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UCL of the Thumb Injury

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(Redirected from Thumb UCL Injury)

Other Names

  • Ulnar Collateral Ligament (Thumb) Injury
  • Skier's Thumb
  • Ulnar Collateral Ligament of the Thumb Injury
  • UCL Injury
  • Thumb Collateral Ligament Injury
  • UCL Avulsion Fracture
  • Rupture of the ulnar collateral ligament of the thumb
  • Stener Lesion

Background

History

  • Needs to be updated

Epidemiology

  • 10 fold more common than injuries to the RCL of thumb (need citation)
  • Represents 86% of all athletic thumb injuries[1]
  • Estimated to have 200,000 cases in the US per year[2]
  • Represents between 7% and 32% of all skiing injuries[3]

Pathophysiology

Illustration of one mechanism of injury[4]
Diagram of a normal ulnar collateral ligament complex. pUCL (proper ulnar collateral ligament), aUCL (accessory ulnar collateral ligament)[5]
Stener lesion (torn ulnar collateral ligament displaced superficial to adductor aponeurosis)[6]

General

  • Characterized by avulsion or rupture of the UCL of the thumb
  • UCL: Protects medial side of MCPJ of thumb

Chronic

  • Historically, injury was seen in 'gamekeepers' from repetitive breaking of rabbit necks
  • This was a more insidious, degenerative condition

Acute

  • Now more commonly seen in skiers, sports
  • Typically an acute injury
  • Stock-strap forcibly abducting thumb during a fall or plant maneuver with exaggerated extension abduction

Etiology

  • Radial directed force causing hyperabduction of the Thumb MCPJ
  • Mechanism of injury
    • Fall on an outstretched hand when the thumb is already in abduction
    • Receives an additional valgus stress from the colision

Stener Lesion

  • Adductor Pollicis inserts on the base of the proximal phalanx with the UCL
    • However, partly superficial and partly deep to the UCL ligament
  • Represents interposition of Adductor Pollicis Muscle and Adductor aponeurosis
  • Because of this relationship, the injury can not heal properly
  • Occurs in 64% to 87% of all complete ruptures[7]
  • Usually treated with surgical repair

Pediatric Considerations

  • Presents as a salter harris III avulsion of the UCL insertion[8]
  • Rarely, a true rupture occurs in skeletally immature thumb

Anatomy of the UCL of the thumb

  • Stabilizes the ulnar side of the thumb Metacarpophalangeal Joint
  • Prevents abduction or valgus/ radial deviation of the thumb at the 1st MTPJ

Risk Factors

  • Male > Female [9]
  • Sports
    • Alpine Skiing
    • Football
    • Soccer
    • Hockey
    • Basketball

Differential Diagnosis

Differential Diagnosis Finger And Hand Pain

Clinical Features

Illustration of how to perform the UCL stress test.[10]

History

  • Primarily a clinical diagnosis
  • Patients will report pain at the 1st MCPJ
  • Typically worse with abduction or extension
  • Swelling, ecchymosis may be present acutely
  • Fall on outstretched hand with abducted thumb

Physical Exam: Physical Examination Hand

  • Minimal swelling, bruising
  • No deformity
  • Tenderness at site of UCL injury, typically on the phalanx
  • If palpable mass, consider stener lesion

Special Tests

  • UCL Stress Test (Thumb): Valgus stress causes pain, laxity (> 15-20° typically considered pathologic)
  • Complete tears will lack an endpoint
  • Important to compare to unaffected thumb

Evaluation

Thumb US showing loss of continuity of the UCL, widening of the joint space under controlled stress[11]
UCL avulsion fracture at the ulnar base of the first proximal phalanx
Coronal (a) and sagittal (b) intermediate-weighted fat-saturated images demonstrate a displaced UCL tear (a, white arrow) at the distal insertion of the first MCP joint and a concomitant volar ligament injury at the proximal insertion of the checkrein ligaments (b, black arrow)[12]

Radiographs

  • Standard Radiographs Hand
    • May be normal
    • Evaluate for avulsion injury
    • May see joint space widening
  • Considered dislocated if
    • Displaced more than 1 mm
    • Malrotated
  • Consider stress views
    • Controversial, not widely used
    • False negative rate as high as 25%[13]

Ultrasound

  • Can be helpful to evaluate tear
  • May identify stener lesion
  • Can dynamically stress the UCL
  • Accuracy
    • One study showed 100% accurate when diagnosing a complete UCL rupture[14]

MRI

  • Should be considered diagnostic gold standard
  • Indications
    • Not always required
    • Aid in diagnosis if equivocal history and exam
    • Can help if other soft tissue injuries suspected
  • Diagnostic accuracy[15]
    • Sensitivity 96-100%
    • Specificity 95-100%

Classification

Hintermann Classification

  • Type I: Fracture which is non-displaced, stable in flexion
  • Type II: Displaced fracture
  • Type III: No fracture, joint is stable in flexion
  • Type IV: No fracture, unstable
  • Type V: Fracture present, involving the volar plate, stable in flexion
  • Type VI: Fracture present, involving the volar plate, unstable

