Functional splinting versus plaster cast for ruptures of the ulnar collateral ligament of the thumb. A prospective randomized study of 63 cases

MRI spectrum of injuries to the thumb metacarpophalangeal joint ulnar collateral ligament with a proposed expanded classification of injuries in American football players

Injuries to the ulnar collateral ligament of the thumb metacarpophalangeal joint are of both historic and modern interest for athletes and non-athletes alike. The thumb metacarpophalangeal joint requires stability in both flexion and extension utilizing a combination of static and dynamic stabilizers. This article reviews the magnetic resonance imaging categorization of thumb ulnar collateral ligament injuries and proposes two additional injury patterns seen in high-level and professional athletes who play American football. In addition to the direct magnetic resonance imaging findings in collateral ligament tears, secondary findings of rotation and subluxation can be seen at the thumb metacarpophalangeal joint due to the altered physiologic forces on the joint. Internal brace augmentation via suture tape of a traditional ulnar collateral ligament repair is a novel surgical technique that provides protection during initial healing and the ensuing remodeling phase following repair or reconstruction, resulting in a faster return to play.

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.

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.

Thumb Metacarpophalangeal Joint Ulnar Collateral Ligament Injuries: Management and Biomechanical Evaluation

First described in 1955 as "gamekeeper's thumb," injuries to the ulnar collateral ligament (UCL) of the thumb metacarpophalangeal joint are common and can cause pain and instability, especially during key pinch and grasp. Although primarily diagnosed on physical examination, stress radiographs, ultrasonography, and magnetic resonance imaging can be used to diagnose UCL injuries and distinguish partial from complete tears. If complete rupture occurs, the adductor aponeurosis can become interposed between the retracted UCL stump and its insertion on the proximal phalanx, known as a "Stener lesion." When instability persists after a trial of nonsurgical management or in the setting of complete rupture, there are various methods of repair or reconstruction. Biomechanically, there are no treatments of repair or reconstruction using native tissues that provide equivalent strength to the preinjured ligament. Recently, suture tape augmentation has been used for the repair or reconstruction with excellent short-term results and earlier return to function, although there is a paucity of literature on longer term outcomes. The various methods of surgical treatment yield excellent outcomes with a low incidence of complications.

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?

An Evidence-Based Approach to Casting and Orthosis Management of the Pediatric, Adolescent, and Young Adult Population for Injuries of the Upper Extremity: A Review Article

OBJECTIVE

Review the use of upper-extremity orthoses and casts after injuries to the wrist and hand in the pediatric, adolescent, and young adult population. The common injuries reviewed include pediatric distal radius fractures, scaphoid fractures, metacarpal fractures, mallet fingers, volar plate injuries of the proximal interphalangeal (PIP) joint, and ulnar collateral ligament (UCL) tears of the thumb metacarpophalangeal (MCP) joint.

DATA SOURCES

We conducted a literature review from 1985 to 2016 of upper-extremity orthotic interventions. Non-English language citations and animal studies were excluded. Citations from retrieved studies were used to identify other relevant publications. This review included cases of common injuries to the upper extremity, which required orthotic intervention.

MAIN RESULTS

Immobilization recommendations for nonsurgical pediatric distal radius fractures, nonsurgical metacarpal fractures, mallet fingers, and UCL tears of the thumb MCP include a removable orthosis. Nondisplaced scaphoid fracture orthosis recommendations include initial immobilization in a nonremovable short-arm thumb spica cast. Volar plate injuries of the PIP joint require buddy straps for healing.

CONCLUSIONS

The literature demonstrates the effectiveness of removable orthoses in healing, patient satisfaction, and time to return to activity after many common upper-extremity injuries. Removable orthoses should be considered an equal or superior treatment method to cast immobilization, immobilization of additional joints, or longer periods of immobilization.

