Complication rates after RCL repair (N= 4; 22.2%) were higher than UCL repair (N= 7; 11.3%). POST-OPERATIVE WEEKS 22-24. Please enter a Recipient Address and/or check the Send me a copy checkbox. Epub 2021 Sep 7. Systematic review and meta-analysis. 1995;18:11611165. eCollection 2021 Apr. Nonoperative treatment led to high patient satisfaction for acute thumb UCL injury in 2 studies.23,29 Thirty-two subjects were treated with thumb-spica immobilization (30 were proximal phalanx avulsion fractures). 2005;24:217221. Skier's thumb is a partial or complete rupture of the ulnar collateral ligament of the metacarpophalangeal joint of the thumb. Our primary purpose was to compare nonoperative treatment with surgical repair and surgical reconstruction of thumb UCL injuries. Rupture of the. Epub 2016 Jan 13. If you log out, you will be required to enter your username and password the next time you visit. Potentially inclusive articles were manually reviewed, discussed among the authors, and a decision was made regarding inclusion or exclusion. Both purely ligamentous and bony avulsion injuries were included. NR, not reported. Acute UCL repair and autograft UCL reconstruction for chronic injury led to excellent clinical outcomes, without a significant difference between the 2 groups. Moher D, Liberati A, Tetzlaff J, et al.. Whether a difference in clinical outcome exists between operative and nonoperative management of thumb UCL acute injuries; Whether a difference in clinical outcome exists between operative and nonoperative management of thumb UCL chronic injuries; Whether a difference in clinical outcome exists between repair and reconstruction of the thumb UCL for acute (less than 3 weeks) UCL injury; Whether a difference in clinical outcome exists between repair and reconstruction of the thumb UCL for chronic (more than 3 weeks) UCL injury; Whether a difference in clinical outcome after reconstruction of the thumb UCL exists between different choices of graft; Whether a difference in clinical outcome after operative treatment exists between acute and chronic UCL injuries. the thumb. You will receive email when new content is published. Mean Quality Appraisal Tool score was 13.1 3.5 (range, 819), which correlated with a 54.6% 14.5% quality rating. 2015 Nov-Dec;7(6):511-7. doi: 10.1177/1941738115607208. Mean study follow-up was 42.8 months. However, thumb UCL reconstruction was hypothesized to be significantly better than repair for chronic UCL injury. Bostock S, Morris MA. Corresponding Author Hisham M. Awan, MD, The Ohio State University Hand and Upper Extremity Center, 915 Olentangy River Rd, Suite 3200, Columbus, OH 43212 (hisham.awan@osumc.edu). They may even tear completely. There is also significant performance bias, as there are multiple different methods of treatment, providers, graft, suture, and fixation types, as well as methods and duration of immobilization. This is the first study to compare complication rates between radial and ulnar collateral ligament injuries of the thumb. 1992;8:713732. What are the symptoms of GameKeeper's Thumb? Abstract Objectives: Rupture of the ulnar collateral ligament (UCL) is a frequent injury of the hand. 11. Search performed on November 17, 2011. 2019 Apr;47(5):1103-1110. doi: 10.1177/0363546519831705. [31] The adductor pollicis supplies active support on the ulnar aspect, whereas the abductor pollicis brevis and flexor pollicis brevis provide dynamic stability on the radial border. 1996;25:527530. Clinical outcome studies after nonoperative or operative treatment of thumb UCL injuries, with a minimum of 2 years mean follow-up, were included. Proximal interphalangeal joint injuries of the hand. Bailie DS, Benson LS, Marymont JV. There is, however, agreement on the treatment goals for repair or reconstruction of the UCL, which are to obtain and maintain an anatomic reduction of the MP joint, reproduce the anatomic origin and the insertion of native ligament, ensure sufficient strength to allow early range of motion, and minimize donor site morbidity if autograft is used.19 Although most surgical undertakings result in good clinical and functional outcomes, there are postoperative complications, including stiffness and decreased range of motion (specifically, restricted flexion at the MP joint), failed reconstruction, infection, neuropraxia, continued pain, implant failure, graft failure, loosening, scarring, and arthrosis.30,43,44 It has been well documented that direct suture techniques fail in chronic injuries.33,45 When repair is