UCL/RCL Instability Grading

  • Grade 1
    • Sprain with no joint instability
    • Tear: Incomplete tear
  • Grade 2
    • Asymmetric joint laxity but endpoint present
    • Tear: incomplete tear
  • Grade 3
    • Joint instability without endpoint
    • 30-35 degrees of joint space opening or 10-15 degrees more than contralateral thumb
    • Tear: complete tear

Management

Long Thumb Spica Brace

Nonoperative

  • Indications
    • Generally driven by an absence of displacement or instability
    • Partial rupture
    • Most type instability grade I, II
    • Most Hinterman Type I, III, V lesions
  • Immobilization
  • Eventually begin rehabilitation

Operative

  • Indications
    • Complete Rupture
    • Hinterman: Type II, IV, VI lesions
    • Valgus laxity >15-20°
    • Stener Lesion
  • Technique
    • Reconstruction with tendon graft
    • Adductor advancement
    • MCP fusion or adductor advancement

Rehab and Return to Play

Rehabilitation

  • Needs to be updated

Return to Play/ Work

  • Typically takes about 3 months

Complications

Prognosis

  • Return to play
    • In grade I/II, there is an excellent return to play rate (need citation)
    • Approaches 100% following anatomic repair (need citation)
  • Operative vs Nonoperative Management
    • Landsman et al: 34/40 successfully treated with immobilization, other 6 did well with subsequent surgery[16]
    • Pichora et al: 29/32 patients did well, however 3 of the patients had bad outcomes even after surgery[17]
  • Bad Outcomes
    • Mostly patients with delayed presentation[18]

Complications

See Also

Internal

External

References

  1. ↑ Baskies, Michael A., and Steve K. Lee. "Evaluation and treatment of injuries of the ulnar collateral ligament of the thumb metacarpophalangeal joint." Bulletin of the NYU hospital for joint diseases 67.1 (2009).
  2. ↑ Hinke, David H., et al. "Ulnar collateral ligament of the thumb: MR findings in cadavers, volunteers, and patients with ligamentous injury (gamekeeper's thumb)." AJR. American journal of roentgenology 163.6 (1994): 1431-1434.
  3. ↑ Carr, Daniel, Robert J. Johnson, and Malcolm H. Pope. "Upper extremity injuries in skiing." The American journal of sports medicine 9.6 (1981): 378-383.
  4. ↑ Image courtesy of islandhandtherapy.com
  5. ↑ McKeon, Kathleen E., Richard H. Gelberman, and Ryan P. Calfee. "Ulnar collateral ligament injuries of the thumb: phalangeal translation during valgus stress in human cadavera." JBJS 95.10 (2013): 881-887.
  6. ↑ Case courtesy of Frank Gaillard, Radiopaedia.org, rID: 7641
  7. ↑ Stener, Bertil. "Displacement of the ruptured ulnar collateral ligament of the metacarpo-phalangeal joint of the thumb." The Journal of Bone & Joint Surgery British Volume 44.4 (1962): 869-879.
  8. ↑ TJ, GRAHAM. "Fractures and dislocations of the hand and carpus in children." Fractuers in Children 419 (1996).
  9. ↑ Chuter GS, Muwanga CL, Irwin LR. Ulnar collateral ligament injuries of the thumb: 10 years of surgical experience. Injury. 2009 Jun;40(6):652-6
  10. ↑ Leggit JC et al. Acute finger injuries: Part II. Fractures, dislocations, and thumb injuries. Am Fam Physician. 2006;73(5):827-834
  11. ↑ https://radiopaedia.org/cases/gamekeeper-thumb-4?lang=us
  12. ↑ Manneck, Sebastian, Filippo Del Grande, and Anna Hirschmann. "Ulnar collateral ligament injuries of the first metacarpophalangeal joint: prevalence of associated injuries on radiographs and MRI." Skeletal radiology 50 (2021): 505-513.
  13. ↑ Harper, Michael T., et al. "Gamekeeper thumb: diagnosis of ulnar collateral ligament injury using magnetic resonance imaging, magnetic resonance arthrography and stress radiography." Journal of Magnetic Resonance Imaging 6.2 (1996): 322-328.
  14. ↑ Melville, David, et al. "Ultrasound of displaced ulnar collateral ligament tears of the thumb: the Stener lesion revisited." Skeletal radiology 42 (2013): 667-673.
  15. ↑ Plancher, Kevin D., et al. "Role of MR imaging in the management of" skier's thumb" injuries." Magnetic resonance imaging clinics of North America 7.1 (1999): 73-84.
  16. ↑ Kuz, Julian E., et al. "Outcome of avulsion fractures of the ulnar base of the proximal phalanx of the thumb treated nonsurgically." The Journal of hand surgery 24.2 (1999): 275-282.
  17. ↑ Pichora, D. R., R. Y. McMurtry, and M. J. Bell. "Gamekeepers thumb: a prospective study of functional bracing." The Journal of hand surgery 14.3 (1989): 567-573.
  18. ↑ Ritting, Andrew W., Paul C. Baldwin, and Craig M. Rodner. "Ulnar collateral ligament injury of the thumb metacarpophalangeal joint." Clinical Journal of Sport Medicine 20.2 (2010): 106-112.
Created by:
John Kiel on 18 June 2019 23:14:29
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Last edited:
4 November 2024 11:53:16
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