Clinical results of the BoneWelding®Fiji® anchor for the treatment of Stener lesions of the thumb

INTRODUCTION

A new technology (Sportwelding®) was recently presented, which uses ultrasonic energy to meld a resorbable suture anchor at the interface with the host bone. A standardized clinical use was not investigated yet. This study prospectively evaluated the surgical and clinical outcomes of the Fiji Anchor® (Sportwelding®, Schlieren, Switzerland) in the repair of an ulnar collateral ligament lesion of the metacarpophalangeal joint of the thumb.

MATERIAL AND METHODS

The range of motion, grip and pinch strength, disability of arm, shoulder and the hand (DASH) and patient rated evaluation (PRWE) score, pain, satisfaction, complications and adverse events were assessed in 24 patients after surgical treatment for an acute displaced rupture or avulsion of the ulnar collateral metacarpophalangeal ligament of the thumb using the Fiji Anchor® after 6, 12 and 52 weeks.

RESULTS

At final follow up, the range of motion of the metacarpophalangeal joint reached almost the contralateral side (49.3° SD 11.7°). Thumb opposition showed a Kapandji score of 9.7 (SD 0.5; range 9-10). Grip strength, the lateral, tip and the three jaw pinch showed nearly similar values compared to the contralateral side (83-101%). Pain was low (0.2 SD 0.7 at rest and 0.6 SD 1.0 during load). The DASH score was 5.0 (SD 7.3) and the PRWE score was 4.1 (SD 9.0). 81% of patients were very satisfied at final follow-up. Two patients were rated unstable during the follow-up period due to a second traumatic event. Three cases experienced difficulties during anchor insertion, whereby incorrect anchor insertion resulted in damage to the suture material; however, this was resolved after additional training.

CONCLUSION

One advantage of this anchor appears to be its stable fixation in cancellous bone. The surgical treatment of an ulnar collateral ligament lesion of the thumb using the Fiji Anchor® can lead to an excellent clinical outcome with a minor complication rate; however, long-term dangers and the cost effectiveness of the procedure are not known yet.

Common Injuries of the Weekend Athlete

Each year increasing numbers of people participate in a wider variety of athletic endeavors. Unlike previous generations, many patients remain in these activities later into their lives, some well beyond retirement. As the population ages and their activities continue, they are subject to injury of various forms affecting all aspects of their bodies.

Therapeutic interventions for acute complete ruptures of the ulnar collateral ligament of the thumb: a systematic review

Background: The aim of this study was to evaluate the effectiveness of interventions for acute complete rupture of the ulnar collateral ligament (UCL) of the thumb in adults.

Methods: The following databases were searched: MEDLINE and EMBASE via OVID, CINAHL and SPORTDiscus via EBSCO, from database inception to 31 ^st January 2018. Inclusion criteria were: (i) randomised controlled clinical trials (RCTs) or study of intervention with a comparator; (ii) participants with diagnosis of acute complete rupture of the UCL of the thumb; (iii) participants aged 18 years of age or older at enrolment; and (iv) published in a peer-reviewed English-language journal.

Results: In total, six studies were identified for inclusion after screening. All studies had a high risk of bias. Three studies were retrospective comparative case series which compared two different surgical techniques (bone anchor versus pull out suture, suture versus pull out suture, suture versus steel wire). Of these studies, three were RCTs, two of which compared different rehabilitation regimes in patients managed surgically (plaster versus early mobilization, new spica versus standard spica). The remaining RCT compared two different rehabilitation regimes in a mixed group of surgically/non-surgically treated patients. The RCT comparing a standard spica with a new spica demonstrated a statistically significant improvement in outcomes with the new spica at all time points (range of motion, Dreiser index and VAS); this was also the only study to provide sufficient outcome data for further analysis.

Conclusion: There is no prospective evidence comparing surgery to non-operative treatment for acute complete ruptures of the ulnar collateral ligament of the thumb. There is weak evidence to suggest that early mobilisation may be beneficial following surgical repair. Further research is necessary to better define which patients benefit from which specific interventions.