attempted, nonanatomical repositioning of the UCL may contribute to the loss of joint motion.46. There are many ways to manage both acute and chronic thumb UCL deficiency, and controversy persists as to the best treatment options. UCLR techniques associated with the highest rates of neuropathy were detachment of the FPM, modified Jobe fixation, and concomitant ulnar nerve transposition, although it remains unclear whether there is a causal relationship between these factors and subsequent development of postoperative ulnar neuropathy due to limitations in the current body of published literature. Smith RJ. Epub 2020 Jun 29. Some error has occurred while processing your request. There are some cases where the fusion is not successful and you will still have pain in . 2021 Jan;49(1):236-248. doi: 10.1177/0363546520921160. Thumb sidedness reported in 3 studies (51 thumbs). MCP fusion was performed on 36.3% (4/11) of patients with RCL (N=1) and UCL (N=3) tears. 1999;24:275282. This leads to what is know as a positive ulnar variance. After significant delay to treatment or even failed nonoperative treatment, excellent clinical outcomes can be achieved, without a difference between initially treating the injury surgically. doi: 10.1016/j.asmr.2020.12.004. The site is secure. 2021 Apr 15;3(2):e527-e533. Part I: anatomy and diagnosis. HHS Vulnerability Disclosure, Help 2014 Oct;42(10):2510-6. doi: 10.1177/0363546513509051. *The Ohio State University Hand and Upper Extremity Center, Columbus, Ohio; Midwest Orthopaedics at Rush, Rush University Medical Center, Chicago, Illinois; and. A p-value of 0.05 was considered statistically significant. At this stage, patients should be advised to wear your splint part-time. Sports Med Arthrosc Rev. It is an often-encountered injury and can lead to chronic pain and instability when diagnosed incorrectly. A score of 0 was assigned if the item was either omitted or not performed. [30] The stability of the MP joint derives from joint congruity, the true and accessory collateral ligaments, the volar plate, and the surrounding intrinsic muscles. Part II: treatment and complications. Glickel SZ, Malerich M, Pearce SM, et al.. Ligament replacement for chronic instability of the, 28. In the event of disagreement among authors for study inclusion, the final decision was made by the senior author (HMA). 25. A chi-square test of independence was performed to examine the relation between UCL versus RCL repair and presence of a complication. There is no uniformly agreed on surgical indication for UCL injuries to the MP joint of the thumb. You may also begin strengthening exercises if needed. Ulnar collateral ligament (UCL) rupture is often seen in patients practicing sports activities, particularly in ski falls. Pain Swelling Bruising A weaker pinch or problems grabbing things when you use your thumb If surgery is needed, the ligament is reconnected to the bone. Throwing status reported in 4 studies. For more information, please refer to our Privacy Policy. A Stener lesion is difficult to diagnose but leads to poor healing and usually indicates operative management. There were 61 studies eliminated as secondary for being in a language other than English. All rights reserved. Acta Chir Scand. Any hard force on the thumb that pulls the thumb away from the hand (called a valgus force) can cause damage to the ulnar collateral ligaments. If given within individual studies, the P values calculated by the authors of the individual studies were used and not retested because of a lack of subject-level data. Orthop Rev. According to the Glickel grading system, 51 excellent (80%) (joint stability not significantly different from unoperated thumb, less than 15% MP joint motion loss, no pain, no ADL limitations, and less than 15% loss of pinch strength), 11 good (17%), and 2 fair (3%) outcomes were observed. Infection is a rare complication of hand surgery. 