Frykman G, Johansson O. Surgical repair of rupture of the, 46. The mean postoperative follow up time was 105.4 days (13-617) and mean time to complication was 71.6 days (13-293). There are many ways to manage both acute and chronic thumb UCL deficiency, and controversy persists as to the best treatment options. J Hand Surg Br. 1989;17:751753. J Bone Joint Surg Am. If you experience a high temperature, excess bleeding, swelling or pain, contact your surgeon. official website and that any information you provide is encrypted For this elbow surgery, the internal brace is most appropriate for the athlete that has a UCL sprain that is not complex. The anti edema management will continue for several weeks. Symptoms of the UCL injury include pain, instability of the MCP joint of the thumb, and weakness in prehension and the chronicity of the injury. Glickel SZ, Malerich M, Pearce SM, et al.. Ligament replacement for chronic instability of the, 28. The fixation technique associated with the highest rate of neuropathy was the modified Jobe (16.9%) versus DANE TJ (9.1%), figure-of-8 (9.0%), interference screw (5.0%), docking technique (3.3%), hybrid suture anchor-bone tunnel (2.9%), and modified docking (2.5%). 12. Only prospective studies can determine this injury course. For more information, please refer to our Privacy Policy. 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. 2018;6(4):1-7. 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. Furthermore, it is interesting that our study quality results using the Quality Appraisal Tool were as low as they were (mean 54% with a range of 33%-79%). This site needs JavaScript to work properly. Am J Sports Med. For example, it can be removed when performing . The mean time from reported injury date to surgery was 202.4 days (2-5969). Search for Similar Articles There is also significant performance bias, as there are multiple different methods of treatment, providers, graft, suture, and fixation types, as well as methods and duration of immobilization. Range of motion returns much sooner, too. Ulnar collateral ligament (UCL) injuries have significantly increased over the past few decades, especially in young throwing athletes. There is currently no consensus on treatment of acute or chronic UCL injuries. Smith RJ. In this minimally invasive technique, the surgeon makes a small cut over the back of the thumb joint and examines the area around the injury for damage. Seventeen articles (n = 1518 cases) met the inclusion criteria, all retrospective cohort studies. Most times, they won't know until they're in the surgery if the internal brace is appropriate. This tool is a 12-item instrument, with each item possibly receiving a minimum integer of 0 and a maximum integer of 2 score points. Clin Orthop Relat Res. 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. 1989;14:567573. government site. A broken thumb usually causes more intense pain, and your thumb may look deformed or misshapen. Eurasian J Med. You will receive email when new content is published. your express consent. Sports Health. Complications after surgery were rare. J Hand Surg Am. Clin J Sport Med. [33,45] When repair is attempted, nonanatomical repositioning of the UCL may contribute to the loss of joint motion.[46]. Fourteen articles were included and analyzed (293 thumbs). Surgery has been recommended for fracture displacement, significant articular involvement, clinical instability, or fragment rotation. 45. Rao S, D'Amore T, Willier DP 3rd, Gawel R, Jack RA 2nd, Cohen SB, Ciccotti MG. Orthop J Sports Med. to maintaining your privacy and will not share your personal information without 2016 Mar;44(3):723-8. doi: 10.1177/0363546515621756. 2005;24:217221. 2006;31:6875. I was able to work while wearing the splint. Mean Quality Appraisal Tool score was 13.1 3.5 (range, 819), which correlated with a 54.6% 14.5% quality rating. abduction-adduction motion. He too had the internal brace augmentation. Simmons underwent surgery, also performed by Shin, to repair a torn UCL in his left thumb (like Trout, Simmons injured his non-dominant thumb). 17. This website also contains material copyrighted by 3rd parties. The outcome of elbow ulnar collateral ligament reconstruction in overhead athletes: a systematic review. All but 2 were level IV evidence. 