Hand and Wrist Injuries: Common Problems and Solutions

Injuries to the hands and wrist are common in athletes. Injuries include acute fractures, dislocations, ligamentous, and tendon injuries, as well as more chronic injuries such as sprains and strains. Complications in the treatment of sports injuries of the hand and wrist may be divided into 2 categories: incorrect or delayed diagnosis and iatrogenic injury related to treatment. This article highlights common sports injuries of the hand and wrist and their complications, and includes tips for successful management.

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.

Gamekeeper’s thumb

Gamekeeper’s thumb is a condition resulting from low-grade repeated force through the ulnar collateral ligament of the thumb metacarpophalangeal joint. In its acute form, it is sometimes known as Skier’s thumb and can be associated with tears, ruptures and fractures. Prompt assessment of the thumb’s structural integrity is therefore important in preventing long-term morbidity of metacarpophalangeal joint instability. Diagnosis is usually made clinically, although radiological imaging can act as a helpful adjunct. Unstable injuries tend to have a better functional outcome if repaired surgically. This article will outline relevant clinical anatomy, injury mechanism, clinical assessment and management of ulnar collateral injuries including Gamekeeper’s thumb.

Gamekeepers thumb

Ulnar collateral ligament (UCL) injury is a common hand injury, with significant morbidity particularly if undiagnosed or treated late. This common sports related injury (e.g. 9.5% of all skiing injuries) has an ever increasing prevalence. Specific imaging investigations may be required as an adjunct to clinical examination to assess the degree of instability and injury to the UCL. These injuries are often misdiagnosed in the emergency department and present late for specialist treatment. Ideally, acute tears (within 2 weeks) are best treated with cast immobilisation or primary repair of the ligament. With chronic instability at the MCP joint due to UCL laxity, dynamic or static ligament reconstruction using free tendon grafts are the best available options. This paper reports the results of a literature review and reports history, treatment and controversies in UCL management.

Ulnar collateral ligament strain of the thumb metacarpophalangeal joint: biomechanical comparison of two postoperative immobilization techniques

BACKGROUND

The aim of this study was to compare postoperative immobilization techniques of the thumb metacarpophalangeal (MP) ulnar collateral ligament (UCL) in a cadaver model of a noncompliant patient.

METHODS

A cadaveric model with fresh-frozen forearms was used to simulate pinch under two immobilization conditions: (1) forearm-based thumb spica splint alone and (2) forearm-based thumb spica splint with supplemental transarticular MP Kirschner wire fixation. Pinch was simulated by thumb valgus loading and flexor pollicis longus (FPL) loading. Ulnar collateral ligament displacements were measured and strain values calculated. Statistical analysis was performed using a repeated measures analysis of variance model.

RESULTS

With valgus thumb loading, we noted a significantly lower UCL strain in the splint and pin group compared to splint immobilization alone. Increased load was associated with a statistically significant increase in UCL strain within each immobilization condition. FPL loading resulted in negative displacement, or paradoxical shortening, of the UCL in both immobilization groups.

CONCLUSIONS

While immobilized, valgus thumb force, as opposed to MP flexion, is a likely contributor to UCL strain during simulated pinch representing noncompliance during the postoperative period. Supplemental thumb MP pin fixation more effectively protects the UCL from valgus strain. UCL shortening with FPL loading likely represents paradoxical MP extension due to flexion of the distal phalanx against the distal splint, suggesting attempted thumb flexion with splint immobilization alone does not jeopardize UCL repair.

CLINICAL RELEVANCE

This study provides a foundation to aid clinical decision-making after UCL repair. It reinforces the practice of surgeons who routinely pin their MP joints, but also brings to attention that the use of temporary MP pin fixation may be considered in difficult cases, such as those with potential noncompliance or tenuous repair.

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.

