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Rupture of the ulnar collateral ligament of the metacarpophalangeal joint of the thumb
Injury (1993) 24,(lo), 697
697
Printed in Great Britain
letters to the Editor Rupture of the ulnar collateral ligament of the metacarpophalangeal joint of the thumb Dear Sir, Engelhardt et al. (Injtly 24 (l), 21)have reported the results of treatment in patients who have undergone repair of the ulnar collateral ligament of the thumb. They report restricted flexion at the first metacarpophalangeal (MCP) joint in eight of 15 cases and suggest that limited movement is an important factor influencing the overall outcome. It is further suggested that these patients may benefit from a shorter period of plaster immobilization in order to minimize the risks of a stiff joint. However, what is not clear from their paper is how they define a stiff joint. Shaw and Morris (1992) have measured 51"as an average range of flexion at the first MCP joint in the general population. More importantly, they also demonstrated significant differences between individuals in the normal range of movement at this joint and demonstrated a correlation between the range of movement when comparing the right with the left thumb. The conclusion is that in a given individual there is no certain way of knowing the mobility of the injured thumb prior to the injury and that any study that reports postoperative stiffness must take into account the range of movement in the opposite thumb. We have recently reviewed 14 patients who have had repair of the ulnar collateral ligament and we have compared the range of flexion at the MCP joint of the injured and uninjured thumbs. Among these patients, the average range of flexion was the same when comparing the injured side with the uninjured side. We suggest that the longestablished notion that these operations can lead to stiffness should be questioned until we can more clearly define a normal range of movement in a given individual. S. H. Bostock FRCS M. A. Morris FRCS
Reference Shaw S. J. and Moms M. A. (1992) The range of motion of the metacarpo-phalangeal joint of the thumb and its relationship injury. 1. Hand Surg. 17B,164.
to
Author’s reply We are aware of Morris’s new publication and we agree with Bostock and Morris that it is difficult to measure the movement of the first MCP joint, in that one has to abolish concomitant flexion of the first carpometacarpal joint, and we are aware of the great interindividual variations in total movement. We did measure the movement of the first MCP joint and compared the measurement with the uninjured side. The ‘stiffness’ was expressed as percentage reduction of flexion compared with the unaffected thumb. ((3 1993 Butterworth-Heinemann 0020-1383/93/100697-01
Ltd
What we have concluded is, that nine patients had restricted flexion in the range from 11 to 75 per cent (average 24 per cent). Those patients aware of the limitation had it confirmed objectively. We found that the decrease in flexion has to be more than 20” to correlate with dissatisfaction. We also found that half of the patients who complained of limited mobility actually had unstable MCP joints, therefore tightening of the ligament during reconstruction could not explain the ‘stiffness’. We raise the suspicion about immobilization because abduction in the carpometacarpal joints was restricted in seven out of nine patients complaining of limited mobility. 0. M. Christensen
Flexor pollicis longus rupture We previously reported three cases of apparently spontaneous rupture of flexor pollicis longus in non-rheumatoid patients (O’Dwyer and Jefferiss, 1989). Despite a careful search of the tendon sheath on each occasion, no cause was found. A 59-year-old female presented recently with a J-month history of inability to flex her thumb at the interphalangeal joint. There was no history of trauma. She suffered from sero-negative rheumatoid arthritis, inactive at presentation. She was on no medication for this condition. Exploration was carried out along the length of the tendon sheath as far proximally as the carpal tunnel, where the tendon was found to be divided. No inflammatory tissue was found. The floor of the tendon sheaths at the site of rupture was explored and only with difficulty was the cause found. A small defect in the capsule, opening like a trap door, revealed an underlying osteophyte of the scaphoid. It was trimmed and the defect repaired. Tendon transfer of flexor sublimis to the ring finger was then performed. The patient made an uneventful recovery. In rheumatoid arthritis, inflammatory synovial tissue invades and erodes the lining of a tendon, thereby exposing the underlying bone (Vaughan-Jackson, 1962). No such activity was present in this case. On this occasion, initial inspection of the floor revealed no abnormality. Only after gentle probing was the defect found. It is imperative that a very thorough search be made at the site of rupture, otherwise the cause may not be revealed, leading to further ruptures. K. J. O’Dwyer FRCS C. D. Jefferiss FRCS
References O’Dwyer K. J. and Jefferiss C. D. (1989) Spontaneous rupture of flexor pollicis longus, a report of three cases. Injury 20, 200. Vaughan-Jackson 0. J. (1962) Rheumatoid hand deformities as considered in the light of tendon imbalance. J. Bone faint Srrrg.
