Thumb metacarpophalangeal joint collateral ligament injury management

Clinical outcomes after primary repair for thumb ulnar collateral ligament ruptures: a systematic review and meta-analysis

There is no consensus on the best surgical technique for treating thumb ulnar collateral ligament (UCL) ruptures. This systematic review and meta-analysis investigates which primary repair technique and postoperative immobilization protocol result in the best clinical outcomes. A literature search was conducted in Embase, Medline ALL Ovid, Web of Science Core Selection and Cochrane Central Register of Controlled Trials. Pain, stability, tip pinch strength, key pinch strength, grip strength, return to work and metacarpophalangeal joint range of motion were collected as postoperative outcomes. In total, 29 studies were included. All surgical techniques resulted in satisfactory clinical outcomes, with no significant differences between bone anchor reinsertion, suture fixation, K-wire fixation and a combination of techniques. K-wire immobilization resulted in worse postoperative pain, but similar stability compared to immobilization without a K-wire. Clinical outcomes after thumb UCL repair are excellent, with no differences in clinical outcomes noted among surgical techniques.

Biological Versus Nonbiological Reconstruction of the Ulnar Collateral Ligament of the Thumb Metacarpophalangeal Joint: A Retrospective Study

PURPOSE

The purpose of this study was to compare clinical and radiologic outcomes of biological ligament reconstruction (BLR) versus nonbiological ligament reconstruction (NBLR) for chronic injuries involving the ulnar collateral ligament of the thumb's metacarpophalangeal joint.

METHODS

Forty-two patients who underwent static BLR (n = 24) or NBLR (n = 18) were included in this retrospective analysis. Preoperative, postoperative, and contralateral thumb measurements (clinical evaluation, radiographs, and subjective outcome questionnaires) were compared over a mean of 38 months of follow-up.

RESULTS

Average postoperative thumb metacarpophalangeal and interphalangeal joint ranges of motion were 2° to 54° and 0 to 71°, respectively, for BLR and 0° to 58° and 0° to 71°, respectively, for NBLR. Average grip and pinch strengths, relative to the unaffected hand, were 102% and 84% versus 103% and 89%, respectively. All patients demonstrated stability with a firm end point, compared with the unaffected thumb. The average Quick Disabilities of the Arm, Shoulder, and Hand score among all patients was 12 for the disability/symptom module, 0 for the sports module, and 17 for the work module. Stiffness was reported among four patients, and no patient sustained wound-related issues or other complications.

CONCLUSIONS

Nonbiological ligament reconstruction of the thumb ulnar collateral ligament generates short-term outcomes comparable with those of BLR, potentially allowing for expedited recovery and rehabilitation.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Ultrasound versus MRI in the evaluation of the thumb metacarpophalangeal joint

An intricate and unique combination of ligamentous, fibrocartilaginous, and osseous structures stabilize the thumb metacarpophalangeal joint. Both ultrasound and high-resolution magnetic resonance imaging are extremely useful in evaluating these critical structures. This article reviews common injuries of the thumb metacarpophalangeal joint, while highlighting the merits, limitations, and pitfalls of the two imaging modalities. A clear appreciation of each method, paired with anatomic knowledge, will lend greater confidence and accuracy to diagnosing impactful injuries and guiding intervention.

Acute Thumb Metacarpophalangeal Joint Ulnar Collateral Ligament Injury: Diagnosis, Management, and Return to Sports Considerations

ABSTRACT

Thumb metacarpophalangeal joint ulnar collateral ligament injuries are common in athletes and range from mild sprains to complete retracted tears. The typical injury mechanism of a valgus force directed onto an abducted or extended thumb is frequently seen in certain sporting activities, such as skiing, football, and baseball. Ultrasound and magnetic resonance imaging are excellent imaging supplements to the clinical evaluation for diagnosis confirmation. Positive treatment outcomes have been demonstrated when these injuries are appropriately managed both nonoperatively and surgically. When deciding on a treatment plan, it is paramount to take the athlete's injury severity and sport-specific factors into account. The aim of this review is to summarize the sport epidemiology, diagnosis, treatment options, and return to play considerations for athletes who sustain an acute thumb metacarpophalangeal joint ulnar collateral ligament injury.

Biomechanical Comparison of 3 Thumb Ulnar Collateral Ligament Repair Methods

PURPOSE

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. We sought to address a gap in the literature by comparing thumb metacarpophalangeal (MCP) joint angle measurements and biomechanical strength before complete, acute UCL tear and after repair with suture anchors (SA), suture tape (ST) anchor augmentation, or reconstruction with palmaris longus graft (PL).

METHODS

Thumbs and, if present, the PL tendon were harvested from 15 fresh-frozen cadavers. Each thumb specimen was secured into a servohydraulic biomechanical testing frame to evaluate native radiographic MCP joint angles at 0° flexion when loaded with 0, 5, and 13 N of radial force. Subsequently, a single hand surgeon (S.M.K.) performed complete transection and UCL repair via 1 of 3 methods: SA (n = 5), ST (n = 5), or reconstruction with PL (n = 5). Following repair, MCP joint angles were radiographically evaluated. Specimens that did not fail during joint angle testing were transferred to a separate testing frame for load-to-failure testing. Angle measurements and mean load-to-failure were compared between the groups, and angulation was also compared with each group's native control.

