PMC This was a retrospective study of all patients seen and treated for thumb injuries at a single institution from January 1, 2015, to December 31, 2019, undergoing RCL or UCL repair (CPT code 26540). Bookshelf Any time there is something concerning you, even if it's a slight concern, always call your surgeon right away. Would you like email updates of new search results? When assessed, most patients returned to their preinjury employment. It is an often-encountered injury and can lead to chronic pain and instability when diagnosed incorrectly. A systematic review of multiple medical databases was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines with specific inclusion and exclusion criteria. Neurological Complications Following Arthroscopic and Related Sports Surgery: Prevention, Work-up, and Treatment. Furthermore, the lack of patient-specific data precluded advanced statistical calculations, and weighted means from individual studies were the basis for comparison. Acta Chir Scand. The mean patient age was 37.8 years (14.0-78.1). Ulnar collateral ligament injuries of the thumb: a comprehensive review. This site needs JavaScript to work properly. Does Weightlifting Improve Cardiovascular Mortality Risk for Older Aged Adults? Ulnar collateral ligament (UCL) injuries of the elbow are a common source of pain and disability in the overhead athlete and more particularly, baseball pitchers. 6,15,19,20,24,29 First described by Frank Jobe in 1986, the procedure has undergone significant evolution . 2021 Apr 15;3(2):e527-e533. This ligament prevents the thumb from pointing too far away from the hand. 1 Major components of the TFCC are the articular disc (AD), meniscus homolog, radioulnar ligaments, and extensor carpi . 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. Search for Similar Articles When evaluating the relationship between ulnar and radial ligamentous injury and the presence or absence of complication, there was no significant difference, however trends were noted, X. This is the first study to compare complication rates between radial and ulnar collateral ligament injuries of the thumb. Lohman M, Vasenius J, Nieminen O, et al.. MRI follow-up after free tendon graft reconstruction of the thumb. Through a small incision along the side of the thumb joint, we will see where the ligament was torn. Hintermann B, Holzach PJ, Schutz M, et al.. Skier's thumbthe significance of bony injuries. Louis DS, Huebner JJ Jr, Hankin FM. Superficial infections are common (5%) after hand surgery and cause redness, swelling, pain and pus around the stitches. J Hand Surg Am. Gamekeeper's thumb: a quantitative evaluation of acute surgical repair. Please confirm that you would like to log out of Medscape. Methodological quality of the study was assessed using the Quality Appraisal Tool (Table 1). [30,43,44] It has been well documented that direct suture techniques fail in chronic injuries. Keyword Highlighting better/same/worse than preoperative status). No study directly compared the clinical outcome between repair and reconstruction of the thumb UCL for acute (less than 3 weeks) or chronic UCL injury. Other than 1 postoperative palmaris longus graft rupture requiring MP joint arthrodesis, no significant complications such as neurovascular injury or superficial or deep infection occurred. In addition, operative management was hypothesized to result in greater patient satisfaction versus nonoperative treatment. A systematic review of multiple medical databases was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines with specific inclusion and exclusion criteria. A secondary purpose was to compare graft choice and surgical technique for reconstruction. Our objective was to compare the complication rates after thumb metacarpophalangeal joint (MCP) radial collateral ligament (RCL) versus ulnar collateral ligament (UCL) repair. Positive ulnar variance is used to describe a forearm where the distal ulna is no longer in line with the distal radius, resulting in the ulnar being longer. Rupture and displacement of the. 2005;87:26322638. Part I of this two-part article focuses on common tendon and . When untreated, this injury may lead to decreased pinch strength, pain, instability, and osteoarthritis. Knowledge of the anatomy and accurate physical examination are essential in the evaluation of a patient with skier's thumb. It is attached on one side to the humerus (the bone of the upper arm) and on the other side to the ulna (a bone in the forearm). Scores assigned to each item are integers 0 (minimum), 1, and 2 (maximum). Kozin SH, Bishop AT. 2021 Mar 10;9(3):2325967121990052. doi: 10.1177/2325967121990052. Levels IIV evidence (according to the Oxford Centre for Evidence Based Medicine used by the American version of the Journal of Bone and Joint Surgery)14 were reviewed for inclusion in this review. abduction-adduction motion. J Bone Joint Surg Am. 24. This is a strong ligament that supports the thumb when pinching or gripping and if it is damaged may lead to a chronic instability of the thumb which causes problems with function. Roy J, MacDermid J, Woodhouse L. Measuring shoulder function: a systematic review of four questionnaires. 