Burr, N

Pratt, AL

English

Brunel University Research Archive

Ulnar Collateral Ligament Injuries of the thumb -An overview of the injury and treatment.Anna L. Pratt1 & Nikki Burr2 , 1 School of Health Sciences and Social Care, Brunel University, UK 2 Royal Free Hospital NHS Trust, London, UKBackground•The thumb is extremely important in daily functional activities and is   used in all functional grips with the exception of the hook grip.  •The ulnar collateral ligament (UCL) is a major stabiliser for the ulnar side of the thumb and injury can cause long term functional instability (Azad  et. al. 2001).•Injury often  results from sport or falls when a forced radial deviation of  the thumb occurs (skiers thumb) (Bostock and Morris 1993, Kahler and McCue 1992) or prolonged repetitive damage (gamekeepers thumb)  (Kozin and Bishop 1994, Roh et al. 1994). •Diagnosis of a rupture can be difficult (Boscheinin-Morrin and Conolly, 2001).AnatomyThe UCL bridges the ulnar aspect of the first metacarpal and the proximal phalanx. It originates from the metacarpal head and inserts into the lateral tubercle of the proximal phalanx (see figure 1).AssessmentLiterature discusses the difficulty of accurately assessing and diagnosing UCL injuries due to the normal varying degrees of laxity at this joint in extension and flexion.  No absolute consensus of opinion was found on the best method of assessment but some pointers are discussed regularly. •Complete rupture may be less painful than incomplete ruptures (Boscheinin-Morrin and Conolly, 2001). •Oedema, bruising and tenderness can make an accurate diagnosis difficult (Glickel et al. 1999) and a local anaesthetic may assist diagnosis.  •Range of motion (ROM) of the contra-lateral thumb should be compared to the injured to determine individual normal movement (Azad et al. 2001, Bostock & Morris 1993, Kahler and McCue 1992, Roh et al.1994). •The metacarpophalangeal (MCP) joint should be tested for stability in both flexion and extension. Instability in extension and flexion indicates rupture of the accessory and UCL proper (Fricker and   Hintermann, 1995)Treatment•Complete tears and Steiner lesions of the UCL should be treated with surgical repair (Azad et al. 2001, Firoozbakhsh et al. 2002) •Partial tears of the UCL are successfully managed conservatively with splints (Kahler and McCue, 1992).  •Immobilisation of the MCP joint is the treatment of choice for both  conservative and surgical management.•There is little literature on the ideal MCP joint immobilisation position or duration. •General consensus within clinical practice and texts is that the MCP joint should be immobilised in slight flexion for at least 4 weeks  although outcomes after this rehabilitation are rarely reported.. Splintage There is a lack of detail regarding the splints used for rehabilitation of these injuries but most clinicians would utilise a thumb spica design. This immobilises the MCP joint whilst allowing inter-phalangeal (IP) joint flexion. •When fabricating splints to protect the ligament therapists must be aware of the patient’s normal ROM.•During splint fabrication opposition to the middle finger, for example,  may position the MCP joint in an unwanted abducted position (figure 2a).   •Therefore care should be taken to avoid abduction whilst trying to maintain a small degree of flexion of the MCP joint (figure 2b). Table 1 Joint position and  immobilisation period for UCL injury treatmentFigure 2a MCP joint with the thumb opposed to the middle fingerFigure 2b MCP joint flexed ensuring no abductionSummary•From available literature the authors can confirm that the period of MCP joint immobilisation should be at least 4 weeks. Many clinicians assess functional stability and joint pain at 4 weeks and then protect the ligament for a further two weeks before increasing function. •Stability at the thumb MCP joint is more important than mobility for many patients so a period of extra immobilisation until the ligament is more stable may be wise. •If a UCL injury remains untreated, weakness of tip and key grip will be noted due to the resistance of the thumb to force abduction  (Roh et al. 1994). •Reduced grip is a reported complication after this injury and may lead to joint fusion at a later date (Bostock and Morris, 1993).Figure 1 Anatomy of the UCLReferencesAzad S.M., Doebler C. Raine C. Dixon J.E. Irvine B.E. Erdmann M.W.H. (2001) A review of the injuries of the ulnar collateral ligament of the thumb. British Journal of Hand Therapy. 