RESULTS

Both ST and SA groups demonstrated comparable stiffness to their native controls, whereas the PL group was significantly more lax. The ST repair was significantly stiffer than the other constructs. ST also required higher forces to reach failure compared to both SA and PL. No difference was found between SA and PL groups.

CONCLUSIONS

Although both ST and SA constructs recapitulate native joint stiffness, repair with ST demonstrated the greatest biomechanical strength in stiffness and load-to-failure.

CLINICAL RELEVANCE

For complete, acute tears of the thumb UCL, ST may be superior for maintaining MCP joint stability and strength over SA and PL.

Pediatric hand ultrasound: common indications, injury, inflammation and masses

Ultrasound is a uniquely valuable tool for evaluating musculoskeletal problems in the pediatric hand. Acute and chronic injuries involving tendons and ligaments of the hand can be quickly assessed and can guide surgical decision-making. Using ultrasound, palpable lesions and masses can be evaluated for cystic and solid components aiding in differential diagnosis. Additionally, ultrasound provides evaluation of acute versus chronic changes of inflammatory arthritis, assessing disease severity and subclinical synovitis and serving as an adjunct to medical management. This review will cover common indications and ultrasound findings of the pediatric hand, focusing on common injuries, inflammatory arthritis and masses. Important anatomical features of the hand will be discussed as well as imaging technique and evaluation in the pediatric patient.

Recent and chronic sprains of the First Metacarpo-Phalangeal Joint

Sprains of the first metacarpo-phalangeal joint (MCPJ) are a common form of hand injury that mainly affects the ulnar collateral ligament. Although the diagnosis is made on the physical findings, radiographs must be obtained and ultrasonography or magnetic resonance imaging (MRI) is necessary in some cases. If the joint is unstable or a bony fragment is displaced, surgery must be performed within 4 weeks after the injury. Beyond this interval, ligament reconstruction is the preferred treatment. The objective of this article is to provide evidence, from both older and recent studies, that guides the choice of the best treatment in clinical practice. To this end, we will address the following questions: (1) What is a Stener lesion? (history and pathophysiology); (2) In addition to the physical examination, what other investigations are appropriate in doubtful cases? (with special attention to the indications of ultrasonography and MRI); (3) What are the clinical and radiological criteria for performing surgery in patients with acute first MCPJ sprains? (4) What reconstruction procedures are appropriate in patients with acute or chronic MCPJ sprains?

[Simplified active motion protocol following Extensor indicis to Extensor pollicis longus tendon transfer using a side-to-side suture]

BACKGROUND

Ruptures of the Extensor pollicis longus tendon are commonly treated by Extensor indicis transfer using Pulvertaft suture technique. Current literature does not yet give evidence for a preferable post-operative therapy protocol. A side-to-side suture technique is significantly stronger than the Pulvertaft repair technique and therefore allows an immediate active postoperative treatment. We present a new postoperative protocol, which is simple, fast and safe, and should make treatment easier for patients and therapists.

PATIENTS AND METHODS

We treated 10 patients with a transfer of the extensor indicis tendon between 07/2016 and 08/2017 according to the new active protocol. Patients were seen for follow-up at 2, 4 and 8 weeks. Thumb range of motion, pinch and grip strength as well as subjective parameters like pain and general satisfaction were measured.

RESULTS

All patients regained full function of their thumbs with retropulsion over the level of the palm at 4 weeks. Median pinch strength was 89 % and grip strength 74 % of the contralateral side at week 4. There was no secondary rupture of the reconstructed tendon over a one-year period. All patients were satisfied with the result of the operation and the protocol.

CONCLUSION

Our new active postoperative protocol for extensor indicis transfer using a side-to-side suture has proven to be safe and less strenuous for patients and therapists and has been established as standard treatment in our clinic.

The Treatment of Chronic Ulnar Collateral Ligament of the Thumb Injury Using Extensor Pollicis Brevis: Surgical Technique

Chronic rupture of the ulnar collateral ligament of the thumb is a complex lesion that typically results in chronic joint instability, functional limitation in pinch, and persistent pain at the metacarpophalangeal (MCP) joint of the thumb. Different surgical techniques have been proposed, including tendon graft and transpositions. In this article, we report our experience in treating chronic ulnar collateral ligament injuries using extensor pollicis brevis tendon in a Sakellarides modified technique. During the surgical procedure, we detach the extensor pollicis brevis proximally and drive the tendon through the neck of the first metacarpal and the base of the proximal phalanx to reconstruct the ligament at the ulnar side. In our experience, the surgical technique provides good MCP joint strength and stability and allows a good functional recovery with few postoperative complications. This technique provides good stability of the MCP joint using an absorbable suture and allows early mobilization of the joint with minimal stiffness.

