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Updated: Jan 12 2024

Thumb Collateral Ligament Injury

Images
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  • Summary
    • Thumb Collateral Ligament Injuries, most commonly ulnar collateral (UCL), are athletic injuries that lead to a decrease in effective thumb pinch and grasp.
    • Diagnosis relies upon thumb MCP radial-ulnar stress exam and MRI studies.
    • Treatment involves anatomic repair or reconstruction which reliably restores the essential function of the collateral ligament.
  • Epidemiology
    • Incidence
      • ulnar collateral ligament (UCL) injury is 10 times more common than radial collateral ligament (RCL) injuries
      • UCL injuries comprises of 86% of all athletic thumb injuries
    • Demographics
      • acute injuries are common in many contact and non-contact sports
        • football, soccer, downhill skiing
        • eponymously known as a Skier's thumb
      • chronic injuries due to attenuation of the ligament under repeated stress
        • eponymously known as a Gamekeeper's thumb
  • Etiology
    • Pathophysiology
      • mechanism of injury
        • radially-directed force causing hyper-abduction moment at the thumb MCP
          • i.e. stationary ski pole and strap contacting the moving skier's thumb into hyper-abduction
      • pathoanatomy
        • Stener lesion
          • avulsed ligament with or without bony attachment is displaced dorsal and superficial to the adductor aponeurosis
            • usually the distal end is retracted proximally
          • the interposed adductor will not allow healing without surgical repair
        • Stener-like RCL lesion rare given overlying abductor aponeurosis
          • RCL injury leads to joint subluxation rather than overt instability
  • Anatomy
    • Osteology
      • thumb metacarpal and phalanx form the metacarpophalangeal joint
      • metacarpal condyles more flattened than finger metacarpals which increases stability
    • Ligaments
      • both UCL and RCL composed of
        • proper collateral ligament
          • resists load with thumb in flexion
        • accessory collateral ligament and volar plate
          • resists load with thumb in extension
        • both ligaments run in dorsal to volar direction from proximal to distal
        • valgus laxity in both flexion and extension is indicative of a complete collateral rupture
      • RCL is compose
    • Biomechanics
      • diarthrodial joint but allows for six degrees of movement
        • flexion-extension, adduction-abduction, and rotation
      • static stability provided by bony anatomy, collateral ligaments, volar plate and dorsal capsule
      • dynamic stability provided by extrinsic and intrinsic muscle groups
        • extrinsics
          • extensor pollicis longus, extensor pollicis brevis, flexor pollicis longus
        • intrinsics
          • abductor pollicis brevis, flexor pollicis brevis, adductor pollicis
        • ulnar-sided tendinous/aponeurotic insertions more robust than radial
  • Classification
      • UCL/RCL Instability Grading
      • Grade 1
      • Sprain with no joint instability (incomplete tear)
      • Grade 2
      • Asymmetric joint laxity but endpoint present (incomplete tear)
      • Grade 3
      • Joint instability without endpoint and 30-35 degrees of joint space opening or 10-15 degrees more than contralateral thumb (complete tear)
  • Presentation
    • History
      • fall on outstretched hand and abducted thumb
      • ball or racquet strike
    • Symptoms
      • common symptoms
        • pain at ulnar aspect of MCP joint worse with pinch or grasp most common for UCL tear
        • radial-sided MCP pain most common complaint for RCL tear
    • Physical exam
      • inspection
        • rarely visible deformity of joint
      • palpation
        • tenderness at site of ligament injury (distal for UCL and proximal for RCL)
        • tender mass signifying Stener lesion
      • motion
        • radial-ulnar stress exam
          • stress both at extension and 30° of MCP flexion
            • avoid allowing phalanx to rotate
          • radial instability in 30° of flexion indicates injury to proper UCL
          • radial instability in extension indicates injury to accessory and proper UCL and/or volar plate
          • local anesthetic may be added to eliminate patient guarding
      • provocative tests
        • anterior and posterior drawer
          • metacarpal held stationary and phalanx translated anteriorly and posteriorly
          • amount of translation and absence of an end point may signify volar subluxation and RCL rupture
        • weakness with resisted pinch
  • Imaging
    • Radiographs
      • recommended views
        • PA
        • lateral
        • oblique
      • optional views
        • stress views
          • controversial
          • may aid in diagnosis if a bony avulsion has already been ruled out
      • findings
        • UCL injury
          • avulsion or condylar fracture
          • Sag sign
            • supination of proximal phalanx relative to the metacarpal
          • volar subluxation of proximal phalanx
            • seen on lateral view
            • indicates associated dorsal capsular tear or extensor tendon injury
        • RCL injury
          • pronation of proximal phalanx
    • MRI
      • indications
        • can aid in diagnosis if exam equivocal
      • sensitivity and specificity
        • 100% sensitivity and specificity
    • Ultrasound
      • accuracy is operator-dependent
      • sensitivity and specificity
        • 76-88% sensitive, 81-83% specific
        • 81% accuracy, 74% positive predictive value, 87% negative predictive value
  • Diagnosis
    • Clinical and MRI
      • diagnosis made by history and physical exam (thumb MCP radial-ulnar stress exam) and confirmed with MRI studies.
