4
l(a) l(b)
1
(a). See Fig. 3. (b) Interpreted at time as normal. When no fracture was present, a leak on the ulnar side still represented a significant lesion, meriting exploration, although careful examination of the arthrogram often outlined the ulnar collateral ligament, even if it was intact (Fig. 2). Perhaps surprisingly, this remained true shortly after a dorsal dislocation of the joint. Four patients had had a dislocation one to three days before arthrography. Three showed only dorsal and volar dye leakage, but one showed an ulnar leakage o f dye and at exploration a rupture of the ulnar collateral ligament was found and repaired. The Hand-- Volume 13
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Fig. 1. Anteroposterior and lateral views of arthrogram six days after a fall. At exploration the rupture of the ulnar collateral ligament was level with the articular surface of the first metacarpal The associated tear of the dorsal capsule extended as far as the extensor pollicis brevis tendon, which was intact.
The five patients with normal arthrograms w h o underwent operation deserve explanation. T w o were patients long after injury w h o had obvious lesions clinically, one a rupture o f ulnar collateral ligament and one a rupture o f extensor pollicis brevis. One was a patient who had symptoms since a fall two months before but had had a dislocation nine years previously and required an arthrodesis for degenerative changes. The other two had recent injuries and no rupture was found on exploration, though one showed evidence o f an old tear of the radial collateral ligament (which was overlapped as the joint seemed unstable) and the other had a fracture o f the radial side o f the head o f the first metacarpal which was presumably also old (though ununited). TABLE 3 S U R V E Y OR A R T H R O G R A M P A T I E N T S M A Y 1980
Total No. Average age (range) Male:l,cmalc No. of m o n t h s average follow up {range) No. of days delay before arthrogram (range) Operation: no operation
Attenders
Non-Attenders
28 32 years (8-58) 13:5 27 (3-54) 15 (2-58)* 17-11
14 28 years (15-58) 11:3 32 (4-55) 17 (1-60) 8:6
*Excluding the atypical patient with an eighteen month delay as inclusion biases a simple average. 260
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Fig. 2. Anteroposterior and lateral views of arthrogram sixteen days after a fall. At exploration the extensor pollicis brevis tendon and dorsal capsule were found to be ruptured, extending right round the ulnar side of the joint. The ulnar collateral ligament was intact, as suggested by the arthrographic appearance. Although there is leakage of dye on the ulnar side of the joint from the capsular tear, the position of the ligament can be seen (c/f Fig. 1).
Long term follow-up T h e patients were reviewed in M a y 1980 and twenty-eight o f the forty-two patients (67~ attended. The follow-up was three to fifty-five m o n t h s f r o m the date o f a r t h r o g r a m / o p e r a t i o n . The attenders appeared to be representative o f the g r o u p as a whole (Table 3). In addition the attenders included two o f the three patients with an arthrodesis, two o f the f o u r patients with a dislocation on the initial radiographs, two o f the four patients who had required repair o f a r u p t u r e d extensor pollicis brevis tendon, and one o f the four patients whose a r t h r o g r a m s was a technical failure. The patients were questioned a b o u t the presence or absencelof s y m p t o m s (the actual f o r m o f question was " A t the present time, does y o u r t h u m b trouble you at a l l ? " ) , a n d then asked leading questions a b o u t aches and pains, weakness o f grip, stiffness and instability. If any s y m p t o m was admitted to, the patient was asked if it was considered troublesome or not troublesome. Fifteen patients had s y m p t o m s , but n o n e felt they were in a n y way troublesome. The c o m m o n e s t s y m p t o m was pain, noted by ten patients, (eight operated, two not ope~:ated) sometimes only with a specific activity such as turning valves at work. Six patients (all operated) noticed stiffness, and three (all operated) c o m p l a i n e d o f weakness o f grip: two Of these were y o u n g men with the d o m i n a n t h a n d involved, one o f w h o m had had an arthrodesis for persistent pain after a repair The Hand-- Volume 13
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Fig. 3a. Not all fractures represent a rupture of the collateral stability. Plain radiographs show a fracture of the base of proximal phalanx on the ulnar side. of a rupture of the proximal end of the radial collateral ligament. The other was a lady of fifty-eight who also complained of pain and had obvious degenerative changes radiographically. N o patient complained of instability. Four patients had noticed a patch o f numbness distal to the longitudinal scar. The patients were also questioned about the scar (if present). All were cosmetically acceptable and none acutely painful if accidentally knocked. Examination was performed to compare the range of movement (flexion/extension) with that of the opposite thumb (which varied greatly, as expected), and also to assess any instability. This was carefully tested in both extension and flexion for both abnormal movement a n d any pain, and again compared with the opposite thumb. Palpation for localised tenderness was related to the joint line, any fracture or wire fixation, or to the scar. Pinch grip was measured in both hands (average of three readings each hand) using the smallest bulb of a standard Martin vigorimeter held in a specially made clamp to prevent it rotating when used for pinch grip. Finally each joint was subjected to radiographic examination. The loss of range o f flexion compared to the opposite thumb (measured to the nearest 5 ~ with a flexible finger goniometer) varied f r o m 0-35 ~ (excluding the two 262