Injury to ulnar collateral ligament of thumb

Injury of the ulnar collateral ligament (UCL) of thumb can be incapacitating if untreated or not treated properly. This injury is notorious for frequently being missed by inexperienced health care personnel in emergency departments. It has frequently been described in skiers, but also occurs in other sports such as rugby, soccer, handball, basketball, volleyball and even after a handshake. The UCL of the thumb acts as a primary restraint to valgus stress and is injured if hyperabduction and hyperextension forces are applied to the first metacarpophalangeal joint. The diagnosis is best established clinically, though MRI is the imaging modality of choice. Many treatment options exist, surgical treatment being offered depending on various factors, including timing of presentation (acute or chronic), grade (severity of injury), displacement (Stener lesion), location of tear (mid-substance or peripheral), associated or concomitant surrounding tissue injury (bone, volar plate, etc.), and patient-related factors (occupational demands, etc.). This review aims to identify the optimal diagnostic techniques and management options for UCL injury available thus far.

Outcomes after injury to the thumb ulnar collateral ligament--a systematic review

OBJECTIVES

Rupture of the ulnar collateral ligament (UCL) is a frequent injury of the hand. When untreated, this injury may lead to decreased pinch strength, pain, instability, and osteoarthritis. There is currently no consensus on treatment of acute or chronic UCL injuries. Our primary purpose was to compare nonoperative treatment with surgical repair and surgical reconstruction of thumb UCL injuries. A secondary purpose was to compare graft choice and surgical technique for reconstruction.

DATA SOURCES

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. Clinical outcome studies after nonoperative or operative treatment of thumb UCL injuries, with a minimum of 2 years mean follow-up, were included. Pain, range of motion, key-pinch strength, and stability testing were used as outcome measures.

MAIN RESULTS

Fourteen articles were included and analyzed (293 thumbs). All but 2 were level IV evidence. Mean Quality Appraisal Tool score was 13.1 (55% overall rating study methodological quality). Thirty-two thumbs were treated nonoperatively and 261 operatively. Mean subject age was 33.9 years. There were 200 acute injuries and 93 chronic injuries. Mean study follow-up was 42.8 months. Nonoperative treatment often failed, necessitating surgery. Acute UCL repair and autograft UCL reconstruction for chronic injury led to excellent clinical outcomes, without a significant difference between the 2 groups. 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. Complications after surgery were rare.

CONCLUSIONS

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.

Management of thumb metacarpophalangeal ulnar collateral ligament injuries

Untreated ulnar collateral ligament (UCL) injury of the thumb metacarpophalangeal joint (MCPJ) can lead to long-term pain and functional limitations.Detection of a UCL injury involves sequential examination of true and accessory ligaments and comparison with the uninjured side.Acute partial UCL injuries can be successfully treated nonoperatively.Acute complete or displaced UCL injuries can be successfully treated with operative repair.In cases of chronic UCL injury, treatment options include static and dynamic reconstructions.If painful arthrosis is present with chronic UCL instability, salvage may be performed with MCPJ fusion.

Collateral ligament injuries of the thumb metacarpophalangeal joint

The ulnar and radial collateral ligaments are primary stabilizers of the thumb metacarpophalangeal (MP) joint. Injury to these ligaments can lead to instability and disability. Stress testing is essential to establish the diagnosis. Complete tear is diagnosed on physical examination when the proximal phalanx of the thumb can be angulated ulnarly or radially on the metacarpal head by 30° to 35° with the MP joint in either zero degrees of extension or 30° of flexion. Lack of a firm end point or angulation measuring >15° on stress testing compared with the contralateral thumb MP joint are also indicative of complete tear. Partial ligament injuries may be managed nonsurgically, but complete tears are usually managed surgically. Various techniques are used to reattach the ligament to bone, including suture anchors and, less commonly, repair of midsubstance tears. Options for managing chronic injuries include ligament repair, ligament reconstruction with a free tendon graft, and arthrodesis of the MP joint.

Closed reduction and treatment of 2 volar thumb metacarpophalangeal dislocations: report of 2 cases

Volar dislocation of the metacarpophalangeal joint of the thumb may be irreducible by closed means. We describe 2 patients with volar dislocation of the thumb metacarpophalangeal joint treated with closed reduction and casting.