Percutaneous Reconstruction of the Ulnar Collateral Ligament of the Metacarpophalangeal Joint of the Thumb: Technique and Results

Objectives The present study aims to describe a new percutaneous technique for the reconstruction of the ulnar collateral ligament of the metacarpophalangeal joint of the thumb with a tendon graft, and to evaluate the functional outcomes and stability six months postoperatively.

Material and methods The percutaneous ligamentoplasty technique was performed with a palmaris longus tendon graft and tenodesis screws in 6 patients with ulnar instability of the thumb (> 30° degrees of radial deviation) for more than 6 weeks. Range of motion, grip strength, and pinch strength (lateral/key pinch, tip pinch, and palmar pinch) were assessed in comparison to the contralateral limb, as well as the Quick Disabilities of the Arm, Shoulder and Hand (DASH) score.

Results At 6 months, the joint movement was of 100%, the grip strength was of 94.8%, the key pinch was of 95%, the palmar pinch was of 85.7%, and the tip pinch was of 93.5% compared to the contralateral limb. The internal tilt was of 14° compared to 9° at the contralateral limb. The Quick DASH score decreased from 24.2 to 2.6 points.

Conclusion We devised this versatile surgical procedure to obtain early mobility with the advantages related to the percutaneous techniques.

A Comparison of Conservative and Operative Management of Thumb Ulnar Collateral Ligament Avulsion Fractures in Children

Background: The optimal management of pediatric thumb ulnar collateral ligament (UCL) avulsion fractures remains poorly defined. The purpose of this study was to elucidate patient outcomes based on initial management and fracture characteristics. Methods: A retrospective study of all patients younger than 18 years of age presenting with a thumb UCL avulsion fracture was performed. Patients were grouped by their initial management. The primary outcome of the study was time to return to full activity. Fractures were characterized by articular surface involvement, displacement, and rotation. Results: Forty-seven patients with thumb UCL avulsion fractures were identified. Ten patients underwent surgery as initial treatment; all healed without complication, with a mean recovery time of 6.2 ± 1.8 weeks. Thirty-seven patients were treated conservatively; although most healed, the recovery time was longer (9.2 ± 8.3 weeks, adjusted hazard ratio = 2.3, 95% confidence interval = 1.0-5.5). Four cases (11%) required conversion to surgery that all healed without complications. Fractures treated with immobilization alone were significantly smaller, less displaced, and less rotated than those initially treated with surgery; however, 19 fractures that would have met criteria for surgery were treated with immobilization and successfully healed within 7.1 ± 2.9 weeks. Fracture characteristics did not predict which patients would fail conservative treatment or have prolonged recovery times. Conclusions: While surgery provided definitive treatment without delay in recovery, immobilization may not be an unreasonable treatment choice even for patients with large or displaced fractures. In cases where patients failed immobilization, surgery as a second-line treatment had good results.

Thumb Ulnar Collateral Ligament Repair with Suture Tape Augmentation

Background: The purpose of this study is to describe our technique of thumb ulnar collateral ligament (UCL) repair with suture tape augmentation and to evaluate the short-term outcomes in our initial series of patients treated with this method of repair. Methods: Patients with minimum one-year follow up after isolated UCL repair with suture tape augmentation were contacted for clinical evaluation, radiographs, and postoperative outcome questionnaires, including the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire and study-specific questions. Thirteen of 15 (87%) consecutive patients who were treated using this method of repair were available for follow-up, 9 with acute tears and 4 with chronic tears. Results: Average post-operative thumb metacarpophalangeal (MCP) and interphalangeal (IP) joint range-of-motion (ROM) was 0-57.5° and 0-71°, respectively, for chronic tears and 2.2-53.9° and 0-71°, respectively, for acute tears. Average grip and pinch strength relative to the unaffected hand was 102% and 84%, respectively, among patients with chronic tears and 103.3% and 88.7%, respectively, among those with acute tears. All patients demonstrated stability with a firm endpoint, relative to the unaffected thumb. The average QuickDASH score among all patients was 11.9 for the disability/symptom module, 0 for the sport module and 16.5 for the work module. Stiffness was reported among 4 patients and no patient suffered wound-related issues or other complications. Conclusions: Thumb UCL repair with suture tape augmentation demonstrates short-term outcomes comparable to what has been reported for other methods of repair. It may potentially allow for an expedited recovery and rehabilitation process.

An anatomical study on the Stener-type lesion of the radial collateral ligament of the metacarpophalangeal joint of the thumb

The Stener-type lesion of the radial collateral ligament is rare. The insertion of the abductor pollicis brevis is believed to preclude its occurrence. The aim of this study was to determine whether this lesion can be induced mechanically. Four specimens were tested in neutral rotation and 20° of supination, in 45° and 30° of flexion, and in the neutral position. The angle of ulnar adduction to form a Stener-type lesion was measured. The lesion occurred only in 45° flexion in all specimens. A lesser angle of flexion decreased the rate of ligament displacement. In the neutral position no ligament displacement was found. A Stener-type lesion of the radial collateral ligament can occur in ulnar adduction and flexion of the metacarpophalangeal joint. Supination of the joint increases the likelihood of ligament displacement. As distal ruptures of the radial collateral ligament are uncommon, a high index of suspicion is required for diagnosis.

