Ulnar collateral ligament injuries of the thumb in athletes FRANK C. McCUE, III, M.D., MICHAEL W. HAKALA, M.D., JAMES R. ANDREWS, M.D., JOSEPH H. GIECK, R.P.T.
INTRODUCTION
The
ulnar collateral ligament of the metacarpophalangeal joint of the thumb is frequently injured during competitive sports. Unfortunately, this ligamentous tear is not infrequently overlooked when it is fresh, especially in the young, poorly supervised athlete. Inadequately treated, or untreated, complete tear of the ulnar collateral ligament results in instability of the joint when it
is stressed-m abduction. This situation jeopardizes one of the most important functions of the hand-the thumb-index pinch. In most sports, normal thumb-index pinch is a vital function for the athlete to be able to perform competitively. There is controversy in the literature over the proper method of treatment of this injury. We have observed From the Hand Service, Division of Orthopedic Surgery and Rehabilitation, University of Virginia Medical Center, Charlottesville, Virginia Dr. Frank C McCue, III, is Associate Professor of Orthopedic Surgery, University of Virginia Medical Center, Charlottesville, Virginia, Team Physician, University of Virginia Football and Athletic Teams Dr. Michael W. Hakala is Instructor of Orthopedic Surgery, University of Virginia Medical Center, Charlottesmlle, Virginia.
Presented, in part, at the First Annual Meeting of the Amencan Orthopaedic Society for Sports Medicine, February 6-7, 1973, Las Vegas, Nevada. 70
that residual thumb-index pinch weakness and instability may occur following an adequate course of conservative treatment, causing the patient to request surgery to alleviate the disability. ANATOMY
The metacarpophalangeal joint of the thumb is a diarthroidal joint capable of flexion, extension, abduction and adduction. Excellent descriptions of the capsular, tendinous and ligamentous attachments around this joint have been given by Kaplan and Stener. 1 The joint is formed by the attachments of the metacarpal head and the base of the proximal phalanx with the medial and lateral sesamoid bones. The capsule which unites these osseous structures is thin dorsally and thicker on the volar surface. The ulnar collateral ligament proper and the accessory ulnar collateral ligament have separate insertions (Figure I). The collateral ligaments reinforce the capsule on each side by inserting into the sides of the metacarpal head and extending distally and volarly to be inserted into the tubercles of the base of the proximal phalanx and into the corresponding sesamoid. The sesamoids are also incorporated into the fibrocartilaginous volar plate of the joint. Therefore, the collateral ligaments and the volar plate with the sesamoids form a contiguous structure. The adductor pollicis muscle is inserted in three ways: partially through a powerful tendon directly into the ulnar side of the
Figure 1-Utnar
view of the dorsal and volar aspects ojthe metacarpophalangealjoint of the thumb in the extended and flexed positions. Note the changes In tension of the proper and accessory ulnar collateral ligaments and the volar plate In the extended and flexed positions.
proximal phalanx; partially through the ulnar sesamoid; and by a fusion of some of its fibers with the ulnar expansion of the dorsal aponeurosis (Figure 2). This latter insertion has prompted Stener’ and others this portion of the dorsal aponeurosis the adductor aponeurosis. Additionally, the tendon of the extensor pollicis longus is connected through the adductor aponeurosis to the ulnar sesamoid bone. to call
MECHANISM OF INJURY
In order to appreciate the mechanism of rupture of the ulnar collateral ligament of
the thumb, it is necessary to understand the roles played by the various soft tissue structures in stabilizing the normal metacarpophalangeal joint. The adductor pollicis and adductor aponeurosis are important for the active stabilization of the metacarpophalangeal joint against forces tending to abduct the thumb, but are of no help as passive obstacles to abduction. It has been shown that if the adductor aponeurosis alone is cut, there is no change in lateral stability of the
metacarpophalangeal joint. Complete severance of the ulnar collateral ligaments makes abnormal abduction possible even if the 71
Figure 2-Anatomv oJthe ulnar aspects of the metacarpophalangealjoint of the thumb adductor pollicis muscle is inserted adductor aponeurosis is left intact.2 In full flexion the ulnar collateral ligament proper is taut and the accessory ulnar collateral ligament is relaxed; the reverse is true in extension (Figure 1 ). If the ulnar collateral ligament proper is cut and the accessory collateral ligament left intact, the metacarpophalangeal joint will be stable in extension, but increased abduction will be possible when the joint is flexed; this increase is slight and won’t be great until the accessory ligament has also been cut. Even with both ulnar collateral ligaments cut, the abnormal abduction mobility will be most apparent in flexion of the metacarpophalangeal joint, because in extension, abduction is restricted by the volar plate and its capsular and ligamentous attachments. The mechanism of injury to the ulnar collateral ligament of the metacarpophalangeal joint of the thumb is usually forcible abduction, but can also be torsion, combined abduction and hyperextension, and 72
more
Note the 3
wavs in
whic
rarely, combined abduction with flex-
ion.