Treatment of grade III thumb metacarpophalangeal ulnar collateral ligament injuries with early controlled motion using a hinged splint

Ulnar collateral ligament (UCL) injuries of the thumb metacarpophalangeal (MCP) joint are some of the more common injuries to the thumb and are usually treated with immobilization. There are benefits, however, to early active motion for healing ligaments. Therefore, these authors incorporated some of the concepts related to early controlled motion and its role in healing, and created a hinged thumb MCP radial and ulnar deviation restriction splint for use with Grade III UCL injuries.

Collateral ligament injuries of the metacarpophalangeal joint of the thumb: a treatment algorithm

The management of injury to the ulnar and radial collateral ligaments at the metacarpophalangeal joint of the thumb is complex. Treatment is dependent upon a number of factors with a wide variety of options for each ligament. Inadequate treatment has the potential to lead to a poor functional outcome. We present the relevant clinical anatomy, mechanism of injury, methods of treatment available and suggest a single treatment algorithm for use in the management of these injuries.

Ulnar collateral ligament injuries of the thumb: 10 years of surgical experience

Over 10 years in our unit, 127 patients underwent surgical repair of an acute thumb ulnar collateral ligament (UCL) rupture for clinically unstable injuries or displaced avulsion fractures. Ultrasound was used when clinical diagnosis was uncertain. The male/female ratio was 3:2, with a mean age of 40 years (range: 12-81 years). Most of them (> or =66%) were hyper-extension/abduction injuries. The most common cause was a fall (49%), followed by sports injuries; skiing accounted for only 2.4%. Ultrasound was 92% sensitive for UCL ruptures (positive predictive value (PPV) 99%). Over 99% of patients had a UCL rupture confirmed at surgery. Other findings included avulsion fractures (21%), dorsal capsular tears (57%) and dorsal capsule infolding (29%). The most common surgical complication was neurapraxia (6.5%). In our population, thumb UCL injuries are rarely caused by skiing. Ultrasound is a useful, sensitive adjunct in acute diagnosis. Dorsal capsular tears and joint interposition are common. Surgery provides excellent results with few long-term complications.

A biomechanical modeling of injury, repair, and rehabilitation of ulnar collateral ligament injuries of the thumb

PURPOSE

The use of early active motion protocols after repair of the thumb ulnar collateral ligament (UCL) theoretically could avoid the complications of postoperative immobilization and improve ligament healing. The goals of this study were as follows: (1) to develop an accurate model of acute UCL rupture, (2) to determine the strain pattern in the UCL during constrained active thumb motion in intact and repaired thumbs, and (3) to determine the load to failure and strain of the UCL during rupture in forced abduction.

METHODS

Sixteen fresh-frozen adult cadaver thumbs were mounted in a testing apparatus designed for testing the strain in the UCL during constrained active motion and abduction load to failure. Strain data for the UCL during motion were measured. Specimens were tested to failure using an MTS machine. Dynamic strain data were acquired throughout the loading cycle. Repair of the torn ligament was performed with a suture anchor technique. Strain and load-to-failure measurements then were repeated in the repaired specimens. Differences in the strain values and failure forces between the intact and repaired specimens then were compared.

RESULTS

A reliable model of a UCL rupture was created. Strains in the UCL were similar during active motion in both intact and repaired specimens. A significant decrease in maximum load to failure was noted in repaired specimens but failure reliably occurred at strains 3 times greater than expected with active motion.

CONCLUSIONS

A controlled active motion therapy protocol after suture anchor repair of a ruptured UCL of the thumb is safe from a biomechanical point of view.