1999;24:275282. The goal of Fusion Arthroplasty of the CMC joint is to fuse the bones together in the thumb so that they do not rub on each other and cause pain. Weakened grip or reduced thumb range of motion may occur. In a recent study, 49% of UCL disruptions of the thumb were caused by a fall onto an outstretched hand. Injury and Surgical Repair to the Thumb This is an injury to the ulnar collateral ligament of the metacarpo-phalangeal (MCP) joint. Objectives: 19. Thorough literature review to define the question, Specific inclusion and exclusion criteria, Appropriate scope of psychometric properties, Sample size calculation and justification, Authors referenced specific procedures for administration, scoring, and interpretation of procedures, Valid conclusions and clinical recommendations, 96% good and excellent outcomes* with stable joint, pain relief, restored strength, and 85% motion retention, 100% good and excellent outcomes,* 85% without pain, 70% without laxity, 82% strength retention, and 79% motion retention, 100% good and excellent outcomes,* 100% without pain or instability, 89% strength retention, and 90% motion retention, 100% stability, 96% key pinch strength retention, and 106% pulp pinch strength retention, 89% without pain, 89% pinch strength retention, 93% grip strength retention, and 74% motion retention, 100% good and excellent outcomes,* 90% strength retention, and 92% motion retention, 100% stability, 100% strength retention, and 100% motion retention, Both returned to previous level of sport and function, Compared intraosseous suture anchor and early mobilization to pullout suture or button and cast immobilization, Both groups significantly improved outcomes, 9 had suture periosteal repair; 1 had pullout suture repair, 31% loss of motion at MP joint; 10% loss of motion at IP joint, Arthroscopic Stener reduction and K-wire MP immobilization, No patient had loss of motion .10 degrees, 8 ligament repairs; 1 anchor; 1 drill hole; 4 K-wire fixations of avulsion, No detectable residual UCL laxity in 10 patients, 2 had less than 15 degrees laxity, 7 pullout suture and K-wire MP immobilization; 25 periosteal soft tissue suture, Palmaris longus via bone tunnels with or without K-wire fixation MP joint, Iliac crest boneperiosteumbone with cortical screw fixation, ECRL bonetendon ligamentoplasty with 1.5-mm titanium screw and suture anchor fixation, Palmaris longus via bone tunnels with K- ire fixation MP joint, 20 excellent, 4 good, and 2 fair results*. Epub 2021 Jan 18. [32] The most common region of rupture of the UCL is at the distal insertion or in the distal aspect of the ligament, leaving the proximal stump intact. 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. Increase in Use of Medial Ulnar Collateral Ligament Repair of the Elbow: A Large Database Analysis. Most patients have minimal pain by 6 weeks after surgery, with nearly full thumb and hand motion by 3 months. Patient Demographics of Thumb RCL and UCL Injuries. Bennet Fracture. The ECRL bone-tendon ligamentoplasty for chronic ulnar instability of the metacarpophalangeal joint of the thumb. Thumb dominance reported in 8 studies (168 thumbs). The Orthopedic Journal of Sports Medicine. 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 Mechanism of injury to the UCL of the MCP joint of the thumb is sudden, forced, radial deviation (abduction) and extension resulting in partial or complete tear of the ligament. Rupture and displacement of the. Dinowitz M, Trumble T, Hanel D, et al.. Failure of cast immobilization for thumb. Concomitant ulnar nerve transposition was associated with a higher neuropathy rate (16.1%) compared with no handling of the ulnar nerve (3.9%). If you're experiencing pain, bruising and swelling in your thumb after an accident such as a fall, be sure to contact your healthcare provider. Complication rates after RCL repair (N= 4; 22.2%) were higher than UCL repair (N= 7; 11.3%). Ford GM, Genuario J, Kinkartz J, Githens T, Noonan T. Am J Sports Med. Orthop Clin North Am. Post-traumatic instability of the metacarpophalangeal joint of the thumb. All but 2 were level IV evidence. Detection bias was present in the inconsistent use of an invalidated outcomes tool (Glickel grading system), visual measurement of range of motion, different tools for strength and stability measurement, and the subjective nature of reporting weakness and stability. 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%.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. Obremskey W, Pappas N, Attallah-Wasif E, et al.. Levels of evidence in Orthopaedic Journals. Looney AM, Fackler NP, Pianka MA, Bodendorfer BM, Fryar CM, Conroy CM, Israel JE, Wang DX, Ciccotti MG, Chang ES. You may also begin strengthening exercises if needed. Disclaimer. Results of surgical treatment of acute and chronic grade III [corrected] tears of the radial collateral ligament of the thumb metacarpophalangeal joint. This is the first study to compare complication rates between radial and ulnar collateral ligament injuries of the thumb. Van Dommelen BA, Zvirbulis RA. 2013;23(4):247-254. Instruct the patient to begin active range of motion exercises of the thumb without stressing the UCL/RCL repair. 