2003;8:8185. #Injury location reported only in 3 studies. gamekeeper's thumb; skier's thumb; stener lesion; ulnar collateral ligament, NOW OVER 19K FOLLOWERS ON TWITTER. Thirty-two thumbs were treated nonoperatively and 261 operatively. Keyword Highlighting The UCL has as its central function maintenance of ulnar stability of the joint, which is paramount for pinch grip. This injury happens when an ulnar collateral ligament (UCL) tough and flexible tissue that connect bones in the thumb gets stretched too far or tears. The diagnosis is best established clinically, though MRI is the imaging modality of choice. Mean subject age was 33.9 years. Thus, the true natural history is yet unknown. Most times, they won't know until they're in the surgery if the internal brace is appropriate. Knowledge of the anatomy and accurate physical examination are essential in the evaluation of a patient with skier's thumb. may email you for journal alerts and information, but is committed Unable to load your collection due to an error, Unable to load your delegates due to an error. The original study using this tool had a mean quality score range of 25% to 96% but had more than half of the studies scoring >75%.16 Despite these study limitations, this systematic review is strong in that it analyzes the largest number of studies and subjects in the literature managed with both nonoperative and operative means for acute and chronic UCL injury. Sollerman C, Abrahamsson SO, Lundborg G, et al.. Functional splinting versus plaster cast for ruptures of the, 41. Arthrosc Sports Med Rehabil. Am J Sports Med. Griffith TB, Ahmad CS, Gorroochurn P, D'Angelo J, Ciccotti MG, Dines JS, Altchek DW, Camp CL. Your surgeon will discuss these options with you. All techniques improved clinical outcomes, including pain, motion, strength, and stability. 2021 Nov 23;9(11):23259671211055428. doi: 10.1177/23259671211055428. After three to four weeks, the joint should heal enough to remove the splint and begin strengthening exercises. Ulnar collateral ligament tear represents 60 percent of upper limb problems in skiers and is frequently overlooked and underdiagnosed. Results of surgical treatment of acute and chronic grade III [corrected] tears of the radial collateral ligament of the thumb metacarpophalangeal joint. After significant delay to treatment or even failed nonoperative treatment, excellent clinical outcomes can be achieved, without a difference between initially treating the injury surgically. This review has demonstrated excellent clinical outcomes after surgical treatment of both acute and chronic UCL injury, without any significant difference between repair and reconstruction for acute and chronic injury, respectively. Hintermann B, Holzach PJ, Schutz M, et al.. Skier's thumbthe significance of bony injuries. [33] Avulsion fractures of the ulnar base of the proximal phalanx occur 20% to 30% of the time. Please confirm that you would like to log out of Medscape. If you experience a high temperature, excess bleeding, swelling or pain, contact your surgeon. 2022 Jul;50(8):2324-2338. doi: 10.1177/03635465211023952. One study15 reported outcomes of 9 patients who had failed nonoperative treatment and underwent subsequent surgical repair. A systematic review of the literature was completed using the MEDLINE, PubMed, and Ovid databases. and twist using your thumb. Background:Thumb ulnar collateral ligament (UCL) tears are common in competitive athletes. Subject demographics are reported in Table 2. Tommy John surgery; ulnar collateral ligament reconstruction; ulnar nerve transposition; ulnar neuropathy. 2. 1995;23:222226. Eventually this abnormal movement will wear out the joint and it will become arthritic. Acute gamekeeper's thumb. Ritting et al[30] assert that operative management of acute injuries is indicated when the thumb is without an endpoint to valgus stress testing. Careers. CMC joint is a saddle-shaped joint composed of the trapezium and the base of the thumb (1st) metacarpal. 1 Major components of the TFCC are the articular disc (AD), meniscus homolog, radioulnar ligaments, and extensor carpi . By nature of the definition of chronic UCL deficiency, patients with remote UCL injury have either been untreated or have failed prior nonoperative treatment (for various reasons such as pain, weakness, or instability) and gone on to necessitate surgical intervention. Further detection bias existed in that not all studies used each clinical outcome (eg, Glickel grade) or radiographic measure postoperatively. Evidence-based use of clinical examination, ultrasonography, and MRI for diagnosing ulnar collateral ligament tears of the metacarpophalangeal joint of the thumb: systematic review and meta-analysis. 1,6,15 The mechanism of injury is a radially directed force on an extended thumb, which can occur when an athlete falls onto an abducted thumb, slides into a baseball base, or attempts to catch a ball. Thumb collateral ligament injuries. 2022 Mar 27;4(3):141-146. doi: 10.1016/j.jhsg.2022.02.008. The purpose of this study is to examine the prevalence and type of ulnar nerve complications after UCLR of the elbow based on the entirety of previously published outcomes in the English literature. These movements include opposing the thumb to each finger, thumb extension/abduction and full wrist movement. 