44B, 764.
697
Printed in Great Britain
letters to the Editor Rupture of the ulnar collateral ligament of the metacarpophalangeal joint of the thumb Dear Sir, Engelhardt et al. (Injtly 24 (l), 21)have reported the results of treatment in patients who have undergone repair of the ulnar collateral ligament of the thumb. They report restricted flexion at the first metacarpophalangeal (MCP) joint in eight of 15 cases and suggest that limited movement is an important factor influencing the overall outcome. It is further suggested that these patients may benefit from a shorter period of plaster immobilization in order to minimize the risks of a stiff joint. However, what is not clear from their paper is how they define a stiff joint. Shaw and Morris (1992) have measured 51"as an average range of flexion at the first MCP joint in the general population. More importantly, they also demonstrated significant differences between individuals in the normal range of movement at this joint and demonstrated a correlation between the range of movement when comparing the right with the left thumb. The conclusion is that in a given individual there is no certain way of knowing the mobility of the injured thumb prior to the injury and that any study that reports postoperative stiffness must take into account the range of movement in the opposite thumb. We have recently reviewed 14 patients who have had repair of the ulnar collateral ligament and we have compared the range of flexion at the MCP joint of the injured and uninjured thumbs. Among these patients, the average range of flexion was the same when comparing the injured side with the uninjured side. We suggest that the longestablished notion that these operations can lead to stiffness should be questioned until we can more clearly define a normal range of movement in a given individual. S. H. Bostock FRCS M. A. Morris FRCS
Reference Shaw S. J. and Moms M. A. (1992) The range of motion of the metacarpo-phalangeal joint of the thumb and its relationship injury. 1. Hand Surg. 17B,164.
to
Author’s reply We are aware of Morris’s new publication and we agree with Bostock and Morris that it is difficult to measure the movement of the first MCP joint, in that one has to abolish concomitant flexion of the first carpometacarpal joint, and we are aware of the great interindividual variations in total movement. We did measure the movement of the first MCP joint and compared the measurement with the uninjured side. The ‘stiffness’ was expressed as percentage reduction of flexion compared with the unaffected thumb. ((3 1993 Butterworth-Heinemann 0020-1383/93/100697-01
Ltd
What we have concluded is, that nine patients had restricted flexion in the range from 11 to 75 per cent (average 24 per cent). Those patients aware of the limitation had it confirmed objectively. We found that the decrease in flexion has to be more than 20” to correlate with dissatisfaction. We also found that half of the patients who complained of limited mobility actually had unstable MCP joints, therefore tightening of the ligament during reconstruction could not explain the ‘stiffness’. We raise the suspicion about immobilization because abduction in the carpometacarpal joints was restricted in seven out of nine patients complaining of limited mobility. 0. M. Christensen
Flexor pollicis longus rupture We previously reported three cases of apparently spontaneous rupture of flexor pollicis longus in non-rheumatoid patients (O’Dwyer and Jefferiss, 1989). Despite a careful search of the tendon sheath on each occasion, no cause was found. A 59-year-old female presented recently with a J-month history of inability to flex her thumb at the interphalangeal joint. There was no history of trauma. She suffered from sero-negative rheumatoid arthritis, inactive at presentation. She was on no medication for this condition. Exploration was carried out along the length of the tendon sheath as far proximally as the carpal tunnel, where the tendon was found to be divided. No inflammatory tissue was found. The floor of the tendon sheaths at the site of rupture was explored and only with difficulty was the cause found. A small defect in the capsule, opening like a trap door, revealed an underlying osteophyte of the scaphoid. It was trimmed and the defect repaired. Tendon transfer of flexor sublimis to the ring finger was then performed. The patient made an uneventful recovery. In rheumatoid arthritis, inflammatory synovial tissue invades and erodes the lining of a tendon, thereby exposing the underlying bone (Vaughan-Jackson, 1962). No such activity was present in this case. On this occasion, initial inspection of the floor revealed no abnormality. Only after gentle probing was the defect found. It is imperative that a very thorough search be made at the site of rupture, otherwise the cause may not be revealed, leading to further ruptures. K. J. O’Dwyer FRCS C. D. Jefferiss FRCS
References O’Dwyer K. J. and Jefferiss C. D. (1989) Spontaneous rupture of flexor pollicis longus, a report of three cases. Injury 20, 200. Vaughan-Jackson 0. J. (1962) Rheumatoid hand deformities as considered in the light of tendon imbalance. J. Bone faint Srrrg.
44B, 764.