DIAGNOSIS
Rupture of the ulnar collateral ligament of the metacarpophalangeal joint of the thumb, either partial or total, should be borne m mind m every instance of injury to this joint m athletes Residual thumb-index pinch and instability pain frequently occur if this injury is overlooked or improperly treated. History There is generally a history of strain in the radial direction. The patient complains of pain and swelling in the web space at the base of the thumb and weakness of the thumb-index pinch. Examination
injuries, the following signs and symptoms are useful in the diagnosis.
In acute
Local tenderness to pressure
over
the ulnar
collateral
rhage
into
ligaments Exudate or hemorthe metacarpophalangeal joint
common, but may be absent Pain in the joint with abduction stress testing. This sign is present m the case of both partial and total tears of the ulnar collateral ligament Swelling along the ulnar side of the metacarpal head This may be caused by proximal displacement of the torn ligament or by the abundant granulation tissue that forms around the torn ligament within a week of the injury. Weakness of thumb-index pinch occurs with both partial and complete ulnar collateral ligament tears. It should be remembered that the adductor pollicis is important for active stabilization of the metacarpophalangeal joint against abduction stresses. If its attachment to the proximal phalanx is loosened or interrupted, there will be some resultant loss of strength of thumb-index pinch. Strength of pinch should be measured with the dynamometer and compared with the normal side/ Instability occurs in cases of complete tear of the ulnar collateral ligament, but may be present to some degree with partial tears Generally, with complete tears, if the patient is asked to press the tip of the index finger against the ulnar side of the thumb, comparison of the two hands will show the affected thumb to be deviated away from the index finger. Tests of stability should always be compared with the unmvolved side, and are performed with the metacarpophalangeal joint in both extension and flexion. Normal stability to abduction stress in extension does not rule out a partial tear of the ulnar collateral ligament, with the metacarpophalangeal joint fully extended, the ulnar collateral ligament proper is relaxed and the accessory collateral ligament and palmar ligaments are taut, while with flexion the reverse is true (Figure 1 ). Thus a tear in the ulnar collateral ligament proper could be missed if joint stability were tested only in full extension An isolated tear such as this would best be demonstrated by comparing combined abduction, flexion and supination on the injured and normal side. If the accessory and proper ulnar collateral ligaments are completely torn and the joint is are
abduction stress, there will be radial play in the joint, as well as flexion and supination of the phalanx. (Figure 3) In troublesome cases the use of local anesthesia on the injured side will assure 4 complete cooperation with stress testmg
subjected
to
pathologic
Roentgenograms Routine radiographs of the hand should be obtained in all cases. Stress views, compared with the other side, should be obtained if there is any doubt in the diagnosis Occasionally the regular views will show in avulsion fracture from the base of the proximal phalanx with proximal and ulnar displacement of the bone fragment (Figure 4). This fragment is frequently attached to the distal end of the ulnar collateral ligament. CLINICAL MATERIAL
Dunng the period from January, 1962, through June, 1972, there were 41 cases of rupture of the ulnar collateral ligament of the metacarpophalangeal joint of the thumb in athletes treated surgically on the Hand Service at the University of Virginia Hospital. During the same period there were 315 cases of sprains of the ulnar collateral ligament treated successfully with plaster or splint immobilization for periods ranging from three to five weeks. Twenty-five of the operated cases were classified as chronic (greater than four weeks from the time of injury) when treated surgically and sixteen were acute. Twenty-two of the athletes were injured while playing