2013Lippincott Williams & Wilkins. 1998;23:503506. An official website of the United States government. FOIA 1-6 weeks: If the ligament is partially torn then a splint or cast is usually worn for six weeks and after its removal a programme of exercises is . UCL repair surgery is a procedure to treat an injury to the UCL, the soft tissue that connects the bones of the thumb and provides stability to the thumb joint. This is the first study to compare complication rates between radial and ulnar collateral ligament injuries of the thumb. Surgery has been recommended for fracture displacement, significant articular involvement, clinical instability, or fragment rotation. When untreated, this injury may lead to decreased pinch strength, pain, instability, and osteoarthritis. 2005;87:26322638. MCP fusion was performed . Conclusions: [23,3638] Kuz et al recommend that most acute avulsion fractures of the thumb UCL be treated nonsurgically, with the exception of displaced fractures with more than 30% articular involvement or bony Stener lesions. *Glickel grading system. Please enable scripts and reload this page. You may search for similar articles that contain these same keywords or you may Transfer bias was present in the difference of length of follow-up, despite a minimum of 2 years, and the proportion of subjects who enrolled and completed that which was actually followed up. Orthopedics. Therefore, these patients were included in the surgical group for analysis, as they did have more than 2 years minimum clinical follow-up after surgical treatment. Thus, the true natural history is yet unknown. sharing sensitive information, make sure youre on a federal When untreated, this injury may lead to decreased pinch strength, pain, instability, and osteoarthritis. Usually it is pulled off of the bone (proximal phalanx) on the nail side of the joint. If you're experiencing pain, bruising and swelling in your thumb after an accident such as a fall, be sure to contact your healthcare provider. Surgical treatment has been advocated for all avulsion fractures of the UCL, as the area of articular cartilage is always greater than the fragment size.41 Abrahamsson et al42 maintain that a proximally displaced ligament, palpated proximal to the MP joint, is a more specific indication for surgery. Symptoms of the UCL injury include pain, instability of the MCP joint of the thumb, and weakness in prehension and the chronicity of the injury. Symptoms are dependent on the cause and severity of injury to the UCL. 2012 Nov 7;94(21):2005-12. doi: 10.2106/JBJS.K.01024. Would you like email updates of new search results? flexion-extension motion. Orthop J Sports Med. There were considerable differences in the outcomes collected within the studies and between studies, which precluded the performance of a meta-analysis. The UCL is a band of tough, fibrous tissue that connects the bones at the base of the thumb. Various complications have been previously documented including transient and permanent neuropathies involving the ulnar, saphenous, and median palmar nerves, neuroma formation, hematoma, infection, donor site harvest tenderness, postoperative stiffness, retear of flexor-pronator muscle, and stress fracture of the ulnar bone bridge. Tension wire fixation of avulsion fractures in the hand. Van Dommelen BA, Zvirbulis RA. 1,5,9,10 In acute cases of complete tears involving high-level . Among cases with concomitant transposition performed, submuscular transposition resulted in a higher rate of reoperation for ulnar neuropathy (12.7%) compared with subcutaneous transposition (0.0%). Weakened grip or reduced thumb range of motion may occur. [41] Abrahamsson et al[42] maintain that a proximally displaced ligament, palpated proximal to the MP joint, is a more specific indication for surgery. 32. 