2022 Mar 27;4(3):141-146. doi: 10.1016/j.jhsg.2022.02.008. While ulnar collateral ligament reconstruction (UCLR) of the elbow is an increasingly commonly performed procedure with excellent results reported in the published literature, less attention has been paid to specifically on the characterization of postoperative ulnar nerve complications, and it is unclear what operative strategies may influence the likelihood of these complications. Abstract. MCP fusion was performed . Exclusion criteria were non-English studies and any study with less than 2 years mean follow-up. 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 *Gender reported in 12 studies (218 subjects). 2015 Nov-Dec;7(6):511-7. doi: 10.1177/1941738115607208. 1999;24:275282. Injuries to the PIP joint remain swollen for long periods of time. Eighty patients were included in the study [N=62 (UCL), N=18 (RCL)]. Study data collected and analyzed included subject demographics, number and gender of the subjects, number of nonoperative thumbs, sidedness, dominance, subject age, subject weight, and body mass index, throwing athlete status, mean duration follow-up, UCL injury classification, location of UCL injury (proximal, midsubstance, or distal), number of subjects with Stener lesions, number of subjects with avulsion fractures, mechanism of injury, injury chronicity (defined by 3 weeks based on repair vs reconstruction treatment dichotomy proposed by Smith in 1977),17 length of symptoms, graft type used (autograft or allograft), and implant used. Surgery has been recommended for fracture displacement, significant articular involvement, clinical instability, or fragment rotation. Moher D, Liberati A, Tetzlaff J, et al.. Results: 1989;71:383387. There is currently no consensus on treatment of acute or chronic UCL injuries. ECRL, extensor carpi radialis longus; IP, interphalangeal; MRI, magnetic resonance imaging; NR, not reported. Objectives: 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. Obremskey W, Pappas N, Attallah-Wasif E, et al.. Levels of evidence in Orthopaedic Journals. 2022 Mar 1;30(1):e1-e8. Epub 2016 Jan 13. An example of the search strategy used for PubMed was ((((((ulnar[Title/Abstract]) AND collateral[Title/Abstract]) AND ligament[Title/Abstract])) OR ucl[Title/Abstract])) AND thumb[Title/Abstract]. Each abstract was manually reviewed, with potentially relevant full text of studies scrutinized for study inclusion or exclusion. In addition, basic science, anatomical/histopathological, imaging, biomechanical, surgical technique, and studies on digits other than the thumb were excluded. The site is secure. 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. [38] Chuter et al[40] contend that surgical repair of acute UCL ruptures is the gold standard of treatment in the presence of gross instability, Stener lesions, or displaced avulsion fractures. Meta-analysis of the pooled data was completed. Post-traumatic instability of the metacarpophalangeal joint of the thumb. Proximal interphalangeal joint injuries of the hand. This injury is sometimes called "skier's thumb" because skiers are prone to this injury when they fall with their hand strapped . Stretching or even a rupture of the graft is also possible. You may be trying to access this site from a secured browser on the server. J Bone Joint Surg Am. 3. Table 1. If the tear is diagnosed later a ligament reconstruction might be a better option. Diagnosis of displaced, 43. I wore a custom plastic splint that immobilized the MCP joint but allowed me to move the IP joint for 8 weeks total. Thumb dominance reported in 8 studies (168 thumbs). Most times, they won't know until they're in the surgery if the internal brace is appropriate. All rights reserved. Descriptive statistics were calculated. 1998;23:503506. Orthop Rev. [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. 23. 1989;14:567573. Van Dommelen BA, Zvirbulis RA. eCollection 2021 Apr. [41] Abrahamsson et al[42] maintain that a proximally displaced ligament, palpated proximal to the MP joint, is a more specific indication for surgery. 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. 