football, while four each were injured during participation in baseball, wrestling and skiing. Basketball accounted for three injuries. Lacrosse, softball, polo and horse jumping resulted in one injury apiece. Forty of the patients were male and only one female. The right hand was injured in twenty-five patients and the left hand in sixteen. The age of the athletes ranged from fifteen to fifty-six years, with only three of the patients being over twentyseven years of age The average age of the patients at the time of injury was 21.4 years. The presenting signs and symptoms in the acute group were pain, swelling, local tento marked laxity of the
derness, moderate
metacarpophalangeal joint
on
abduction 73
radial play
as well as flexion and supination of the phalanx following complete tears of the accessory and proper metacarpophalangeal joint of the thumb
Figure 3-Pathologic stress
testing
thumb subjected to abduction ulnar collateral ligaments of the
in a
Figure 4-Abduction stress roentgenograms of both thumbs following a tear of the ulnar collateral ligament of the metacarpophalangeal joint of the right thumb. Note the widening of the JOint mortice on the ulnar side of the nght thumb and the avulsion fracture from the base of the proximal phalanx 74
stress, and
inability
to
continue
athletic
competition. All of the patients who were operated upon when their injury was chronic, presented with weakness or instability of thumb-index pinch, with pain and weakness of grip being secondary findings. The competitive performance of all of these athletes was hampered because of their in-
jury. However, no surgery was performed because of objective findings alone in the chronic
Each of these patients redue to subjective weakOur indications for surlisted below (Figures 5 and 6). cases.
quested operations ness and disability. gery
are
collateral ligament was torn distally from its attachment to the proximal phalanx, and in the remaining case it had been avulsed with an attached bone fragment from the base of the proximal phalanx. The types of surgical repair employed in this group included: distal re-attachment of the ligament to periosteum and bone with a pull-out wire in twelve cases; distal re-attachment with volar plate repair in two cases; distal repair with adductor pollicis advancement in one case; and Kirschner wire fixation of the avulsion fracture of the base of the proximal phalanx in one case. The incision we routinely used in repairing ulnar collateral ligaments tears is shown in Figure 7. The dissection is started by isolating the adductor aponeurosis (Figure 8). Once the adductor aponeurosis has been divided and retracted, the ulnar collateral ligament is exposed. The palmar flap of the aponeurosis should be retracted so that the accessory collateral ligament and the volar plate can be thoroughly inspected for damage
Figures
5 and 6-Indications for surgery in acute and chronic tears of the ulnar collateral ligament of the
metacarpophalangeal joint of the thumb.
The final result was graded according to the following critena: 1 ) the range of motion of the metacarpophalangeal joint as compared to the other side; 2) strength of the thumb-index pinch as measured with the Jamar dynamometer in the first slot and compared to the uninjured side; 3) the stability of the joint to abduction stress measured in extension and in 20 degrees of flexion; 4) the patient’s symptoms and his ability to perform the functions necessary for him to participate in competitive athletics. Each of these factors was graded on a 10 point scale and the total number of points placed the result in one of four groups;
excellent, good, fair,
or
poor.
TREATMENT
The
mean
time interval from the date of
to the date of surgery in the acute of sixteen patients was 9.8 days. In group
injury
fifteen of these sixteen cases, the ulnar
(Figure 9).
The ligamentous repair or re-attachment is made with the metacarpophalangeal joint in 15% to 20% of flexion so that the collateral ligament proper is under the proper tension, and also to prevent loss of flexion post-operatively. The patients were immobilized four to five weeks post-operatively in a short arm plaster splint or thumb
spica
cast.