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. Accessibility This leads to what is know as a positive ulnar variance. The major arc of motion of the thumb MP joint is flexion and extension, although there is some abduction, adduction, and rotation.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.31 The adductor pollicis supplies active support on the ulnar aspect, whereas the abductor pollicis brevis and flexor pollicis brevis provide dynamic stability on the radial border. 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. Superficial infections tend to settle quickly with oral antibiotics and regular dressings. Furthermore, it is interesting that our study quality results using the Quality Appraisal Tool were as low as they were (mean 54% with a range of 33%-79%). Scores assigned to each item are integers 0 (minimum), 1, and 2 (maximum). Epub 2020 Jun 29. Epub 2014 Oct 22. 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. Although the natural history of chronically untreated UCL injury eventually leads to pain and loss of function, surgery intervened in the studies present. This site needs JavaScript to work properly. This article provides a review of . Usually it is pulled off of the bone (proximal phalanx) on the nail side of the joint. Patients who fail nonoperative management have persistent thumb pain, decreased pinch strength, decreased grip strength, limited activities of daily living (especially opening jars and turning keys), continued instability, and early arthrosis.15,39 It is not entirely clear why patients fail nonoperative treatment, but some authors contend that failure may be because of irreducible displacement of the ruptured ligament.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. Rupture of the ulnar collateral ligament (UCL) is a frequent injury of the hand. Part I of this two-part article focuses on common tendon and . Some broken bones do not heal even when they get the best surgical or nonsurgical treatment. Baar H, Baar B, Kaplan T, Erol B, Tetik C. Chir Main. Mean study follow-up was 42.8 months. 2003;8:8185. When a broken bone fails to heal it is called a "nonunion." A "delayed union" is when a fracture takes longer than usual to heal. 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. The UCL is also known as the medial collateral ligament or "Tommy John Ligament". Purpose: Samora, Julie Balch MD, PhD*; Harris, Joshua D. MD; Griesser, Michael J. MD; Ruff, Michael E. MD*; Awan, Hisham M. MD*. 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. Exclusion criteria were non-English studies and any study with less than 2 years mean follow-up. NR, not reported. Proximal interphalangeal joint injuries of the hand. Physical examination of the thumb demonstrates the instability of the MCP joint, impossibility of opposition of the thumb, and the weakening of gripping force.5,6 This injury can have many names such as "skiers thumb", "gamekeepers thumb", and "break dancers thumb.". better/same/worse than preoperative status). Deep infections around the tendons and bones are rare and may need admission to hospital for intravenous antibiotics and further surgery. 1. Careers. Careers. Treatment of chronic injuries of the. Figure 46-2 Approach to the ulnar collateral ligament. Surgical Repair of Ulnar Collateral Ligament of ThumbDr. Before 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. 20. All material on this website is protected by copyright, Copyright 1994-2023 by WebMD LLC. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flowchart search algorithm with PubMed database. Mayo Clinic works with baseball players of all levels, from youth leagues to Major League Baseball, to enhance prevention and treatment of ulnar collateral ligament (UCL) injuries, also known as Tommy John injuries. 2022 Mar 27;4(3):141-146. doi: 10.1016/j.jhsg.2022.02.008. Epub 2021 Sep 7. Bostock S, Morris MA. Early and late postoperative complications were recorded. 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. All rights reserved. Epub 2016 Jan 13. 