Early Return to Play With Thumb Spica Gauntlet Casting for Ulnar Collateral Ligament Injuries Complicated by Adjacent Joint Dislocations in Collegiate Football Linemen

Background: Treatment of thumb ulnar collateral ligament (UCL) ruptures in elite athletes aims to restore thumb stability while minimizing lost playing time. Thus, surgical repair with early protected return to play in a thumb spica cast has been advocated. The purpose of this study was to document adjacent joint dislocations after primary surgical repair sustained during protected return to play with thumb spica casting in elite-level football players. Methods: Three Division I collegiate starting linemen sustaining adjacent joint dislocations in thumb spica casts following acute surgical repair of ipsilateral thumb UCL ruptures were retrospectively reviewed. Demographic data were recorded as well as the timeline for injury, treatment, and subsequent return to sport. Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores were obtained at final follow-up. Results: The mean time from thumb UCL injury to surgical repair was 8.7 days, and the mean return to sport was 13.3 days from surgery. There were 4 simple dislocations including 3 proximal interphalangeal (PIP) joints and 1 elbow. Each PIP dislocation was close reduced and treated with buddy straps with immediate return to play. The elbow dislocation was close reduced and splinted with return to play 22 days after injury. The mean QuickDASH score was 2.3 at 12 month follow-up. Conclusions: This report highlights that while thumb spica casting protects the surgically repaired thumb UCL and allows for earlier return to play, it risks placing additional stress upon adjacent joints and therefore adjacent injury. Appropriate counseling of the risks and benefits of this treatment strategy is essential.

Fracture of first metacarpal head: A rare case presentation and review of literature

Fractures around the head and neck region of first metacarpal are unusual and have not been reported in literature. We report a case of fracture of head of first metacarpal with intact articular surface, treated with open reduction and internal fixation, with a follow up period of six months. Surgical procedure, intraoperative difficulties in obtaining reduction and steps to overcome them have been described. Satisfactory functional outcomes can be achieved using stable internal fixation with minimal hardware and early mobilization in first metacarpal head fractures.

Efficacy of Primary Repair in Professional Athletes with Chronic Radial Collateral Ligament Injuries of Thumb Metacarpophalangeal Joint

Background: Management of grade III injuries of the radial collateral ligament (RCL) of the thumb is controversial. These injuries are often treated with early surgery. However, early surgery may not be practical for the professional athlete. We report on the outcome of delayed primary repair of chronic RCL injuries without the use of tendon grafts or tendon transfers. Methods: Twelve elite professional athletes with 15 soft tissue RCL injuries who underwent delayed surgery (greater than 6 weeks) were included in this study. Athletes were managed with splinting and ongoing play during the sporting season, and underwent surgery at the conclusion of the season. Mean duration from injury to surgery was 5 months. Mean follow-up was 4.2 years after surgery. Patient-report outcome measures including pain, satisfaction rating, and disability of the arm, shoulder and hand (DASH) scores were collected. Examination findings including range of motion, laxity, and grip and pinch strength were also measured. Return-to-play data were collected for all athletes. Results: The RCL was able to be primarily repaired with suture anchors in all cases. All twelve patients were able to return to competitive play at the same pre-injury professional level. Post-operative joint function such as range of motion and laxity were comparable to the unaffected contralateral side, as were grip and lateral pinch strengths. Tip-pinch strength is lower compared to the unaffected side, but is comparable to age and sex-matched reference group. Conclusions: Delayed primary repair of the RCL is a viable option and results in satisfactory long-term outcomes. This option may be more preferable to the professional athlete who wishes to avoid surgery during the sporting season.

Performance and Return to Sport After Thumb Ulnar Collateral Ligament Surgery in National Football League Players

Background: Acute ruptures of the ulnar collateral ligament (UCL) of the thumb are common injuries in sports. Surgical repair of complete tears has yielded excellent results in elite athletes. Methods: National Football League (NFL) players who underwent thumb UCL surgery and matched controls were identified. Demographic and performance data were collected. Performance scores were calculated using a standardized scoring system. Return to sport (RTS) in the NFL was defined as playing in at least 1 NFL game after thumb UCL surgery. Comparisons between case and control groups and preoperative and postoperative time points were made using paired-samples Student t tests. Results: Twenty-three players were identified (mean age: 28.8 ± 3.4 years and mean experience in the NFL: 5.9 ± 3.4 years). Twenty-two players (95.7%) were able to return to sport in the NFL at an average of 132.2 ± 126.1 days. The overall 1-year NFL career survival rate of players undergoing thumb UCL surgery was 87.0%. There was not a statistically significant decrease in games per season and career length for any position following surgery. No positions had a significant difference in postoperative performance when compared with preoperative performance, and there was no significant performance difference postoperatively when compared with matched controls. Conclusions: There is a high rate of RTS in the NFL following thumb UCL surgery. Players who underwent thumb UCL surgery played in a similar number of games per season and had similar career lengths in the NFL as controls. No position group had any significant postoperative performance score differences when compared with postindex matched controls.