2022 Jul;50(8):2324-2338. doi: 10.1177/03635465211023952. In these cases, a new graft may be used to perform a second reconstruction. Wolters Kluwer Health, Inc. and/or its subsidiaries. Thus, the true natural history is yet unknown. Acute UCL repair and autograft UCL reconstruction for chronic injury led to excellent clinical outcomes, without a significant difference between the 2 groups. 8600 Rockville Pike J Bone Joint Surg Am. There is currently no consensus on treatment of acute or chronic UCL injuries. J Hand Surg Br. 15 -17,19 Therefore, UCL reconstruction has become a common procedure to address UCL insufficiency in adolescent, collegiate, and professional throwers. Your surgeon will discuss these options with you. This is the first study to compare complication rates between radial and ulnar collateral ligament injuries of the thumb. Educate the patient on anti edema management. unstable when the thumb is used. Am J Sports Med. Acute gamekeeper's thumb. Jackson M, McQueen MM. 17. SAGE Open Med. At this stage, patients should be advised to wear your splint part-time. Possible complications include: - Abrahamsson SO, Sollerman C, Lundborg G, et al.. Accessibility Thus, a patient with delayed presentation of UCL injury can still achieve predictably successful outcomes, equivalent to acute repair, with autograft UCL reconstruction. 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%. Only 1 study reported significant loss of either MP and interphalangeal joint motion (P < 0.005).25 Except for 2 patients with significant postoperative weakness, full or near-full strength (key pinch and grip) was restored in all studies. [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. I had a UCL injury (incomplete, didn't require surgery) with a small avulsion fracture to my right thumb in 2015 at the age of 36. The evidence regarding operative and nonoperative treatments of acute and chronic thumb UCL insufficiency is primarily limited to level IV retrospective case series and level V expert opinion. 1. 6. The site is secure. Epub 2014 Dec 30. 45. Although many injuries can be managed conservatively, some require more invasive interventions to prevent complications and loss of function. 14 It is important to diagnose complete tears early because . Morphometric Evaluation of Collateral Ligaments of the First Metacarpophalangeal Joint. J Bone Joint Surg Am. J Bone Joint Surg Am. 38. Abstract Objectives: Rupture of the ulnar collateral ligament (UCL) is a frequent injury of the hand. 1976;58:106112. Causes. 1996;25:527530. Federal government websites often end in .gov or .mil. Evaluation and management of elbow injuries in the adolescent overhead athlete. Study design: 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. Our primary purpose was to compare nonoperative treatment with surgical repair and surgical reconstruction of thumb UCL injuries. Although the natural history of chronically untreated UCL injury eventually leads to pain and loss of function, surgery intervened in the studies present. The overall complication rate after primary thumb RCL and UCL repair was 13.8%. Comparison of Outcomes Based on Graft Type and Tunnel Configuration for Primary Ulnar Collateral Ligament Reconstruction in Professional Baseball Pitchers. Eventually this abnormal movement will wear out the joint and it will become arthritic. Furthermore, there was no donor site morbidity from autograft harvest sites across all studies. **Stener lesion status reported in 6 studies (145 thumbs). Stener B, Petersen I. Electromyographic investigation of reflex effects upon effects upon stretching the partially ruptured medial collateral ligament of the knee joint. Some injuries can be associated with a Stener lesion, which is displacement of the ruptured ligament proximal to the adductor aponeurosis, effectively precluding healing without operative treatment.6, Acute injuries can be treated with immobilization or surgically with direct repair using bone anchors, direct repair using bone tunnels and pullout sutures, or tension band fixation of bony avulsions.79 If an injury is chronic, there are several operative treatment options, including ligament reconstruction with tendinous autograft or allograft, bonesoft tissuebone autograft, or even fusion of the MP joint.1012. Comparison of results after surgical repair of acute and chronic ulnar collateral ligament injury of the thumb. Please enable it to take advantage of the complete set of features! 