The
injury
mean time
interval from the date of
to the date of surgery in
twenty-five
the chronic group was sixty-seven days. Eleven of these athletes were not seen initially or treated by temporary splinting and taping to allow continued athletic participation, and did not receive an adequate trial of conservative therapy as recommended by Bunnell,’ and Coonrad and
patients
in
Goldner.&dquo;6 The remaining 14 patients were treated with 4 weeks of cast immobilization followed by splinting. This method failed in all of these cases and the patients required a subsequent reconstructive procedure because of functional instability. The type of reconstruction varied with the pathology found at the time of surgery, but in 24 of the 25 cases, the repair included distal
conservatively
75
advancement or re-attachment of the torn ligament combined with advancement of the adductor pollicis attachment to the proximal phalanx in a method similar to that of Neviaser and Wilson.’ Eight patients also had the volar plate reconstructed. RESULTS
The surgical result was excellent or good in all 16 of the acute cases. The clinical results of conservative therapy in the chronic group were described previously. In 24 of the 25 chronic cases, the result was either good or excellent. The patients in the chronic group averaged 7 degrees more laxity on abduction stress testing when compared to the acute group of patients. Ten of the chronic cases lost 5 degrees or less of extension of the metacarpophalangeal joint compared with the normal side. Four of these patients also lost 5 degrees or less of flexion compared with the uninjured side. These patients also exhibited slight reduction in strength of
pinch and in grip strength as tested on the Jamar dynamometer. However, this did not alter their ability to return to athletic com-
Figure 76
7-The
surgical
incision most
frequently
petition. Overall, the best results
were obwho had primary ligamentous repair. There was one poor result and this occurred in a fifty-six year old skier who had surgery thirteen weeks after his initial injury and in whom there were obvious degenerative changes in the joint at the time of surgery. He still has a weak, stiff and painful metacarpophalangeal joint and may require arthrodesis in the future. All athletes who participated in team sports subsequently returned to play at the same position without any noticeable change in their functional ability. One patient was a twenty-one year old University of Virginia football player and baseball pitcher who tore the ulnar collateral ligament of his dominant thumb during the latter part of the 1963 football season. He was treated with plaster immobilization for five weeks and did well until the baseball season started. He was unable to pitch because of instability of thumb-index pinch and weakness of grip and played at first base that year. He had a surgical reconstruction following the baseball schedule, some seven months from the
tained
used
in
in
the acute
the chronic
cases
cases.
Figure
8-The dissection has been started aponeurosis In this illustration
by isolating
the adductor aponeurosis. The
Figure 9-The adductor aponeurosis has been divided and retracted, granulation tissue seen along its distal margin 77
exposing the
torn
probe
is
passed beneath the
ulnar collateral
ligament
with
time of
He returned to level the next year.
injury.
collegiate
pitch
at
the
DISCUSSION
Prior to the reports of Moberg and Stener3 in 1953 and Strande1l4 in 1959, the literature contained very few reports on injury to the collateral ligaments of the metacarpophalangeal joint of the thumb. Although the number of case reports and experimental studies on rupture of the ulnar collateral ligament has increased in recent years, there still is controversy over the proper method of treatment of this injury. No series to date has concerned itself solely with the loss of function and treatment of this injury in athletes. Bunnell’ (1948) noted that the ulnar collateral ligament may be torn by lateral sprains and result in weakness of pinch. He stated that good results would be obtained with 4 weeks of splinting if the injury were recent; in older injuries he advised ligamentous repair and capsulorrhaphy with reinforcement by a fascia lata graft, or arthrodesis. Watson-Jones’ (1955) stressed the importance of long conservative therapy in order to prevent lengthening of the ligament and subsequent recurrent subluxation of the
joint. Moberg and Stener3 (1953) reported good results in 13 out of 14 patients treated by primary ligament repair with the pullout wire technique. Frykman and Johansson9 in 1956 had excellent results in13 of 14 patients treated surgically. Wosnik10 (1958) stated that plaster immobilization