Additional Dorsal Fibrocartilage Repair in a Combined Radial Collateral Ligament and Dorsal Fibrocartilage Injury of the Thumb Metacarpophalangeal Joint

The purpose of this study was to evaluate the necessity of an additional dorsal fibrocartilage (DFC) repair in combined radial collateral ligament (RCL) and DFC injuries of the thumb metacarpophalangeal joint (MPJ). Eight cadaveric thumbs were used. Ulnar/radial deviation, prosupination, and volar/dorsal laxity were measured. Serial sectioning was performed of the RCL and the DFC. The RCL followed by the DFC were then reattached sequentially. Measurements were performed for intact, RCL cut, RCL+DFC cut, RCL repair alone, and RCL+DFC repair. The neutral position shifted ulnarly, pronated, and subluxed volarly after RCL+DFC cut. Volar subluxation was reduced with RCL+DFC repair compared with RCL repair alone. With external loading, ulnar deviation, pronation, and volar laxity increased significantly after RCL+DFC cut. Ulnar deviation reduced significantly with RCL+DFC repair (12.4°, 10.8°, and 10.9°) compared with RCL repair alone (14.4°, 14.3°, and 18.9°) at 0°, 30°, and 60°, respectively. Pronation reduced significantly with RCL+DFC repair (7.1° and 9.4°) compared with RCL repair alone (10.2° and 12.6°) at 0° and 30°, respectively. Volar subluxation reduced significantly with RCL+DFC repair (0.9 mm and 1.2 mm) compared with RCL repair alone (2.1 mm and 1.8 mm) at 30°and 60°, respectively. Radial collateral ligament repair alone does not restore anatomic dorsoradial stability of the thumb MPJ in a combined RCL and DFC injury. Combined repair of the RCL and the DFC is recommended to reduce the MPJ to its native position and minimize postoperative laxity. [Orthopedics. 2019; 42(2):e268-e272.].

Efficacy of a radial-based thumb metacarpophalangeal-stabilizing orthosis for protecting the thumb metacarpophalangeal joint ulnar collateral ligament

STUDY DESIGN

Basic research (biomechanics).

INTRODUCTION

The high degree of motion that occurs at the thumb metacarpophalangeal (MCP) joint must be taken into account when immobilizing a partially torn or repaired thumb ulnar collateral ligament.

PURPOSE OF THE STUDY

To determine the efficacy of a radial-based thumb MCP-stabilizing orthosis in resisting abduction across the thumb ulnar collateral ligament.

METHODS

Ten fresh cadaveric hands were mounted to a custom board. An anteroposterior radiograph of the thumb was obtained with a 2 N preload valgus force applied to the thumb, and the angle between the Kirschner wires was measured as a baseline. Subsequently, 20, 40, 60, 80, and 100 N valgus forces were applied 15 mm distal to the MCP joint. Anteroposterior radiographs of the thumb were obtained after each force was applied. The angle of displacement between the wires was measured and compared with the baseline angle. The angles were measured with an imaging processing tool. A custom radial-based thumb MCP-stabilizing orthosis was fashioned for each cadaveric thumb by a certified hand therapist. The aforementioned loading protocol was then repeated.

RESULTS

The radial-based thumb MCP-stabilizing orthosis significantly reduced mean abduction angles at each applied load.

DISCUSSION

We found that our orthosis, despite being hand-based and leaving the thumb IP and CMC joints free, significantly reduced mean abduction angles at each applied load.

CONCLUSIONS

This investigation provides objective evidence that our radial-based thumb MCP-stabilizing orthosis effectively reduces the degree of abduction that occurs at the thumb MCP joint up to at least 100 N.

LEVEL OF EVIDENCE

n/a (cadaveric).

A Biomechanical Evaluation of a 2-Suture Anchor Repair Technique for Thumb Metacarpophalangeal Joint Ulnar Collateral Ligament Injuries

BACKGROUND

A complete thumb ulnar collateral ligament (UCL) repaired with 1-suture anchor has been demonstrated to be significantly weaker compared with the intact UCL. The objective of this study is to test the biomechanical strength of a 2-anchor thumb UCL repair.

METHODS

Nine paired fresh-frozen hands were used for this biomechanical analysis. One thumb from each pair was randomized to the control group and one to the repair group. In the control group, the UCL was loaded to failure in tension. In the repair group, the UCL was dissected off of the proximal phalanx, subsequently repaired with a 2-anchor technique, and then tested to failure.

RESULTS

The mean yield load was 342 N (95% confidence interval [CI], 215-470 N) in the control group and 68 N (95% CI, 45-91 N) in the repair group. The mean maximum load at failure was 379 N (95% CI, 246-513 N) in the control group and 84 N (95% CI, 62-105 N) in the repair group. The mean stiffness was 72 N/m (95% CI, 48-96 N/m) in the control group and 17 N/m (95% CI, 13-21 N) in the repair group. The mean displacement at failure was 7.8 mm (95% CI, 7-9 mm) in the control group and 7.8 mm (95% CI, 7-9 mm) in the repair group.

CONCLUSIONS

The 2-anchor repair technique we tested does not acutely reestablish the strength of the insertion of the native insertion of the UCL with this technique.