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. Please try after some time. In sports or at work, injuries to the collateral ligament of the thumb's metacarpophalangeal (MCP) joint and the proximal interphalangeal (PIP) joints of the fingers are common [].The most common mechanism for a thumb ulnar collateral ligament (UCL) rupture is the forced abduction and hyperextension of the MCP joint of the thumb [2,3,4,5,6,7], which can occur when someone falls on the thumb . For more information, please refer to our Privacy Policy. This systematic review has demonstrated excellent clinical outcomes (pain, strength, motion, and stability) after surgical treatment (repair and autograft reconstruction) of both acute and chronic UCL injury, without any significant difference between repair and reconstruction for acute and chronic injury, respectively. 15. Pain, range of motion, key-pinch strength, and stability testing were used as outcome measures. UCL injuries occur via thumb MCP hyperabduction or hyperextension ; in contrast, RCL injuries result from a forced or sudden thumb MCP adduction moment. modify the keyword list to augment your search. Surgical management of chronic, 42. Figure 46-1 Muscle-splitting incision through fascia to expose the ulnar collateral ligament. Patient Demographics of Thumb RCL and UCL Injuries. 1992;8:713732. Both purely ligamentous and bony avulsion injuries were included. 1999;24:7075. 1994;23:797804. All continuous data for independent and dependent variables were assimilated with weighted means and SDs based on the number of subjects or thumbs and the applicable means and SDs. important to begin moving your fingers right after surgery and keep them moving to avoid stiffness. government site. All but 2 were level IV evidence. Sakellarides HT, DeWeese JW. Pichora DR, McMurtry RY, Bell MJ. It essentially forms a soft-tissue sling that keeps the radial head in place on the humerus. Rupture of the ulnar collateral ligament (UCL) is a frequent injury of the hand. Injury and Surgical Repair to the Thumb This is an injury to the ulnar collateral ligament of the metacarpo-phalangeal (MCP) joint. No significant difference in the outcome was demonstrated between different types of autograft used for UCL reconstruction. The procedure involves a synthetic tape that is about a millimeter in width but exceedingly strong. 2020 Apr 28;14(1):25-30. doi: 10.1055/s-0040-1710154. #Injury location reported only in 3 studies. The UCL is also known as the medial collateral ligament or "Tommy John Ligament". Ulnar neuropathy was defined as any symptoms or objective sensory and/or motor deficit(s) after surgery, including resolved transient symptoms. Jupiter JB, Sheppard JE. Pain reduction was significantly improved in all subjects (P < 0.05). Background:Thumb ulnar collateral ligament (UCL) tears are common in competitive athletes. This site needs JavaScript to work properly. This damage may lead to temporary or permanent numbness or weakness. Complications after surgical treatment of UCL injury are rare. There were 61 studies eliminated as secondary for being in a language other than English. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. 2014 Oct;42(10):2510-6. doi: 10.1177/0363546513509051. Kuz JE, Husband JB, Tokar N, et al.. Performance Orthopaedics and Sports Medicine, Wilmington, Ohio. 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. If you log out, you will be required to enter your username and password the next time you visit. One study15 reported outcomes of 9 patients who had failed nonoperative treatment and underwent subsequent surgical repair. Please try again soon. Management of thumb metacarpophalangeal ulnar collateral ligament injuries. HHS Vulnerability Disclosure, Help Federal government websites often end in .gov or .mil. Rupture of the. Epub 2021 Jan 18. Throwing status reported in 4 studies. 2014 Dec;33(6):384-9. doi: 10.1016/j.main.2014.10.003. Complications after this procedure may include nerve or blood vessel damage. Samora, Julie Balch MD, PhD*; Harris, Joshua D. MD; Griesser, Michael J. MD; Ruff, Michael E. MD*; Awan, Hisham M. MD*. Unilateral injuries: 291 and bilateral injury: 1. Rao S, D'Amore T, Willier DP 3rd, Gawel R, Jack RA 2nd, Cohen SB, Ciccotti MG. Orthop J Sports Med. eCollection 2022 May. Metacarpophalangeal joint motion ranged from 79% to 100% compared with the contralateral thumb. 2000;16:345357. The surgical approach associated with the highest rate of neuropathy was detachment of flexor pronator mass (FPM) (21.9%) versus muscle retraction (15.9%) and muscle splitting (3.9%). Continue to stretch before and after throwing . Concomitant ulnar nerve transposition was associated with a higher neuropathy rate (16.1%) compared with no handling of the ulnar nerve (3.9%). RESULTS The mean follow-up time was 22.2 months (range 6-54 months). Some broken bones do not heal even when they get the best surgical or nonsurgical treatment. Am J Sports Med. 1977;59:1421. Doi: 10.1177/2325967118769328. *Glickel grading scale. 