however adequate the will not technique, give satisfactory results in the majority of cases. Strandell’ in 1959 reported the outcome of surgery in 35 consecutive cases: 27 excellent results, 4 good results, and 4 poor results. Kaplanl, 12 described two chronic cases of &dquo;gamekeeper’s thumb&dquo; in which restoration of the ulnar collateral ligament of the thumb failed to result in clinical improvement. He performed experimental investigations on five preserved hand specimens, and stated that forced radial deviation of the 78
by itself,
thumb did not rupture the ulnar collateral ligament of the metacarpophalangeal joint. He concluded that the defect causing radial subluxation of the thumb with ulnar displacement of the head of the first metacarpal was not a rupture of the ulnar collateral ligament, but instead a disruption of the dorsal extensor apparatus between the adductor and extensor tendons and rupture of the dorsal capsule, with secondary displacement of the extensor pollicis longus tendon to the radial side of the metacarpal head where it acts as a deforming force. In his studies the ulnar collateral ligament remained intact but migrated toward the volar aspect of the joint, thus displacing the base of the proximal phalanx volarly and producing radial rotation of the thumb. Stener’ (1962) emphasized the frequency of rupture of the ulnar collateral ligament at its distal attachment with interposition of the adductor aponeurosis between the torn end of the ligament and its site of attachment to the proximal phalanx. He describes the variations in pathology of this injury, and reports good results with early surgical repair in 34 patients. Kessler13 in 1963 stressed that late instability of the metacarpophalangeal joint of the thumb could be prevented by early diagnosis (aided by stress X-rays) and primary ligamentous repair. Coonrad and Goldners (1968) state that ulnar or radial subluxation injuries should be initially treated with immediate immobilization in a plaster cast for 4 weeks and that surgical repair should rarely be considered as initial pnmary treatment. Surgical treatment should be considered if there is pain and functional impairment after an adequate trial of immobilization in a plaster cast.
Our observations concur with Stener’s that tears of the ulnar collateral ligament occur most frequently at its distal attachment. We have excellent or good results in all 16 of the acutely operated cases in athletes and in 24 of the 25 chronic cases. It is our feeling that old injuries which require reconstruction for functional instability should have the adductor pollicis attachment advanced at the time of surgery. The mechanism of injury and resulting func-
ugure
impairment vary with the sport and specific position played by the athlete. In specific situations we feel that temporary taping and splinting may be utilized to allow
is the result if a torn ulnar collateral ligament goes unnoticed or is inadequately treated. In most sports, thumb-index pinch is a vital function for the athlete to perform
continued athletic participation without the final surgical result. The method of taping we use at the University of Virginia is illustrated in Figure 10. The metacarpophalangeal joint of the thumb is stabilized to the hand with the first strips of tape. Then the index finger is taped to the thumb, holding it in adduction, and to prevent abduction at the joint.
competitively.
tional
the
jeopardizing
SUMMARY
Injury to the ulnar collateral ligament of metacarpophalangeal joint of the thumb is frequent in competitive sports. All too often, especially in young, poorly supervised athletes, there is a tendency to either overthe
look or minimize this injury thumb-index pinch weakness and
Residual
instability
During the period from 1962 to 1972 at University of Virginia Hospital, there were 41 surgical repairs and reconstructions for ulnar collateral ligament injuries to the the
thumb in athletes In fourteen of the twentyfive chronic cases conservative treatment, consisting of four weeks of cast immobilization, failed. In all twenty-five of the chronic cases the patient requested reconstructive surgery because of functional instability, pain, or weakness of thumb-index pinch. The results obtained with surgical repair or reconstruction were good to excellent in 40 of our 41 1 patients. All patients who participated in team sports returned to competitive athletics at the same team position they played prior to their injury. Temporary splinting and taping may be used to allow continued athletic participation, if this is feasible in the particular athlete’s case, without seriously jeopardizing the final surgical result. The mechanism of injury, diagnosis, indications for surgery, and a means of surgical repair are descnbed. References EB. Functional and Surgical Anatomy of the Hand Philadelphia, J. B. Lippin-
1
Kaplan
2
Stener B collateral
cott Co , 1953 Displacement of the ruptured ulnar ligament of the metacarpophalan-
geal joint anatomical
of the thumb A clinical and . study. J Bone Joint Surg, 44-B
869-879, 1962 3.