6 (2) 50-52Boscheinin-Morrin J. and Conolly W.B. (2001) The Hand: Fundamental of therapy. Butterworth Heinemann, Oxford.Bostock S. and Morris M.A. (1993) The range of motion of the MP joint of the thumb following operative repair of the ulnar collateral ligament.  Journal of Hand Surgery 18B(6):710-1Downey D.J. Moneim M.S. Omer G.E. (1995) Acute gamekeeper’s thumb. Quantitative outcome of surgical repair. American Journal of Sports Medicine 23 (2) 222-226Firoozbakhsh K, Yi I.S, Moneim M.S, Umada Y. (2002) A study of Ulnar Collateral Ligament of the Thumb Metacarpophalangeal joint.  Clinical Orthopaedics and Related Research 403:240-247.Fricker R. and Hintermann B. (1995) Skier’s thumb treatment, prevention and recommendations.  Sports Medicine 19 (1):73-79Glickel S.Z, Barron O.A, Eaton  R.G (1999) Dislocations and Ligament injuries in the digits In: Green D.P. Hotchkiss R.N. Pederson W.C. (eds) Green’s Operative Hand Surgery, 4th Edition, Churchill Livingstone, New York.Kahler D.M. & McCue F.C. (1992) Metacacpophalangeal and proximal interphalangeal joint injuries of the hand, including the thumb.  Clinics in Sports Medicine 11(1):57-76Kozin S.H. and Bishop A.T. (1994) Game Keeper’s thumb. Early diagnosis and treatment. Orthopaedic Review 23 (10) 797-804.Perko M. (1998) Joint and ligament injuries In: Conolly W.B. Atlas of Hand Surgery, Churchill Livingstone, New York.Roh M. Weiss A.C. Akelman E. (1994) Skier’s thumb: a review. Rhode Island Medicine 77 (11): 685-386Sollerman C. Abrahamsson S-O Lundborg G. Adalbert K.(1991) Functional splinting versus plaster cast ruptures of the UCL of the thumb.  A prospective randomised study of 63 cases.  Acta Orthop Scand 62 (6): 524-526.Author/s Degree of MCP jointImmobilisation period of  joint  (weeks)Management Mean outcome Azad et al. (2001)Not specified 4 Surgical and conservative Not specifiedDowney et al. (1995)Not specified 4 + 2 protection Surgical 22.8° less than contra lateral (42 months) Fricker and Hintermann (1995)Slight flexion and ulnar deviation3 to 4 wks protection until 6 weeksConservative Not specifiedGlickel et al. (1999)Normal alignment and slight flexion4 + 2 weeks protectionConservative Not specifiedKahler and McCue (1992)20° flexion 3 to 4 + protection until week 5 or 6 Surgical and conservativeNot specifiedPerko (1998) 20° flexion 4 + 2 weeks protectionSurgical and conservativeNot specifiedRoh et al. (1994)Not specified 4 Conservative Not specifiedSollerman et al. (1991)Prevention of deviation5-8 Surgical and conservativeROM °54 (15 months)UlnarCollateral Ligament(Torn)MCP Joint

A review of the injuries of the ulnar collateral ligament of the thumb.

Author/s Degree of MCP joint Immobilisation period of joint (weeks) Management Mean outcome Azad

Joint and ligament injuries In: Conolly W.B. Atlas of Hand Surgery,

Metacacpophalangeal and proximal interphalangeal joint injuries of the hand, including the thumb. Clinics

Skier’s thumb treatment, prevention and recommendations.

Skier’s thumb: a review. Rhode Island Medicine 77 (11): 685-386 Sollerman C. Abrahamsson S-O Lundborg G. Adalbert K.(1991) Functional splinting versus plaster cast ruptures of the UCL of the thumb. A prospective randomised study of 63 cases.

The range of motion of the MP joint of the thumb following operative repair of the ulnar collateral ligament.

Ulnar collateral ligament injuries of the thumb- An overview of the injury and treatment

Ulnar collateral ligament injuries of the thumb- An overview of the injury and treatment

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