36. A systematic review of the literature was completed using the MEDLINE, PubMed, and Ovid databases. Highlight selected keywords in the article text. This injury is sometimes called "skier's thumb" because skiers are prone to this injury when they fall with their hand strapped . In these cases, a new graft may be used to perform a second reconstruction. SAGE Open Med. Return-to-Play Rates and Clinical Outcomes of Baseball Players After Concomitant Ulnar Collateral Ligament Reconstruction and Selective Ulnar Nerve Transposition. In addition, operative management was hypothesized to result in greater patient satisfaction versus nonoperative treatment. The https:// ensures that you are connecting to the Surgery has been recommended for fracture displacement, significant articular involvement, clinical instability, or fragment rotation.38 Chuter et al40 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. This ligament prevents the thumb from pointing too far away from the hand. A broken thumb can also cause numbness or tingling. Erickson BJ, Harris JD, Chalmers PN, Bach BR Jr, Verma NN, Bush-Joseph CA, Romeo AA. No study directly compared nonoperative to operative treatment. Any hard force on the thumb that pulls the thumb away from the hand (called a valgus force) can cause damage to the ulnar collateral ligaments. 1998;23:503506. 16. 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. 1-6 weeks: If the ligament is partially torn then a splint or cast is usually worn for six weeks and after its removal a programme of exercises is . Arthritis Rheum. All authors independently performed the search. [30,43,44] It has been well documented that direct suture techniques fail in chronic injuries. 415 Ray C Hunt Drive, Suite 3200 Charlottesville, VA 22903 434-982-HAND (4263) A Bennet fracture is an intra-articular fracture of the 1st metacarpal fracture caused by an axial force applied to the thumb in flexion, that requires surgical fixation when displaced. 14. American Society of Anesthesiologist (ASA) status, Wound Class, UCL versus RCL repair, date of surgery), post-operative treatment (immobilization and rehab), complication type (prolonged stiffness/pain, instability, reoperation, salvage arthrodesis of the first MCP joint), complication treatment, and outcome of the complication (e.g. 1-8 Nevertheless, UCL injuries have also been described in javelin throwers, tennis players, arm wrestlers, collegiate wrestlers, and quarterbacks. Complications, failures, and reoperations are rare after surgical treatment of UCL injury. 2009;6:e1000097. The overall complication rate after primary thumb RCL and UCL repair was 13.8%. 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. Would you like email updates of new search results? 2015 Apr;46(2):281-92. doi: 10.1016/j.ocl.2014.11.007. Unauthorized use of these marks is strictly prohibited. 44. official website and that any information you provide is encrypted Delma S, Ozdag Y, Baylor JL, Grandizio LC, Klena JC. A UCL consists of three bands or divisions: the anterior (front), posterior (back) and transverse (across) bands. Does Weightlifting Improve Cardiovascular Mortality Risk for Older Aged Adults? After the surgery you will lose some mobility in the thumb, but you are still able to grasp objects. Am J Sports Med. Rupture of the ulnar collateral ligament (UCL) is a frequent injury of the hand. Bean CH, Tencer AF, Trumble TE. 2012 Nov 7;94(21):2005-12. doi: 10.2106/JBJS.K.01024. Various complications have been previously documented including transient and permanent neuropathies involving the ulnar, saphenous, and median palmar nerves, neuroma formation, hematoma, infection, donor site harvest tenderness, postoperative stiffness, retear of flexor-pronator muscle, and stress fracture of the ulnar bone bridge. ||Injury chronicity not always defined, but we used ,3 weeks for acute injury and .3 weeks for chronic injury. Selection bias was presented based on the variance in subject age, gender, hand dominance, injury chronicity, injury location, the presence or absence of bony avulsion, the presence or absence of Stener lesion, and the retrospective nature of most of the studies. For all statistical analysis within all studies analyzed, P < 0.05 was deemed significant. Although the natural history of chronically untreated UCL injury eventually leads to pain and loss of function, surgery intervened in the studies present. J Hand Surg Glob Online. Of the 262 potentially relevant studies, 14 studies were identified for review11,15,1829 (Figure 1). Diagnosis of displaced, 43. Studies that duplicated patient populations from the same authors were excluded. Am J Sports Med.
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