Performance and Return to Sport After Thumb Ulnar Collateral Ligament Repair in Major League Baseball Players

Background

Acute ruptures of the ulnar collateral ligament (UCL) of the thumb are common injuries in sports. Surgical repair has yielded excellent results and high return-to-sport (RTS) rates in elite athletes.

Purpose

To determine (1) the RTS rate in Major League Baseball (MLB) players following thumb UCL repair, (2) postoperative career length and games played per season, (3) pre- and postoperative performance, (4) postoperative performance compared with matched control players, and (5) whether dominant and nondominant hand injuries respond differently.

Study Design

Cohort study; Level of evidence, 3.

Methods

MLB players who underwent thumb UCL surgery from August 3, 1987, to September 6, 2016, were identified. Demographic and performance data were collected for each player, and matched controls were identified. RTS in the MLB was defined as playing in at least 1 MLB game after surgery. Comparisons were made by use of paired-samples Student t tests.

Results

Twenty-one players were identified, with a mean ± SD age of 31.7 ± 3.9 years and mean experience in the MLB of 8.6 ± 3.3 years at time of surgery. Twenty-one players (100%) achieved RTS in the MLB at a mean 120.0 ± 75.9 days. No significant decrease was found in games per season or career length for any position following surgery. Infielders had a significantly lower rate of postoperative wins above replacement (WAR) compared with preoperatively (P = .006), but no significant differences in postoperative performance score were found compared with controls after the index date. No significant difference was found for performance between players undergoing surgery on their dominant hand and those who had surgery on their nondominant (glove) hand compared with controls.

Conclusion

In this study, 100% of MLB players achieved RTS after thumb UCL repair, with in-season players returning at a mean of 8 weeks. Players who underwent thumb UCL repair played in a similar number of games per season and had similar career lengths in the MLB as controls. Infielders had a significantly lower postoperative WAR compared with preoperatively, but no significant postoperative performance score differences were noted when infielders were compared with post-index date matched controls. No significant performance differences were noted with regard to surgery on dominant and nondominant hands.

Dorsoradial Instability of the Thumb Metacarpophalangeal Joint: A Biomechanical Investigation

PURPOSE

To define the role of the dorsal capsule and associated dorsal fibrocartilage (DFC) and their interactions with the radial collateral ligament (RCL) as a thumb metacarpophalangeal (MCP) joint stabilizer.

METHODS

Eight cadaveric thumbs were mounted onto a custom jig with 20 N of muscle load applied. The thumb position in space was digitized to measure ulnar-radial, pronation-supination, and volar-dorsal laxity at 0°, 30°, and 60° MCP joint flexion. Serial sectioning was performed and measurements were repeated for the intact state, proper RCL insufficiency, proper and accessory (complete) RCL insufficiency, complete RCL with 50% DFC (radial) insufficiency, and complete RCL with complete DFC insufficiency.

RESULTS

Ulnar-radial deviation, pronation-supination, and volar-dorsal translation significantly changed at 30° and 60° MCP joint flexion when comparing complete RCL insufficiency with complete RCL with 50% DFC insufficiency. At 30° flexion, significant increases were found in ulnar deviation, pronation, and volar translation, and there was a decrease in supination. At 60° flexion, ulnar deviation, pronation, and volar translation increased and radial deviation decreased significantly. At 30° flexion, the resting position significantly pronated and translated volarly. At 60° flexion, the resting position significantly shifted ulnarly, pronated, and translated volarly.

CONCLUSIONS

The DFC acts as a secondary stabilizer of the thumb MCP joint, working in tandem with the RCL. It acts by stabilizing the MCP joint dorsoradially when external forces are applied across the joint. This cadaveric study shows that RCL insufficiency with a concomitant DFC injury is less likely to be stable than RCL injuries alone, and that this effect is more pronounced with MCP joint flexion.

CLINICAL RELEVANCE

Increasing incompetence of the secondary stabilizers of the RCL, such as the DFC, will likely result in increased clinical instability upon physical examination. The results of this study also suggest the need to consider repair of the DFC at the time of RCL repair.

Finger Injuries in Ball Sports

Finger injuries are common in athletes playing in professional ball sports. Understanding the intricate anatomy of the digit is necessary to properly diagnose and manage finger injuries. Unrecognized or poorly managed finger injuries can lead to chronic deformities that can affect an athlete's performance. Multiple factors and treatment options should be considered to provide the best functional outcome and rapid return to play for an athlete. This article discusses the mechanism of injury, diagnosis, treatment, and return-to-play recommendations for common finger injuries in ball sports.

Expediting Professional Athletes' Return to Competition

Return-to-play (RTP) decisions often represent a challenge to physicians caring for athletes. The multifaceted and unique nature of each RTP decision makes standardization of the decision-making process impossible and demands of the physician thoughtful consideration of all competing interests and variables. Such difficult medical decisions are further complicated by unique ethical and legal considerations. Although no concrete RTP recommendations are available, the consensus of experienced team physicians and knowledge of the rules and regulations that apply to RTP are helpful guides to treating the various upper extremity injuries that occur in elite athletes.