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. 1989;17:751753. 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). Superficial infections tend to settle quickly with oral antibiotics and regular dressings. 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. Commonly, the joint will be permanently enlarged due to the scarring of the healing process. Range of motion returns much sooner, too. 1961;43-A:541546. In these patients, after failure of nonoperative treatment at anywhere from 1 month to more than 6 years, nearly all patients can achieve complete pain relief, normal pinch and grip strength, joint stability, and range of motion after surgical reconstruction. A score of 2 was assigned if the item was completely and accurately performed and reported. Disclaimer. Leland DP, Pareek A, Therrien E, Wilbur RR, Stuart MJ, Krych AJ, Levy BA, Camp CL. three muscles provide deforming forces at the base of the thumb. [15] In patients who had failed nonoperative treatment, who were subsequently taken to surgery, it was found that many of the small avulsion fractures had rotated with the fragment's articular surface rotated out of the plane, precluding fracture healing.[15]. ||Injury chronicity not always defined, but we used ,3 weeks for acute injury and .3 weeks for chronic injury. Thumb sidedness reported in 3 studies (51 thumbs). Subject demographics are reported in Table 2. PLoS Med. Alejandro Badia Orthopedic Hand Surgeon Hands, Elbow, Shoulder and Wrist - Badia Hand to Shoulder Ce. doi: 10.1016/j.asmr.2020.12.004. Part II: treatment and complications. Thumb Metacarpophalangeal Joint Ulnar Collateral Ligament: Early Outcomes of Suture Anchor Repair with Suture Tape Augmentation. Docs Struggle to Keep Up With the Flood of New Medical Knowledge. 5. All but 2 studies were level IV evidence (there was one level II prospective cohort19 and one level III evidence retrospective comparative study20). If the UCL is completely torn, the ruptured ligament may cause a lump inside the thumb. HHS Vulnerability Disclosure, Help Meta-analysis of the pooled data was completed. Complications after surgery were rare. Data is temporarily unavailable. The ECRL bone-tendon ligamentoplasty for chronic ulnar instability of the metacarpophalangeal joint of the thumb. PMC The outcome of elbow ulnar collateral ligament reconstruction in overhead athletes: a systematic review. In addition, this study examined how the rate of ulnar nerve complications varied as a function of surgical exposures, graft fixation techniques, and ulnar nerve management strategies. Nonoperative treatment often failed, necessitating surgery. Only prospective studies can determine this injury course. Complications, failures, and reoperations are rare after surgical treatment of UCL injury. UCLR case series that contained complications data were included. The .gov means its official. 2009;34:304308. Acute rupture of the ulnar collateral ligament (UCL) of the thumb - also known as 'skier's thumb' - is a common injury which may cause long-term complications if inadequately treated. The range of motion of the MP joint of the thumb following operative repair of the. gamekeeper's thumb; skier's thumb; stener lesion; ulnar collateral ligament, NOW OVER 19K FOLLOWERS ON TWITTER. Mean Quality Appraisal Tool score was 13.1 (55% overall rating study methodological quality). Inclusion criteria included English language studies after nonoperative or operative treatment of thumb UCL injuries with a minimum of 2 years mean follow-up. Complications after surgery were rare. Eurasian J Med. [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. 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. Mean Quality Appraisal Tool score was 13.1 (55% overall rating study methodological quality). 2009;61:623632. If the tear is diagnosed early a repair will be possible. 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. The search was performed on November 17, 2011, using PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines.13 There were no limits placed on study publication date. The Orthopedic Journal of Sports Medicine. 2021 Apr 22;9:20503121211003362. doi: 10.1177/20503121211003362. 1987;214:113120. 2022 Jun;54(2):191-196. doi: 10.5152/eurasianjmed.2022.22024. FOIA 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%). 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. Part I: anatomy and diagnosis. 31. 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. There are many ways to manage both acute and chronic thumb UCL deficiency, and controversy persists as to the best treatment options. Kaplan EB.
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