Moberg E,
Stener B Injuries to the ligaments of the thumb and fingers Diagnosis, treatment and prognosis Acta Chir Scand, 106
4
Strandell G Total Rupture of the Ulnar Collateral Ligament of the Metacarpophalangeal Joint of the Thumb Results of Surgery in 35 Cases Acta Chir Scand, 118
166-186, 1953
72-80, 1959 5. Bunnell S
Surgery of the Hand Ed. 4, J B Lippincott Co , 1964 Coonrad RW, Goldner JL A Study of the Pathological Findings and Treatment in SoftTissue Injury of the Thumb Metacarpophalangeal Joint With a Clinical Study of the Normal Range of Motion in One Thousand Thumbs and a Study of Post Mortem
Philadelphia,
6.
10-A method
of taping the thumb and hand with ulnar collateral ligament injury.
an
79
Findings of Ligamentous Structures in Relation to Function. J Bone and Joint Surg, 50-A: 439-451, Apnl 1968. 7. Neviaser RJ, Wilson JN, Lievano A. Rupture of the Ulnar Collateral Ligament of the Thumb (Gamekeeper’s Thumb). Correction by Dynamic Repair. J. Bone and Joint Surg, 53-A 1357-1364, Oct., 1971. 8. Watson-Jones R: Fractures and Joint Injuries. Ed. 3, Edinburgh and London, E. and S. Livingstone, 1955. 9. Frykman G, Johansson O: Surgical Repair of Rupture of the Ulnar Collateral Ligament of the Metacarpophalangeal Joint of the Thumb. Acta Chir Scand, 112: 58-64, 1956. Low Back
Pain/Ferguson-Editorial
Continued
from
10. Wosmk H: Die Geschlossenen Bandverletzungen des Daumengrundgelenks. Hefte zur Unfallheilkundr, 56 45 47, 1958. 11. Kaplan EB. Lateral Subluxation of the Metacarpophalangeal Joint of the Thumb: Experimental Study. Bull Hosp Joint Dis, 21:
200-205, 1960. 12.
EB: The Pathology and Treatment of Radial Subluxation of the Thumb with Ulnar Displacement of the Head of the First Metacarpal. J Bone and Joint Surg, 43-A:
Kaplan
541-546, June 1961. 13. Kessler I. Chronic Subluxation of the Metacarpophalangeal Joint of the Thumb. J Bone and Joint Surg, 45-B . 805, Nov. 1963.
Comment
page 69
logical studies (which could
thousands of laboring employees of an industrial plant. Standing films projected in the anteroposterior as well as lateral planes were projected along with routine obliques. There was no justified correlation between the presence of defects and complaints, disabilities, work restrictions, lost work time, or subsequent development of low back
It has not been my privilege to survey college athletes but in over twenty-five years of experience with professional football players plus a significant number of high school and college linemen and linebackers there has not been an impressive correlation of complaints with positive radiological findings. Past experiences have led me to the belief that given a negative history of back pain in spite of positive radiological evidence along the lines of the subject in question we do not reject an athlete unless there is substantive evidence of significant vertebral body changes or slippage. If we find such our experience has been that the history has
problems.
been falsified.
not be afforded) that proper conditioning played the significant role in alleviation of signs and symptoms. That the treatment was empiric is not denied. Furthermore, well over fifteen or even twenty years ago the undersigned was a
participant
80
in
a
study encompassing
many
INTRODUCTION
The
ulnar collateral ligament of the metacarpophalangeal joint of the thumb is frequently injured during competitive sports. Unfortunately, this ligamentous tear is not infrequently overlooked when it is fresh, especially in the young, poorly supervised athlete. Inadequately treated, or untreated, complete tear of the ulnar collateral ligament results in instability of the joint when it
is stressed-m abduction. This situation jeopardizes one of the most important functions of the hand-the thumb-index pinch. In most sports, normal thumb-index pinch is a vital function for the athlete to be able to perform competitively. There is controversy in the literature over the proper method of treatment of this injury. We have observed From the Hand Service, Division of Orthopedic Surgery and Rehabilitation, University of Virginia Medical Center, Charlottesville, Virginia Dr. Frank C McCue, III, is Associate Professor of Orthopedic Surgery, University of Virginia Medical Center, Charlottesville, Virginia, Team Physician, University of Virginia Football and Athletic Teams Dr. Michael W. Hakala is Instructor of Orthopedic Surgery, University of Virginia Medical Center, Charlottesmlle, Virginia.