Thumb collateral ligament injuries in the athlete

PURPOSE OF REVIEW

The purpose of this review is to identify current principles in the diagnosis and treatment of collateral ligament injuries of the thumb in the athlete.

RECENT FINDINGS

Cadaver studies have clearly identified the ulnar and radial collateral ligaments origin and insertion footprints for repair or reconstruction. Ulnar and radial collateral ligament injuries are common in athletics. History and physical examination are paramount in determining partial versus complete tear. When surgical treatment is indicated, placing the repair/reconstruction in the anatomic footprint restores stability while maintaining motion. The senior author's preferred techniques are reported.

Injuries to the Collateral Ligaments of the Metacarpophalangeal Joint of the Thumb, Including Simultaneous Combined Thumb Ulnar and Radial Collateral Ligament Injuries, in National Football League Athletes

BACKGROUND

Thumb collateral ligament injuries occur frequently in the National Football League (NFL). In the general population or in recreational athletes, pure metacarpophalangeal (MCP) abduction or adduction mechanisms yield isolated ulnar collateral ligament (UCL) and radial collateral ligament (RCL) tears, respectively, while NFL athletes may sustain combined mechanism injury patterns.

PURPOSE

To evaluate the incidence of simultaneous combined thumb UCL and RCL tears among all thumb MCP collateral ligament injuries in NFL athletes on a single team.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A retrospective review of all thumb injuries on a single NFL team from 1991 to 2014 was performed. All players with a thumb MCP collateral ligament injury were included. Collateral ligament injuries were confirmed by review of both physical examination findings and magnetic resonance imaging. Player demographics, surgical details, and return-to-play data were obtained from the team electronic medical record and surgeons' records.

RESULTS

A total of 36 thumbs in 32 NFL players were included in the study, yielding an incidence of 1.6 thumb MCP collateral ligament injuries per year on a single NFL team. Of these, 9 thumbs (25%) had a simultaneous combined UCL and RCL tear injury pattern confirmed on both physical examination and MRI. The remaining 27 thumbs (75%) were isolated UCL injuries. All combined UCL/RCL injuries required surgery due to dysfunction from instability; 63.0% of isolated UCL injuries required surgical repair ( P = .032) due to continued pain and dysfunction from instability. Repair, when required, was delayed until the end of the season. All players with combined UCL/RCL injuries and isolated UCL injuries returned to play professional football the following season.

CONCLUSION

Simultaneous combined thumb UCL and RCL tear is a previously undescribed injury pattern that occurred in 25% of thumb MCP collateral ligament injuries on a single NFL team over a 23-year period. All players with combined thumb UCL/RCL injuries required surgical repair, which was significantly higher compared with players with isolated UCL injuries. Team physicians and hand surgeons treating elite football players with suspected thumb collateral ligament injuries should examine for RCL and UCL instability and consider MRI if any concern exists for a combined ligament injury pattern, as this injury is likely frequently missed.

Diagnosis, Treatment, and Return to Play for Four Common Sports Injuries of the Hand and Wrist

Hand and wrist injuries in the high-level athlete are challenging because they may be underestimated by the patient, family, and team, and return to play may be longer than desired. The needs of the player and the team must be balanced with the long-term functional ramifications of the injury. Four common soft-tissue sports injuries are flexor digitorum profundus avulsion, flexor pulley rupture, extensor carpi ulnaris dislocation, and thumb metacarpophalangeal joint ulnar collateral ligament injury. For each of these injuries, the assessment, treatment, and considerations for return to play should be individualized on the basis of the patient, the sport, and the timing of the injury.

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

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

Ulnar collateral ligament injuries of the thumb: a comprehensive review

Injuries to the thumb ulnar collateral ligament (UCL) are common. Failure to address the ensuing laxity of the metacarpophalangeal joint can lead to compromised grip and pinch, pain, and ultimately osteoarthritis. Instability to valgus stress with the lack of a firm end point is a strong indicator of complete rupture of the UCL. Nonoperative treatment is reserved for incomplete ruptures of the thumb UCL. Operative intervention is typically performed for complete ruptures. Repair of acute ruptures and reconstruction for chronic injuries yield excellent results. Complications are rare and most patients show preservation of motion, key pinch, and grip strength.

Volar dislocation of the thumb metacarpophalangeal joint with acute repair of the ulnar collateral ligament

Volar dislocations of the thumb metacarpophalangeal joint are uncommon and can be associated with rupture of the ulnar collateral ligament (UCL). We report a case where a volar thumb dislocation was successfully closed reduced, but instability required open repair of the UCL. Early motion protocol helped achieve favorable results.

Return to football and long-term clinical outcomes after thumb ulnar collateral ligament suture anchor repair in collegiate athletes

PURPOSE

To evaluate return to play after complete thumb ulnar collateral ligament (UCL) injury treated with suture anchor repair for both skill position and non-skill position collegiate football athletes and report minimum 2-year clinical outcomes in this population.