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Fig. 3b. Arthrography showed only a small dorso-radial leak of dye and the patient was treated conservatively. When reviewed eighteen months later he had an excellent result, being asymptomatic and having full movement and good grip strength. The fracture appeared to have united. patients with an arthrodesis). We appreciate that Coonrad and Goldner (1968) recorded significant side to side variations in uninjured thumbs. The loss was mainly o f full flexion rather than extension. The average loss was 15 ~ in the operated group (fourteen patients) and 7 ~ in the non-operated group (twelve patients). With each measurement only accurate to (at best) 5 ~ o f arc, these figures are not significantly different. Only one patient had obvious ulnar instability, measured to be about 45 ~ in extension (when it was most marked). Curiously, this was a patient who had had a normal arthrogram but had had overlapping of his r a d i a l collateral ligament fortyone months previously. No patient had radial instability. Nine patients had some localised tenderness, usually related to the joint line, though in one case caused by a broken end of Pulvertaft wire on the far side of the proximal phalanx. The pinch grip strength was best expressed as a percentage of that in the opposite hand. When the dominant hand was involved (seventeen patients) the average figure was 97% with a range from 73-117%. In the operated group the average strength was 100% (ten patients) and in the non-operated group 93% (seven patients). When the non-dominant hand was involved (eleven patients) the average figure was 78% with a range from 59-105%. in the operated group the average figure was 79~ (six patients) and in the non-operated group 78% (five patients). Neither of these operated vs. non-operated comparisons was significantly different. The three patients who had noticed weakness of grip had strengths of 81% The [[and-- Volume 13
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Fig. 4. The reported appearance of an antero-posterior view of an arthrogram of the first metacarpophalangeal joint with a displaced ruptured ulnar collateral ligament (Stener lesion). 1 represents the adductor aponeurosis and 2 the displaced ulnar collateral ligament.
(dominant hand after repair of fracture ulnar side base of proximal phalanx), 96% (arthrodesed dominant hand), and 62% (fifty-eight year old lady, degenerative changes, non-dominant hand). The patient who clinically exhibited instability (though his only symptom was a patch of numbness distal to his dorso-radial scar) had a grip strength of 62% in his non-dominant hand. Eleven of the twenty-six patients subjected to radiography (the two patients with an arthodesis were excluded) had had fractures, of which all but two had had operative fixation. Three of the operated ones (all on the ulnar side of the base of the proximal phalanx) appeared not to have united four, eight and twenty-seven months after operation. These three patients still had localised tenderness at the fracture site. DISCUSSION Although tile mechanisms of injury described by our patients was in similar proportions to that found by Lamb (1971), the variety of lesions is much greater. Lamb (1971) performed thirty operations, but only one patient had a fracture whereas twenty-two had a ruptured collateral ligament. The present paper includes data on twenty-five patients who underwent operation and thirteen of these required fixation of a fracture of the base of the proximal phalanx. Six patients h a d a rupture of the ulnar collateral ligament, and one the radial collateral ligament. Four patients required repair of a ruptured extensor pollicis brevis tendon in addition to an extensive capsular tear (two of these patients also had a ruptured ulnar collateral ligament) and two underwent a primary arthrodesis for degenerative changes. With 264
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the aid of arthrography, it was decided not to operate on many patients (17), and only one patient was explored and no lesion found. The results o f this conservative approach seemed to have been soundly based from reviewing the patients an average o f twenty-seven months later, when there were no detectable subjective or objective differences in the function of the operated and non-operated thumbs. It seems unlikely that ruptures of the important ulnar side structures have therefore been missed by this investigation. The operated patients would be expected to include the more serious injuries and this group accounted for most of the residual minor problems. Typical arthrographic appearances found are shown in Figs. 1 to 3. In no case was the appearance depicted diagrammatically in Fig. 4 observed. Displacement of the ruptured ulnar collateral ligament outwith the adductor aponeurosis was reported by Stener (1962), who found it in twenty-five of thirty-nine consecutive cases. Bowers and Hurst (1977) found this lesion in three of the eight patients they operated on and Mogensen and Mattsson (1980) found it in sixteen (25%) of their cases. However, Smith (1977) in his large series o f sixty-nine patients, operated on twenty one patients for :ulnar instability without associated fracture within twentyone days of injury and found a Stener lesion in only three. The arthrographic appearance shown in Fig. 2 was interpreted by Bowers and Hurst (1977) as an undisplaced rupture, but