10. When untreated, this injury may lead to decreased pinch strength, pain, instability, and osteoarthritis. *Glickel grading scale. Instability of the metacarpophalangeal joint of the thumb. J Hand Surg Am. Wolters Kluwer Health [32], Nonsurgical treatment has been advocated for nondisplaced, or minimally displaced avulsion fractures of the UCL either with functional bracing[35] or via thumb spica casting or splinting. Key, pulp, and tip pinch and grip strength were either equivalent or only mildly weak compared with the contralateral thumb and hand in all subjects. J Hand Surg Glob Online. A Comparison of Acute Versus Chronic Thumb Ulnar Collateral Ligament Surgery Using Primary Suture Anchor Repair and Local Soft Tissue Advancement. Nonoperative treatment often failed, necessitating surgery. Chest pain, difficulty breathing, nausea, vomiting Cold fingers, or painful fingers that are not normal in color Increasing redness beginning 7 days after surgery Looney AM, Wang DX, Conroy CM, Israel JE, Bodendorfer BM, Fryar CM, Pianka MA, Fackler NP, Ciccotti MG, Chang ES. An anatomic basis for treatment. Nonoperative treatment of acute UCL injury (with or without a Stener lesion) frequently fails, leading to chronic pain, instability, and weakness, eventually prompting surgical intervention.. eCollection 2022 May. There is currently no consensus on treatment of acute or chronic UCL injuries. eCollection 2021 Oct. Rashidi A, Haj-Mirzaian A, Dalili D, Fritz B, Fritz J. Eur Radiol. official website and that any information you provide is encrypted In general, be guided by symptoms and if an activity hurts, it is probably best avoided. Am J Sports Med. 2015 Apr;46(2):281-92. doi: 10.1016/j.ocl.2014.11.007. doi: 10.1097/JSA.0000000000000322. There were no cases of intraoperative ulnar nerve injury reported. Kaplan EB. Accessibility This tool is a 12-item instrument, with each item possibly receiving a minimum integer of 0 and a maximum integer of 2 score points. Does Weightlifting Improve Cardiovascular Mortality Risk for Older Aged Adults? Ulnar collateral ligament injuries of the thumb (gamekeeper or skier thumb) are more common than the radial side but both can cause significant disability. After the nerves exit the spinal cord, they connect from the Axillary (armpit) and upper arm . Continue to stretch before and after throwing . Intravenous regional anesthesia is commonly preferred for routine hand and wrist surgeries because it is well tolerated, safe, reliable, and has a rapid onset. Proximal interphalangeal joint injuries of the hand. Most patients have minimal pain by 6 weeks after surgery, with nearly full thumb and hand motion by 3 months. A score of 2 was assigned if the item was completely and accurately performed and reported. 1962;124:396411. Epub 2014 Oct 22. Mechanism of injury to the UCL of the MCP joint of the thumb is sudden, forced, radial deviation (abduction) and extension resulting in partial or complete tear of the ligament. There is currently no consensus on treatment of acute or chronic UCL injuries. Landsman JC, Seitz WH Jr, Froimson AI, et al.. Splint immobilization of gamekeeper's thumb. 21. UCLR case series that contained complications data were included. Differences in range of motion, pinch strength, biomechanical strength, or joint angulation have previously been investigated for various means of treatment of ulnar collateral ligament (UCL) tears. Long-term results of ligament reconstruction. Because patients can start moving the thumb within days, it also mitigates some of the negative consequences of prolonged immobilization, such as stiffness and muscle atrophy. This injury can have many names such as "skiers thumb", "gamekeepers thumb", and "break dancers thumb.". I wore a custom plastic splint that immobilized the MCP joint but allowed me to move the IP joint for 8 weeks total. Nonoperative treatment of acute UCL injury (with or without a Stener lesion) frequently fails, leading to chronic pain, instability, and weakness, eventually prompting surgical intervention. After the surgery you will lose some mobility in the thumb, but you are still able to grasp objects. There are many ways to manage both acute and chronic thumb UCL deficiency, and controversy persists as to the best treatment options. SYMPTOMS: The thumb may be swollen, bruised and painful. Clin Orthop Relat Res. If the tear is diagnosed later a ligament reconstruction might be a better option. 22. Erickson BJ, Harris JD, Chalmers PN, Bach BR Jr, Verma NN, Bush-Joseph CA, Romeo AA. Although many injuries can be managed conservatively, some require more invasive interventions to prevent complications and loss of function. Wilk KE, Arrigo CA, Dugas JR, Cain EL, Andrews JR. Wong TC, Ip FK, Wu WC. Both x-ray and magnetic resonance imaging evidence confirmed no increase in MP joint osteoarthritis at up to 75 months, postoperatively. If the force is too strong, the ligaments can tear. PMC 1994;23:797804. Bone-periosteum-bone graft reconstruction for chronic ulnar instability of the metacarpophalangeal joint of the thumbminimum 5-year follow-up evaluation. Conclusion: