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Injuries to the Ulnar Collateral Ligament of the Thumb Metacarpophalangeal Joint (Gamekeeper’s Thumb)
6
Injuries to the Ulnar Collateral Ligament of the Thumb Metacarpophalangeal Joint (Gamekeeper’s Thumb) S. Brent Brotzman, MD | Steven R. Novotny, MD
BACKGROUND The classic “gamekeeper’s thumb” was first described in Scottish gamekeepers as a chronic instability of the thumb MCP joint ulnar collateral ligament. Stener in 1962 reported the nonhealing lesion of the UCL outside the adductor aponeurosis, not specifically an acute injury. “Skier’s thumb” was coined by Schultz, Brown, and Fox in 1973, with skiing being the most common cause of acute ulnar collateral ligament (UCL) rupture (e.g., after a fall causing the ski pole to stress and tear the ulnar collateral ligament of the thumb MCP joint). Even though these eponyms exist, most injuries do not involve sports. Static lateral pinch stability is provided by a strong collateral ligament complex: Proper UCL runs from the metacarpal lateral condyle to the proximal phalanx and the accessory collateral ligaments, which attach more volarly on the metacarpal and insert on the volar plate and sesamoids. The proper collateral ligaments are taut in flexion while the accessories are in taut extension. The tendinous attachments of the thenar muscles— especially the adductor pollicis attaching into the ulnar sesamoid—contribute some dynamic stability. The UCL provides resistance to radially applied forces (e.g., pinching or holding large objects). A torn UCL weakens the key pinch grip strength and allows volar subluxation of the proximal phalanx. With prolonged instability, the MCP joint frequently degenerates. The amount of valgus laxity of normal thumbs varies widely. In full MCP joint extension, valgus laxity averages 6 degrees, and in 15 degrees of MCP joint flexion it increases to an average of 12 degrees. It has been shown that the valgus laxity may vary if the joint is tested in supination and pronation (Mayer et al. 2014). It is recommended to standardize the stress examination in neutral rotation. The adductor aponeurosis (when torn or pulled distally) frequently entraps the UCL, preventing anatomic ligament reduction and healing of the UCL (Stener lesion) (Fig. 6.1). The typical mechanism of injury is an extreme valgus stress to the thumb (e.g., falling on an abducted thumb).
EVALUATION Patients typically have a history of a valgus injury to the thumb followed by pain, swelling, and frequently ecchymosis at the ulnar aspect of the thumb MCP joint. Palpation of the ulnar aspect of the MCP joint may reveal a small lump, which may be indicative of a Stener lesion or avulsion fracture. Radiographs are necessary to evaluate for fractures, which may have significant ramifications on management. Dinowitz et al. (1997) reported a series of 9 patients
with avulsion fractures with <2.0 mm displacement who all did poorly after at least 6 weeks of immobilization and rehab. Rotation of the fragment was felt to limit healing. All were salvaged with subsequent surgery. Kaplan reported on two patients with wellaligned fractures with displaced ligaments (Kaplan 1998). Shear fractures can occur after the ligament has been avulsed. In addition to plain films (three views of the thumb and carpus), valgus stress testing radiographs should be obtained. Because patients who are acutely injured will guard from pain, 1% lidocaine should be injected into the joint before stress testing. Many patients are seen days or weeks after the injury and the intra-articular lidocaine may not be adequate. Performing wrist median and radial nerve blocks provides complete anesthesia and allows multiple examinations if needed. Also an Adductor aponeurosis MCP joint
Normal ulnar collateral ligament
A
Rupture of ulnar collateral ligament Interposed adductor aponeurosis
B
Adductor aponeurosis divided
Fig. 6.1 Complete rupture of the ulnar collateral ligament resulting in a Stener lesion. The distal attachment has been avulsed from the bone. AB, The interposed adductor aponeurosis prevents the ligament from being reduced. Therefore, leaving joint potentially unstable.
29
30
SECTION 1 Hand and Wrist Injuries
MCP joint anesthetic injection insufflates tissue, which could influence the fit of a brace or cast, especially once the fluid absorbs. The integrity of the proper (ulnar collateral) ligament is assessed by valgus stress testing with the MCP joint of the thumb in 30 degrees of joint flexion. This test can be done clinically or with radiographic documentation. Some concern exists as to whether an exuberant exam can precipitate a Stener lesion. Adler et al. demonstrated on cadavers that serial ligament sectioning and stressing a Stener lesion could not be provoked (Adler et al. 2012). The literature varies as to the degree of angulation on valgus stressing that is compatible with complete rupture of the UCL. Thirty to 35 degrees of radial deviation of the thumb on valgus stressing or 15 degrees greater than the uninjured side indicates a complete UCL rupture and is an indication for surgical correction. With complete ruptures (>30 degrees of opening) the likelihood of a UCL ligament displacement (Stener lesion) is greater than 80%. The question of need or utility of advanced imaging should be discussed because they could be part of the evaluation. No advanced imaging technique has 100% sensitivity or specificity, and there is a cost involved. We are finding longer times for insurance companies to authorize or deny a study, which could turn an acute injury to a chronic injury before the special imaging is complete, then requiring another wait for surgical authorization. Papandrea and Fowler in 2008 reviewed current literature on ultrasound and MRI for evaluation of this injury. Given the structural and time constraints of MRI, ultrasound (possibly office-based ultrasound) could lead to a conclusion sooner. Looking at just two articles on ultrasound diagnosis of UCL Stener lesions shows there may be uncertainty in ultrasound conclusions. O’Callaghan et al. report 48 patients studied by ultrasound per protocol. All 13 patients with positive tests were explored (O’Callaghan et al. 1994). Ten of 13 positive tests showed true Stener lesions; the remainder at surgery were labeled partial Stener lesions. In Susic et al.’s publication 14 patients with clinically unstable UCL underwent US (Susic et al. 1999). At surgery all were ruptured, 5 were Stener lesions, yet only two of the five were identified on ultrasound. That means 60% of the dislocated lesions were missed on ultrasound.
TREATMENT Stable Thumb on Valgus Stressing (No Stener Lesion) • The ligament is only partially torn, and healing will occur with nonoperative treatment. • The thumb is immobilized for 4 weeks in a short arm spica cast or thermoplastic splint (molded), usually with the thumb IP joint free. • Active and passive thumb motion is begun at 3 to 4 weeks, but valgus is avoided. • If ROM is painful at 3 to 4 weeks, re-evaluation by a physician is indicated. • The thermoplastic splint is removed several times a day for active ROM exercises. • Grip-strengthening exercises are begun at 6 weeks after injury. A brace is worn for protection in contact situations for 2 months (Rehabilitation Protocol 6.1). • If one has access to reliable hand therapy, comparable results have been achieved with a fabricated forearm-based spica splint hinged at the MCP (Sollerman et al. 1991).
• The MCP is allowed an arc of 50 degrees motion. Other authors express satisfaction with a hand-based hinged MCP splint allowing a 35-degree arc of motion (Michaud et al. 2010). These rehab studies discuss the monitoring and individual modifications rationale during the healing period. Biomechanical modeling of strains on repaired UCL has shown load to failure three times higher than loads expected with flexion and extension (Harley et al. 2004). This study supports the clinical findings of the early motion rehab protocol post surgery.