  • Treatment
    • Nonoperative
      • immobilization for 4 to 6 weeks
        • indications
          • Grade 1 and 2 partial UCL and RCL tears
          • < 15° side to side variation of varus/valgus instability
        • outcomes
          • excellent rate of return to sport without residual laxity or disability
    • Operative
      • RCL/UCL repair
        • indications
          • acute Grade 3 injuries with
            • >15° side to side variation of varus/valgus instability
            • >30-35° of opening
          • Stener lesion
        • outcomes
          • >90% with outcomes rated excellent for UCL repair
          • 96% good to excellent outcomes for RCL repair
      • reconstruction of ligament with tendon graft
        • indications
          • chronic injury (older than 3-8 weeks)
          • incompetent ligament tissues
        • outcomes
          • 92% satisfaction rate in one series
      • adductor advancement
        • indications
          • acute UCL rupture
            • done in conjunction with UCL repair
        • outcomes
          • 100% return to sport reported in one series
      • MCP fusion or adductor advancement
        • indications
          • chronic injuries
          • salvage procedure for failed repairs or reconstructions
  • Techniques
    • Immobilization for 4 to 6 weeks
      • technique
        • immobilization in splint or cast to off-load injured UCL or RCL
        • some protocols advocate for use of removable splint and immediate active and passive range of motion
          • patient must avoid stress on ligament during exercises
        • grip and pinch strengthening began around 4-6 weeks
    • RCL repair
      • approach
        • straight longitudinal incision on radial aspect of the thumb
        • abductor aponeurosis may need to be resected to expose joint capsule and ligament
        • take care to spare dorsal cutaneous branches of the radial sensory nerve
      • technique
        • pull-out sutures or loaded suture anchors can be used to re-oppose the ligament to its origin
        • repair MCP joint capsule and abductor tissues
        • K-wire may be placed to immobilize the joint temporarily
    • UCL repair
      • approach
        • S-shaped or chevron incision overlying MCP joint
      • technique
        • trans-osseous sutures, suture anchors with or without suture augmentation, and direct ligament repair to periosteum all described
      • rehab
        • joint immobilization leaving the IP joint free
        • strengthening begun at 4-6 weeks
      • complications
        • skin necrosis if pullout suture technique used
        • decreased pinch strength
    • Tendon reconstruction with tendon graft
      • approach
        • S-shaped or chevron incision overlying MCP joint
      • technique
        • multiple techniques described using various tissues sources, configurations and fixation constructs
        • palmaris longus autograft weaved through bone tunnels
          • can be secured with interference screws, cortical button or suture anchors
    • Adductor advancement
      • approach
        • S-shaped or chevron incision overlying MCP joint
      • technique
        • adductor aponeurosis repaired to native distal insertion of UCL
    • MCP fusion
      • approach
        • dictated by prior surgeries and concomitant pathology
      • technique
        • various fixation methods (k-wire, compression screws, plates)
        • MCP fused in 15 degrees of flexion
  • Complications
    • Stiffness
      • incidence
        • MCP and IP stiffness most common complication following repair
    • Persistent instability
      • incidence
        • 15% with residual instability for grade 3 injuries treated with immobilization
      • treatment
        • ligament reconstruction for chronic injuries
    • Superficial radial neurapraxia
      • numbness distal to incision
      • treatment
        • observation
  • Prognosis
    • Prognosis 
      • return to play rates approach 100% following anatomic repair
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