Presented, in part, at the First Annual Meeting of the Amencan Orthopaedic Society for Sports Medicine, February 6-7, 1973, Las Vegas, Nevada. 70
that residual thumb-index pinch weakness and instability may occur following an adequate course of conservative treatment, causing the patient to request surgery to alleviate the disability. ANATOMY
The metacarpophalangeal joint of the thumb is a diarthroidal joint capable of flexion, extension, abduction and adduction. Excellent descriptions of the capsular, tendinous and ligamentous attachments around this joint have been given by Kaplan and Stener. 1 The joint is formed by the attachments of the metacarpal head and the base of the proximal phalanx with the medial and lateral sesamoid bones. The capsule which unites these osseous structures is thin dorsally and thicker on the volar surface. The ulnar collateral ligament proper and the accessory ulnar collateral ligament have separate insertions (Figure I). The collateral ligaments reinforce the capsule on each side by inserting into the sides of the metacarpal head and extending distally and volarly to be inserted into the tubercles of the base of the proximal phalanx and into the corresponding sesamoid. The sesamoids are also incorporated into the fibrocartilaginous volar plate of the joint. Therefore, the collateral ligaments and the volar plate with the sesamoids form a contiguous structure. The adductor pollicis muscle is inserted in three ways: partially through a powerful tendon directly into the ulnar side of the
Figure 1-Utnar
view of the dorsal and volar aspects ojthe metacarpophalangealjoint of the thumb in the extended and flexed positions. Note the changes In tension of the proper and accessory ulnar collateral ligaments and the volar plate In the extended and flexed positions.
proximal phalanx; partially through the ulnar sesamoid; and by a fusion of some of its fibers with the ulnar expansion of the dorsal aponeurosis (Figure 2). This latter insertion has prompted Stener’ and others this portion of the dorsal aponeurosis the adductor aponeurosis. Additionally, the tendon of the extensor pollicis longus is connected through the adductor aponeurosis to the ulnar sesamoid bone. to call
MECHANISM OF INJURY
In order to appreciate the mechanism of rupture of the ulnar collateral ligament of
the thumb, it is necessary to understand the roles played by the various soft tissue structures in stabilizing the normal metacarpophalangeal joint. The adductor pollicis and adductor aponeurosis are important for the active stabilization of the metacarpophalangeal joint against forces tending to abduct the thumb, but are of no help as passive obstacles to abduction. It has been shown that if the adductor aponeurosis alone is cut, there is no change in lateral stability of the
metacarpophalangeal joint. Complete severance of the ulnar collateral ligaments makes abnormal abduction possible even if the 71
Figure 2-Anatomv oJthe ulnar aspects of the metacarpophalangealjoint of the thumb adductor pollicis muscle is inserted adductor aponeurosis is left intact.2 In full flexion the ulnar collateral ligament proper is taut and the accessory ulnar collateral ligament is relaxed; the reverse is true in extension (Figure 1 ). If the ulnar collateral ligament proper is cut and the accessory collateral ligament left intact, the metacarpophalangeal joint will be stable in extension, but increased abduction will be possible when the joint is flexed; this increase is slight and won’t be great until the accessory ligament has also been cut. Even with both ulnar collateral ligaments cut, the abnormal abduction mobility will be most apparent in flexion of the metacarpophalangeal joint, because in extension, abduction is restricted by the volar plate and its capsular and ligamentous attachments. The mechanism of injury to the ulnar collateral ligament of the metacarpophalangeal joint of the thumb is usually forcible abduction, but can also be torsion, combined abduction and hyperextension, and 72
more
Note the 3
wavs in
whic
rarely, combined abduction with flex-
ion.
DIAGNOSIS
Rupture of the ulnar collateral ligament of the metacarpophalangeal joint of the thumb, either partial or total, should be borne m mind m every instance of injury to this joint m athletes Residual thumb-index pinch and instability pain frequently occur if this injury is overlooked or improperly treated. History There is generally a history of strain in the radial direction. The patient complains of pain and swelling in the web space at the base of the thumb and weakness of the thumb-index pinch. Examination
injuries, the following signs and symptoms are useful in the diagnosis.