METHODS

For this retrospective study, inclusion criteria were complete rupture of the thumb UCL and suture anchor repair in a collegiate football athlete performed by a single surgeon who used an identical technique for all patients. Data collection included chart review, determination of return to play, and Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) outcomes.

RESULTS

A total of 18 collegiate football athletes were identified, all of whom were evaluated for follow-up by telephone, e-mail, or regular mail at an average 6-year follow-up. Nine were skill position players; the remaining 9 played in nonskill positions. All players returned to at least the same level of play. The average QuickDASH score for the entire cohort was 1 out of 100; QuickDASH work score, 0 out of 100; and sport score, 1 out of 100. Average time to surgery for skill position players was 12 days compared with 43 for non-skill position players. Average return to play for skill position players was 7 weeks postoperatively compared with 4 weeks for non-skill position players. There was no difference in average QuickDASH overall scores or subgroup scores between cohorts.

CONCLUSIONS

Collegiate football athletes treated for thumb UCL injuries with suture anchor repair had quick return to play, reliable return to the same level of activity, and excellent long-term clinical outcomes. Skill position players had surgery sooner after injury and returned to play later than non-skill position players, with no differences in final level of play or clinical outcomes. Management of thumb UCL injuries in collegiate football athletes can be safely and effectively tailored according to the demands of the player's football position.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Superimposed electrical stimulation improves mobility of pre-stiff thumbs after ulnar collateral ligament injury of the metacarpophalangeal joint: a randomized study

OBJECTIVE

This study aimed at testing the ability of the superimposed electrical stimulation technique to restore the mobility of pre-stiff thumbs after operative repair for rupture of the ulnar collateral ligament.

MATERIAL AND METHODS

Eight patients demonstrating a pre-stiff metacarpophalangeal joint were involved in two rehabilitation sessions of a counterbalanced design. In the voluntary contraction session, they performed 20min of repeated active flexions of the impaired metacarpophalangeal joint. In the superimposed electrical stimulation session, they performed 20min of percutaneous neuromuscular electrical stimulations which were superimposed to voluntary flexion.

RESULTS

Mean active range of motion improvement from pre- to post-session was significantly greater in the superimposed electrical stimulation condition compared to the voluntary contraction condition (11±5 deg versus 3±4 deg; P<0.01).

CONCLUSION

Superimposing electrical stimulation to voluntary contractions is an efficient technique to improve active range of motion of the pre-stiff metacarpophalangeal joint of the thumb.

Early active mobilization following UCL repair With Mitek bone anchor

Ulnar collateral ligament (UCL) injuries of the thumb are common. Surgical repair is accepted as the treatment of choice for complete rupture of the ligament. Biomechanical studies have suggested that Mitek bone anchor repairs are potentially safe and strong enough to allow early controlled active mobilization. To date, there have been no studies to compare early active mobilization following Mitek bone anchor repair to standard postoperative rehabilitation involving thumb spica immobilization for the first 4 to 6 weeks. We performed a small pilot randomized control trial to assess the outcome of this new rehabilitation technique to that of standard immobilization following UCL repair with Mitek bone anchor. Our results show that on average early active mobilization leads to an earlier return to full hand function (6 vs. 8 wk) and an earlier return to work (7 vs. 11 wk). There is no difference in the final range of motion achieved. We suggest that Mitek bone anchor repairs for UCL ruptures are robust enough to allow early active mobilization and that a larger trial is warranted to assess whether early active mobilization is superior to standard rehabilitation.

Reconstruction of chronic thumb metacarpophalangeal joint radial collateral ligament injuries with a half-slip of the abductor pollicis brevis tendon

PURPOSE

To evaluate a reconstructive method for chronic radial collateral ligament (RCL) injuries of the thumb metacarpophalangeal (MCP) joint using a combination of RCL advancement and the transfer of a half-slip of the abductor pollicis brevis tendon.

METHODS

Eight patients (4 male and 4 female; mean age, 25 y) with chronic RCL injury of the thumb MCP joint were enrolled. All patients were referred to our institution because of continuing pain and instability on the radial side of the MCP joint when grasping or pinching objects. The mechanism of the injury was adduction stress to the thumb during sporting activities in 5 patients, a heavy object falling on the thumb in 1, and a fall in 2. The mean duration from RCL injury to surgery was 20 weeks. The average postoperative follow-up was 51 months. We evaluated postoperative outcomes including pain, range of motion of the thumb MCP joint, grip strength, key pinch strength, Disabilities of the Arm, Shoulder, and Hand score, and ability to return to preinjury work or sporting activities.

RESULTS

No patients demonstrated continuing symptoms, and the MCP joint was stable after surgery. Postoperative grip and pinch strength (37 and 6.3 kg, respectively) were increased compared with preoperative values (34 and 3.9 kg, respectively). All patients returned fully to their preinjury work or sporting activities within 6 months after surgery. Although postoperative flexion was decreased by an average of 6°, no patients noted functional deficiency.

CONCLUSIONS

We recommend the reconstructive method of RCL advancement and transfer of a half-slip of the abductor pollicis brevis tendon to alleviate pain and improve grip and pinch strength in chronic RCL injuries of the thumb MCP joint.