Unstable Thumb on Valgus Stressing (>30 Degrees) • Because 80% of patients with a complete rupture are found to have a Stener lesion (thus obtaining a poor healing result if treated nonoperatively), it is critical to make the correct diagnosis of stable versus unstable gamekeeper’s thumb. As we’ve seen, it isn’t possible to be 100% accurate with advanced imaging. Physical exam is excellent at diagnosing instability; absent fractures, bony excrescences, or concomitant soft tissue tumors, a palpable enlargement ulnar to the metacarpal head, can be considered diagnostic. Without other evidence one needs to discuss risks and benefits of the three treatment paths—surgery, imaging, conservative care—and encourage patient involvement in the decision. • Operative repair requires direct visualization of the local anatomy. Results can be improved by re-creation of normal anatomy. Carlson has demonstrated the anatomic origins and insertions of both the UCL and RCL of the thumb MCP joint (Carlson et al. 2012). They determined the center of the ulnar collateral ligament origin to be 4.2 mm volar to the dorsal surface of the metacarpal head, 5.3 mm proximal to the articular surface, and 7 mm from the volar cortex. The phalangeal insertion center was 9.2 mm from the dorsal surface, 3.4 mm distal to the articular surface and 2.8 mm dorsal to the volar cortex. This work provides context to the deliberateness with which placement of anchors or drill holes is undertaken. Lee et al.’s biomechanical simulation study to determine optimal tunnel placement for UCL reconstruction used four constructs: cruciate, two parallel, proximal apex V, and distal apex V (Lee et al. 2005). All constructs restored valgus load stability. The proximal apex V restored range of motion not significantly different from the native state. The other 3 constructs resulted in significantly decreased range of motion. • Numerous published reports exist demonstrating effective surgical repair of avulsed ulnar collateral ligaments and repair of bony involvement. Weiland et al. (1997) reported anchored repairs in acute injury with excellent functional results. Tip, chuck, key, and pinch strengths and laxity were almost indistinguishable comparing operative and noninjured sides. Grip strength was slightly decreased. Range of motion loss was approximately 10 degrees at the MPJ and IPJ. Twenty percent of patients had self-reported minor symptoms at maximum exertion. Glickel et al. reported results for UCL replacement for chronic instability. A tendon graft was passed intraosseously and tied extracutaneously (Glickel et al. 1993). Twenty-four of 26 patients had good or excellent results with significantly improved function and few complications. Osterman et al. (1981) reported their results using acute repair, reconstruction with graft, and reconstruction
6 Injuries to the Ulnar Collateral Ligament of the Thumb Metacarpophalangeal Joint (Gamekeeper’s Thumb)
31
REHABILITATION PROTOCOL 6.1 Rehabilitation Protocol After Repair or Reconstruction of the Ulnar Collateral Ligament of the Thumb Metacarpophalangeal Joint The early motion protocol allows 35–50 degree motion with hinged splint protecting the MCP from radial or ulnar deviation. Static splint with ADLs if pain at 2 to 3 weeks. If no pain at 6 weeks, brace not necessary at night or light activities. Protected repair from aggressive activity. If pain continues at 6 weeks, brace for a total of 12 weeks. 3 Weeks • Remove bulky dressing. • Remove MCP joint pin (K-wire) if used for joint stabilization. • Fit with wrist and thumb static splint for continual wear. 6 Weeks • Begin active and gentle passive ROM exercises of the thumb for 10 minutes each hour.
with adductor advancement. Acute repair had the best results with 92% pinch strength and 84% normal motion. Both types of reconstruction gave adequate function. Adductor advancement resulted in a slight strength advantage (85% vs 81%), however, the graft reconstruction had a significantly improved range of motion over advancement (78% vs 65%). They reported that repair within two weeks produces the best result, and reconstruction in chronic injury demonstrates significant functional improvement. • Most surgeons feel more comfortable with an open procedure. Ryu and Fagan (1995) with soft tissue Stener and Badia (2006) with bony injury demonstrated successful treatment in their patients via arthroscopic treatment.
• Avoid any lateral stress to the MCP joint of the thumb. • Begin dynamic splinting if necessary to increase passive ROM of the thumb. 8 Weeks • Discontinue splinting. Wrist and thumb static splint or short opponens splint may be useful during sports-related activities or heavy lifting. • Begin progressive strengthening. 12 Weeks • Allow the patient to return to unrestricted activity.
REFERENCES A complete reference list is available at https://expertconsult .inkling.com/. FURTHER READING Bean HG, Tencher AF, Trumble TE. The effect of thumb metacarpophalangeal ulnar collateral ligament attachment site of joint range of motion: an in vivo study. J Hand Surg Am. 1999;24:283–287. Chuter GS, Muwanga CL, Irwin LR. Ulnar collateral ligament injuries of the thumb: 10 years of surgical experience. Injury. 2009;40:652–656. Heyman P. Injuries to the ulnar collateral ligament of the thumb metacarpophalangeal joint. J Am Acad Orth Surg. 1997;5:224–229.
REFERENCES Adler T, Eisenbarth I, Hirschman MT, et al. Can clinical examination cause a Stener lesion in patients with skier’s thumb? Clinical Anatomy. 2012;25:762–766. Badia A. Arthroscopic reduction and internal fixation of bony gamekeeper’s thumb. Orthopedics. 2006;29:675–678. Carlson MG, Warner KK, Meyers KN, et al. Anatomy of the thumb metacarpophalangeal ulnar and radial collateral ligaments. J Hand Surg. 2012;37: 2021–2026. Dinowitz M, Trumble T, Hanel D, et al. Failure of cast immobilization for thumb ulnar collateral ligament avulsion fractures. J Hand Surg. 1997;22: 1057–1063. Glickel SZ, Malerich M, Pearce SM, et al. Ligament replacement for chronic instability of the ulnar collateral ligament of the metacarpophalangeal joint of the thumb. J Hand Surg Am. 1993;18:930–941. Harley BJ, Werner FW, Green JK. A biomechanical modeling of injury, repair and rehabilitation of ulnar collateral ligament injuries of the thumb. J Hand Surg. 2004;29:915–920. Kaplan S. The Stener lesion revisited: a case report. J Hand Surg Am. 1998;23: 833–836. Lee SK, Kubiak EN, Lawler E, et al. Thumb metacarpophalangeal ulnar collateral ligament injuries: a biomechanical simulation study of four static reconstructions. J Hand Surg Am. 2005;30:1056–1060.
Mayer SW, Rush DS, Leversedge FJ. The influence of thumb metacarpophalangeal joint rotation on the evaluation of ulnar collateral ligament injuries: a biomechanical study in a cadaver model. J Hand Surg Am. 2014;39:474–479. Michaud EJ, Flinn S, Seitz WH. Treatment of grade III thumb metacarpophalangeal ulnar collateral ligament injuries with early controlled motion using a hinged splint. J Hand Therapy. Jan-Mar, 2010:77–82. O’Callaghan BI, Kohut G, Hoogewoud HM. Gamekeeper thumb: identification of the Stener lesion with US. Radiology. 1994;192:477–480. Osterman A, Hayken G, Bora F. A qualitative evaluation of thumb function after ulnar collateral repair and reconstruction. J Trauma. 1981;21:854–861. Papandrea RF, Fowler T. Injury at the thumb UCL: is there a Stener lesion? J Hand Surg Am. 2008;33:1882–1884. Ryu J, Fagan R. Arthroscopic treatment of acute complete thumb metacarpophalangeal ulnar collateral ligament tears. J Hand Surg. 1995;20:1037–1042. Sollerman C, Abrahamnsson SO, Lundborg G, et al. Functional splinting versus plaster cast for ruptures of the ulnar collateral ligament of the thumb. Acta Orthop Scand. 1991;62:524–526. Susic D, Hansen BR, Hansen TB. Ultrasonography may be misleading in the diagnosis of ruptured and dislocated ulnar collateral ligaments of the thumb. Scand J Plast Reconstr Hand Surg. 1999;33:319–320. Weiland AJ, Berner SH, Hotchkiss RN, et al. Repair of acute ulnar collateral ligament injuries of the thumb metacarpophalangeal joint with an intraosseous suture anchor. J Hand Surg Am. 1997;22:585–591.
31.e1
Injuries to the Ulnar Collateral Ligament of the Thumb Metacarpophalangeal Joint (Gamekeeper’s Thumb) S. Brent Brotzman, MD | Steven R. Novotny, MD
BACKGROUND The classic “gamekeeper’s thumb” was first described in Scottish gamekeepers as a chronic instability of the thumb MCP joint ulnar collateral ligament. Stener in 1962 reported the nonhealing lesion of the UCL outside the adductor aponeurosis, not specifically an acute injury. “Skier’s thumb” was coined by Schultz, Brown, and Fox in 1973, with skiing being the most common cause of acute ulnar collateral ligament (UCL) rupture (e.g., after a fall causing the ski pole to stress and tear the ulnar collateral ligament of the thumb MCP joint). Even though these eponyms exist, most injuries do not involve sports. Static lateral pinch stability is provided by a strong collateral ligament complex: Proper UCL runs from the metacarpal lateral condyle to the proximal phalanx and the accessory collateral ligaments, which attach more volarly on the metacarpal and insert on the volar plate and sesamoids. The proper collateral ligaments are taut in flexion while the accessories are in taut extension. The tendinous attachments of the thenar muscles— especially the adductor pollicis attaching into the ulnar sesamoid—contribute some dynamic stability. The UCL provides resistance to radially applied forces (e.g., pinching or holding large objects). A torn UCL weakens the key pinch grip strength and allows volar subluxation of the proximal phalanx. With prolonged instability, the MCP joint frequently degenerates. The amount of valgus laxity of normal thumbs varies widely. In full MCP joint extension, valgus laxity averages 6 degrees, and in 15 degrees of MCP joint flexion it increases to an average of 12 degrees. It has been shown that the valgus laxity may vary if the joint is tested in supination and pronation (Mayer et al. 2014). It is recommended to standardize the stress examination in neutral rotation. The adductor aponeurosis (when torn or pulled distally) frequently entraps the UCL, preventing anatomic ligament reduction and healing of the UCL (Stener lesion) (Fig. 6.1). The typical mechanism of injury is an extreme valgus stress to the thumb (e.g., falling on an abducted thumb).
EVALUATION Patients typically have a history of a valgus injury to the thumb followed by pain, swelling, and frequently ecchymosis at the ulnar aspect of the thumb MCP joint. Palpation of the ulnar aspect of the MCP joint may reveal a small lump, which may be indicative of a Stener lesion or avulsion fracture. Radiographs are necessary to evaluate for fractures, which may have significant ramifications on management. Dinowitz et al. (1997) reported a series of 9 patients
with avulsion fractures with <2.0 mm displacement who all did poorly after at least 6 weeks of immobilization and rehab. Rotation of the fragment was felt to limit healing. All were salvaged with subsequent surgery. Kaplan reported on two patients with wellaligned fractures with displaced ligaments (Kaplan 1998). Shear fractures can occur after the ligament has been avulsed. In addition to plain films (three views of the thumb and carpus), valgus stress testing radiographs should be obtained. Because patients who are acutely injured will guard from pain, 1% lidocaine should be injected into the joint before stress testing. Many patients are seen days or weeks after the injury and the intra-articular lidocaine may not be adequate. Performing wrist median and radial nerve blocks provides complete anesthesia and allows multiple examinations if needed. Also an Adductor aponeurosis MCP joint
Normal ulnar collateral ligament
A
Rupture of ulnar collateral ligament Interposed adductor aponeurosis
B
Adductor aponeurosis divided
Fig. 6.1 Complete rupture of the ulnar collateral ligament resulting in a Stener lesion. The distal attachment has been avulsed from the bone. AB, The interposed adductor aponeurosis prevents the ligament from being reduced. Therefore, leaving joint potentially unstable.
29
30
SECTION 1 Hand and Wrist Injuries
MCP joint anesthetic injection insufflates tissue, which could influence the fit of a brace or cast, especially once the fluid absorbs. The integrity of the proper (ulnar collateral) ligament is assessed by valgus stress testing with the MCP joint of the thumb in 30 degrees of joint flexion. This test can be done clinically or with radiographic documentation. Some concern exists as to whether an exuberant exam can precipitate a Stener lesion. Adler et al. demonstrated on cadavers that serial ligament sectioning and stressing a Stener lesion could not be provoked (Adler et al. 2012). The literature varies as to the degree of angulation on valgus stressing that is compatible with complete rupture of the UCL. Thirty to 35 degrees of radial deviation of the thumb on valgus stressing or 15 degrees greater than the uninjured side indicates a complete UCL rupture and is an indication for surgical correction. With complete ruptures (>30 degrees of opening) the likelihood of a UCL ligament displacement (Stener lesion) is greater than 80%. The question of need or utility of advanced imaging should be discussed because they could be part of the evaluation. No advanced imaging technique has 100% sensitivity or specificity, and there is a cost involved. We are finding longer times for insurance companies to authorize or deny a study, which could turn an acute injury to a chronic injury before the special imaging is complete, then requiring another wait for surgical authorization. Papandrea and Fowler in 2008 reviewed current literature on ultrasound and MRI for evaluation of this injury. Given the structural and time constraints of MRI, ultrasound (possibly office-based ultrasound) could lead to a conclusion sooner. Looking at just two articles on ultrasound diagnosis of UCL Stener lesions shows there may be uncertainty in ultrasound conclusions. O’Callaghan et al. report 48 patients studied by ultrasound per protocol. All 13 patients with positive tests were explored (O’Callaghan et al. 1994). Ten of 13 positive tests showed true Stener lesions; the remainder at surgery were labeled partial Stener lesions. In Susic et al.’s publication 14 patients with clinically unstable UCL underwent US (Susic et al. 1999). At surgery all were ruptured, 5 were Stener lesions, yet only two of the five were identified on ultrasound. That means 60% of the dislocated lesions were missed on ultrasound.
TREATMENT Stable Thumb on Valgus Stressing (No Stener Lesion) • The ligament is only partially torn, and healing will occur with nonoperative treatment. • The thumb is immobilized for 4 weeks in a short arm spica cast or thermoplastic splint (molded), usually with the thumb IP joint free. • Active and passive thumb motion is begun at 3 to 4 weeks, but valgus is avoided. • If ROM is painful at 3 to 4 weeks, re-evaluation by a physician is indicated. • The thermoplastic splint is removed several times a day for active ROM exercises. • Grip-strengthening exercises are begun at 6 weeks after injury. A brace is worn for protection in contact situations for 2 months (Rehabilitation Protocol 6.1). • If one has access to reliable hand therapy, comparable results have been achieved with a fabricated forearm-based spica splint hinged at the MCP (Sollerman et al. 1991).
• The MCP is allowed an arc of 50 degrees motion. Other authors express satisfaction with a hand-based hinged MCP splint allowing a 35-degree arc of motion (Michaud et al. 2010). These rehab studies discuss the monitoring and individual modifications rationale during the healing period. Biomechanical modeling of strains on repaired UCL has shown load to failure three times higher than loads expected with flexion and extension (Harley et al. 2004). This study supports the clinical findings of the early motion rehab protocol post surgery.
Unstable Thumb on Valgus Stressing (>30 Degrees) • Because 80% of patients with a complete rupture are found to have a Stener lesion (thus obtaining a poor healing result if treated nonoperatively), it is critical to make the correct diagnosis of stable versus unstable gamekeeper’s thumb. As we’ve seen, it isn’t possible to be 100% accurate with advanced imaging. Physical exam is excellent at diagnosing instability; absent fractures, bony excrescences, or concomitant soft tissue tumors, a palpable enlargement ulnar to the metacarpal head, can be considered diagnostic. Without other evidence one needs to discuss risks and benefits of the three treatment paths—surgery, imaging, conservative care—and encourage patient involvement in the decision. • Operative repair requires direct visualization of the local anatomy. Results can be improved by re-creation of normal anatomy. Carlson has demonstrated the anatomic origins and insertions of both the UCL and RCL of the thumb MCP joint (Carlson et al. 2012). They determined the center of the ulnar collateral ligament origin to be 4.2 mm volar to the dorsal surface of the metacarpal head, 5.3 mm proximal to the articular surface, and 7 mm from the volar cortex. The phalangeal insertion center was 9.2 mm from the dorsal surface, 3.4 mm distal to the articular surface and 2.8 mm dorsal to the volar cortex. This work provides context to the deliberateness with which placement of anchors or drill holes is undertaken. Lee et al.’s biomechanical simulation study to determine optimal tunnel placement for UCL reconstruction used four constructs: cruciate, two parallel, proximal apex V, and distal apex V (Lee et al. 2005). All constructs restored valgus load stability. The proximal apex V restored range of motion not significantly different from the native state. The other 3 constructs resulted in significantly decreased range of motion. • Numerous published reports exist demonstrating effective surgical repair of avulsed ulnar collateral ligaments and repair of bony involvement. Weiland et al. (1997) reported anchored repairs in acute injury with excellent functional results. Tip, chuck, key, and pinch strengths and laxity were almost indistinguishable comparing operative and noninjured sides. Grip strength was slightly decreased. Range of motion loss was approximately 10 degrees at the MPJ and IPJ. Twenty percent of patients had self-reported minor symptoms at maximum exertion. Glickel et al. reported results for UCL replacement for chronic instability. A tendon graft was passed intraosseously and tied extracutaneously (Glickel et al. 1993). Twenty-four of 26 patients had good or excellent results with significantly improved function and few complications. Osterman et al. (1981) reported their results using acute repair, reconstruction with graft, and reconstruction
6 Injuries to the Ulnar Collateral Ligament of the Thumb Metacarpophalangeal Joint (Gamekeeper’s Thumb)
31
REHABILITATION PROTOCOL 6.1 Rehabilitation Protocol After Repair or Reconstruction of the Ulnar Collateral Ligament of the Thumb Metacarpophalangeal Joint The early motion protocol allows 35–50 degree motion with hinged splint protecting the MCP from radial or ulnar deviation. Static splint with ADLs if pain at 2 to 3 weeks. If no pain at 6 weeks, brace not necessary at night or light activities. Protected repair from aggressive activity. If pain continues at 6 weeks, brace for a total of 12 weeks. 3 Weeks • Remove bulky dressing. • Remove MCP joint pin (K-wire) if used for joint stabilization. • Fit with wrist and thumb static splint for continual wear. 6 Weeks • Begin active and gentle passive ROM exercises of the thumb for 10 minutes each hour.
with adductor advancement. Acute repair had the best results with 92% pinch strength and 84% normal motion. Both types of reconstruction gave adequate function. Adductor advancement resulted in a slight strength advantage (85% vs 81%), however, the graft reconstruction had a significantly improved range of motion over advancement (78% vs 65%). They reported that repair within two weeks produces the best result, and reconstruction in chronic injury demonstrates significant functional improvement. • Most surgeons feel more comfortable with an open procedure. Ryu and Fagan (1995) with soft tissue Stener and Badia (2006) with bony injury demonstrated successful treatment in their patients via arthroscopic treatment.
• Avoid any lateral stress to the MCP joint of the thumb. • Begin dynamic splinting if necessary to increase passive ROM of the thumb. 8 Weeks • Discontinue splinting. Wrist and thumb static splint or short opponens splint may be useful during sports-related activities or heavy lifting. • Begin progressive strengthening. 12 Weeks • Allow the patient to return to unrestricted activity.
REFERENCES A complete reference list is available at https://expertconsult .inkling.com/. FURTHER READING Bean HG, Tencher AF, Trumble TE. The effect of thumb metacarpophalangeal ulnar collateral ligament attachment site of joint range of motion: an in vivo study. J Hand Surg Am. 1999;24:283–287. Chuter GS, Muwanga CL, Irwin LR. Ulnar collateral ligament injuries of the thumb: 10 years of surgical experience. Injury. 2009;40:652–656. Heyman P. Injuries to the ulnar collateral ligament of the thumb metacarpophalangeal joint. J Am Acad Orth Surg. 1997;5:224–229.
REFERENCES Adler T, Eisenbarth I, Hirschman MT, et al. Can clinical examination cause a Stener lesion in patients with skier’s thumb? Clinical Anatomy. 2012;25:762–766. Badia A. Arthroscopic reduction and internal fixation of bony gamekeeper’s thumb. Orthopedics. 2006;29:675–678. Carlson MG, Warner KK, Meyers KN, et al. Anatomy of the thumb metacarpophalangeal ulnar and radial collateral ligaments. J Hand Surg. 2012;37: 2021–2026. Dinowitz M, Trumble T, Hanel D, et al. Failure of cast immobilization for thumb ulnar collateral ligament avulsion fractures. J Hand Surg. 1997;22: 1057–1063. Glickel SZ, Malerich M, Pearce SM, et al. Ligament replacement for chronic instability of the ulnar collateral ligament of the metacarpophalangeal joint of the thumb. J Hand Surg Am. 1993;18:930–941. Harley BJ, Werner FW, Green JK. A biomechanical modeling of injury, repair and rehabilitation of ulnar collateral ligament injuries of the thumb. J Hand Surg. 2004;29:915–920. Kaplan S. The Stener lesion revisited: a case report. J Hand Surg Am. 1998;23: 833–836. Lee SK, Kubiak EN, Lawler E, et al. Thumb metacarpophalangeal ulnar collateral ligament injuries: a biomechanical simulation study of four static reconstructions. J Hand Surg Am. 2005;30:1056–1060.
Mayer SW, Rush DS, Leversedge FJ. The influence of thumb metacarpophalangeal joint rotation on the evaluation of ulnar collateral ligament injuries: a biomechanical study in a cadaver model. J Hand Surg Am. 2014;39:474–479. Michaud EJ, Flinn S, Seitz WH. Treatment of grade III thumb metacarpophalangeal ulnar collateral ligament injuries with early controlled motion using a hinged splint. J Hand Therapy. Jan-Mar, 2010:77–82. O’Callaghan BI, Kohut G, Hoogewoud HM. Gamekeeper thumb: identification of the Stener lesion with US. Radiology. 1994;192:477–480. Osterman A, Hayken G, Bora F. A qualitative evaluation of thumb function after ulnar collateral repair and reconstruction. J Trauma. 1981;21:854–861. Papandrea RF, Fowler T. Injury at the thumb UCL: is there a Stener lesion? J Hand Surg Am. 2008;33:1882–1884. Ryu J, Fagan R. Arthroscopic treatment of acute complete thumb metacarpophalangeal ulnar collateral ligament tears. J Hand Surg. 1995;20:1037–1042. Sollerman C, Abrahamnsson SO, Lundborg G, et al. Functional splinting versus plaster cast for ruptures of the ulnar collateral ligament of the thumb. Acta Orthop Scand. 1991;62:524–526. Susic D, Hansen BR, Hansen TB. Ultrasonography may be misleading in the diagnosis of ruptured and dislocated ulnar collateral ligaments of the thumb. Scand J Plast Reconstr Hand Surg. 1999;33:319–320. Weiland AJ, Berner SH, Hotchkiss RN, et al. Repair of acute ulnar collateral ligament injuries of the thumb metacarpophalangeal joint with an intraosseous suture anchor. J Hand Surg Am. 1997;22:585–591.
31.e1