A study of ulnar collateral ligament of the thumb metacarpophalangeal joint

The current study examined the biomechanical properties of intact and repaired ulnar collateral ligaments of the metacarpophalangeal joint of the thumb to determine a safe rehabilitation protocol after repair. In the first part of the study mechanical properties of the ligament were examined and the induced stress and strain were determined during simulated pinch and grip. In the second part of the study the strength and limitations of ulnar collateral ligament repair using a mini-Mitek bone suture anchor was determined. The biomechanical study was done on 16 fresh-frozen thumbs from male cadavers. Failure load, maximum stress, and Young's modulus of intact ulnar collateral ligament were 294.3 +/- 28.2 N, 11.4 +/- 1.2 MPa, and 37.3 +/- 5.1 MPa, respectively. There was no significant correlation between the low grip force and the ligament strain. There was, however, a significant correlation between the pinch force and the ligament strain. The failure load and joint rigidity of intact ulnar collateral ligaments were significantly higher (3.1 and 2.3 times, respectively) than the mini-Mitek repaired ligaments. The current study suggests that pinch activity during the rehabilitative process after repair or reattachment of the ulnar collateral ligament should be eliminated. Repaired ligaments with mini-Mitek bone suture anchors may be able to do a moderate range of motion during postoperative rehabilitation; however, additional in vivo studies are necessary before any clinical recommendation is made.

The use of ultrasound in the diagnosis of injuries of the ulnar collateral ligament of the thumb

We describe the use of a specialist referral clinic and ultrasound assessment for all injuries to the ulnar collateral ligament of the metacarpophalangeal joint of the thumb presenting to an Accident and Emergency (A&E) department. Senior House Officers in the A&E department were able to correctly diagnose only 45% of the ruptures of the ulnar collateral ligament. The overall agreement between specialist clinic examination and ultrasound for injury to the ulnar collateral ligament was 85% (kappa 0.647). When compared with the operative finding ultrasound had a positive predictive value for rupture of 94%. An algorithm is presented for the assessment of injuries to the ulnar collateral ligament in A&E departments.

Repair of acute ulnar collateral ligament injuries of the thumb metacarpophalangeal joint with an intraosseous suture anchor

Thirty-six consecutive patients with 37 complete tears of the ulnar collateral ligament of the thumb metacarpophalangeal (MP) joint were treated with primary repair using a miniature intraosseous suture anchor. Thirty patients were evaluated by clinical examination or by questionnaire at an average of 11 months after repair. Loss of interphalangeal joint motion averaged 15 degrees on the involved side versus the other side, while loss of MP joint motion averaged 10 degrees. There was no significant difference on stress testing measurements between repaired and nonrepaired thumbs. There were no instances of nerve injury, infection, device failure, or reoperation. The authors concluded that this is a safe and effective method for repair of complete tears of the ulnar collateral ligament of the thumb MP joint.

Assessment of thumb positioning in the treatment of ulnar collateral ligament injuries. A laboratory study

In the treatment of ulnar collateral ligament injuries in the metacarpophalangeal joint of the thumb, a cast or splint is often molded with the thumb and hand positioned so the patient can return quickly to a particular sport or activity. However, it is unknown whether a given position of immobilization or whether an early rehabilitation program will compromise ligament healing by causing undue tension in the ligament. To better define acceptable positions for thumb immobilization and a safe range of motion, this laboratory study measured strain in the ulnar collateral ligament at different degrees of metacarpophalangeal joint flexion. Ligament strain was found to increase with increasing joint flexion; the most significant increases in strain occurred as the joint moved from 0 degree to 25 degrees of flexion, with the dorsal portion of the ligament demonstrating greater strain than the palmar portion. Based on these results, immobilization of the metacarpophalangeal joint in excessive flexion and unrestricted early rehabilitation exercises should be done with caution and guided by the grade of injury or the quality of repair.

Reinsertion of the ruptured ulnar collateral ligament of the metacarpophalangeal joint with an absorbable self-reinforced polylactide tack

70 patients with total avulsion or rupture of the ulnar collateral ligament of the first metacarpophalangeal joint were treated surgically, using an absorbable self-reinforced poly-L-lactide mini-tack placed through the ligament and a channel in the base of the proximal phalanx. The device stabilized the joint immediately, and 69 ligaments remained stable at 6 months. The subjective result was good or satisfactory in 66 of the cases. One case needed further surgery for pain in the scar and another developed local infection 9 months post-operatively. On the basis of these findings, the new absorbable fixation method seems to be a suitable method for clinical use.