in the example explored by us the ligament was intact. In the present study, four of the patients who had had repair of a ruptured ulnar collateral ligament attended for review. Two had had a repair six and sixteen days after injury and both had residual symptoms (pain in both and weakness of grip in one). Two had had an extensor indicis dynamic repair fifty-seven and fiftyeight days after injury. One had some pain but the only symptom of the other was that his index finger involuntarily flexed when he flexed his thumb. Frank (1972) studied forty one patients of whom thirty two had fractures and Smith (1977) found fractures in twenty four of his eighty-six patient's. More recently, Mogensen (1980) found avulsion fractures in ten out of sixty-six patients. It therefore seems surprising that in his major review Stener (1963b) could only find seven unstable injured thumbs with associated fractures. Other studies have deliberately excluded patients with fractures (e.g. Bowers, 1977). In our experience they form a large proportion of these injuries and do well with early operation, although some may take a long time to unite. Only one o f our patients required a secondary procedure (arthrodesis). The incidence of a patch Of numbness distal to the scar (four patients out of seventeen operated reviewed patients) was disturbing, especially as straight longitudinal incisions had been used and not the V shaped incision described by Mogensen (1980). None of the patients considered the numbness to the troublesome, but with due operative care and awareness of this possible complication we shall take steps to avoid this in the future. It is evident that there is still considerable delay in these patients coming to Orthopaedic attention in this country (averaging fifty days in our patients without fractures) and much of the published work is reported from Scandinavian and American centres. More emphasis should perhaps be given to the importance of these injuries in the hand injury training of general practitioners and casualty officers. The H a n ~
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CONCLUSION
We feel that early surgery is indicated for many injuries of the first metacarpophalangeal joint and that arthrography is helpful in demonstrating extensive capsular tears where stress radiography would probably be normal because of the presence of intact collateral ligaments (Resnick, 1976). Good results have been obtained using clinical evaluation supplemented by arthrography to determine which patients should be treated conservatively. Without arthrography some patients (for example Fig. 3) would have undergone an unnecessary operation. REFERENCES BOWERS, W. H. and HURST, L. C. (1977) Gamekeeper's Thumb. Evaluation by Arthrography and Stress Roentgenography. The Journal of Bone and Joint Surgery, 59A: 519-524. COONRAD, R. W. and GOLDNER, J. L. (1968) A Study of the Pathological Findings and Treatment in Soft-Tissue Injury of the Thumb Metacarpophalangeal Joint with a Clinical Study of the Normal Range of Motion in One Thousand Thumbs and a Study of Post Mortem Findings of Ligamentous Structures in /Relation to Function. The Journal of Bone and Joint Surgery, 50A: 439-451. FRANK, W. E. ~ind DOBYNS, J. (1972) Surgical Pathology of Collateral Ligamentous Injuries of the Thumb. Clinical Orthopaedics and Related Research, 83:102-114. FRYKMAN, G. and JOHANSSON, O. (1956) Surgical Repair of Rupture of the Ulnar Collate?al Ligament of the Metacarpo-Phalangeal Joint of the Thumb. Acta Chirurgica Scandinavica, 112: 58-64. KESSLER, 1. (1963) Complete Avulsion of the Ulnar Collateral Ligament of the Metacarpophatangeal Joint of the Thumb. Clinical Orthopaedics and Related Research, 29: 196-200. LAMB, D. W., ABERNETHY, P. J. and FRAGIADAKIS, E. (1971) Injuries of the Metacarpophalangeal Joint of the Thumb. The Hand, 3: 164-168. L INSCHEID, R. L. (1974) Arthrography of the Metacarpophalangeal Joint. Clinical Orthopaedics and Related Resarch, 103: 91. MOGENSEN, B. A. and MATTSSON, H. S. (1980) Post-traumatic Instability of the Metacarpophalangeal Joint of the Thumb. The Hand, 12: 85-90. NEV1ASER, R~ J., WILSON, J. N. and LIEVANO, A. (1971) Rupture of the Ulnar Collateral Ligament of the Thumb. (Gamekeeper's Thumb). Correction by Dynamic Repair. The Journal of Bone and Joint Surgery, 53A: 1357-1364. PALMER, A. K. and LOUIS, D. S. (1978) Assessing ulnar instability of the metacarpophalangeal joint of the thumb. The Journal of Hand Surgery, 3: 542-546. RESNICK, R. and DANZIG, L. A. (1976) Arthrographic Evaluation of Injuries of the First Metacarpophalangeal Joint: Gamekeeper's Thumb. American Journal of Roentgenology, 126: 1046-1052. SMITH, R. J. (1977) Post-Traumatic Instability of the Metacarpophalangeal Joint of the Thumb. The Journal of Bone and Joint Surgery, 59A: 14-21. STENER, B. (1962) Displacement of the Ruptured Ulnar Collateral Ligament of the Metacaropphalangeal Joint of the Thumb. A Clinical and Anatomical Study. The Journal of Bone and Joint Surgery, 44B: 869-879. STENER, B. (1963a) Hyperextension Injuries of the Metacarpophalangeal Joint of the Thumb. Rupture of Ligaments, Fracture of Sesamoid Bones, Rupture of Flexor Pollicis Brevis. An Anatomical and Clinical Study. Acta Chirurgica Scaudinavica, 125: 275-293. STENER, B. (1963b) Skeletal Injuries Associated with Rupture of the Ulnar Collateral Ligament of the Metacarpophalangeal Joint of the Thumb. A Clinical and Anatomical Study. Acta Chirurglca Scandinavica, 125: 583-586. ZILBERMAN, Z., ROTSCH1LD, E. and KRAUSS, L. (1965) Rupture of the Ulnar Collateral Ligament of the Thumb. The Journal of Trauma, 5: 477-481.
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