In acute
Local tenderness to pressure
over
the ulnar
collateral
rhage
into
ligaments Exudate or hemorthe metacarpophalangeal joint
common, but may be absent Pain in the joint with abduction stress testing. This sign is present m the case of both partial and total tears of the ulnar collateral ligament Swelling along the ulnar side of the metacarpal head This may be caused by proximal displacement of the torn ligament or by the abundant granulation tissue that forms around the torn ligament within a week of the injury. Weakness of thumb-index pinch occurs with both partial and complete ulnar collateral ligament tears. It should be remembered that the adductor pollicis is important for active stabilization of the metacarpophalangeal joint against abduction stresses. If its attachment to the proximal phalanx is loosened or interrupted, there will be some resultant loss of strength of thumb-index pinch. Strength of pinch should be measured with the dynamometer and compared with the normal side/ Instability occurs in cases of complete tear of the ulnar collateral ligament, but may be present to some degree with partial tears Generally, with complete tears, if the patient is asked to press the tip of the index finger against the ulnar side of the thumb, comparison of the two hands will show the affected thumb to be deviated away from the index finger. Tests of stability should always be compared with the unmvolved side, and are performed with the metacarpophalangeal joint in both extension and flexion. Normal stability to abduction stress in extension does not rule out a partial tear of the ulnar collateral ligament, with the metacarpophalangeal joint fully extended, the ulnar collateral ligament proper is relaxed and the accessory collateral ligament and palmar ligaments are taut, while with flexion the reverse is true (Figure 1 ). Thus a tear in the ulnar collateral ligament proper could be missed if joint stability were tested only in full extension An isolated tear such as this would best be demonstrated by comparing combined abduction, flexion and supination on the injured and normal side. If the accessory and proper ulnar collateral ligaments are completely torn and the joint is are
abduction stress, there will be radial play in the joint, as well as flexion and supination of the phalanx. (Figure 3) In troublesome cases the use of local anesthesia on the injured side will assure 4 complete cooperation with stress testmg
subjected
to
pathologic
Roentgenograms Routine radiographs of the hand should be obtained in all cases. Stress views, compared with the other side, should be obtained if there is any doubt in the diagnosis Occasionally the regular views will show in avulsion fracture from the base of the proximal phalanx with proximal and ulnar displacement of the bone fragment (Figure 4). This fragment is frequently attached to the distal end of the ulnar collateral ligament. CLINICAL MATERIAL
Dunng the period from January, 1962, through June, 1972, there were 41 cases of rupture of the ulnar collateral ligament of the metacarpophalangeal joint of the thumb in athletes treated surgically on the Hand Service at the University of Virginia Hospital. During the same period there were 315 cases of sprains of the ulnar collateral ligament treated successfully with plaster or splint immobilization for periods ranging from three to five weeks. Twenty-five of the operated cases were classified as chronic (greater than four weeks from the time of injury) when treated surgically and sixteen were acute. Twenty-two of the athletes were injured while playing football, while four each were injured during participation in baseball, wrestling and skiing. Basketball accounted for three injuries. Lacrosse, softball, polo and horse jumping resulted in one injury apiece. Forty of the patients were male and only one female. The right hand was injured in twenty-five patients and the left hand in sixteen. The age of the athletes ranged from fifteen to fifty-six years, with only three of the patients being over twentyseven years of age The average age of the patients at the time of injury was 21.4 years. The presenting signs and symptoms in the acute group were pain, swelling, local tento marked laxity of the
derness, moderate
metacarpophalangeal joint
on
abduction 73
radial play
as well as flexion and supination of the phalanx following complete tears of the accessory and proper metacarpophalangeal joint of the thumb
Figure 3-Pathologic stress
testing
thumb subjected to abduction ulnar collateral ligaments of the
in a
Figure 4-Abduction stress roentgenograms of both thumbs following a tear of the ulnar collateral ligament of the metacarpophalangeal joint of the right thumb. Note the widening of the JOint mortice on the ulnar side of the nght thumb and the avulsion fracture from the base of the proximal phalanx 74
stress, and
inability
to
continue
athletic
competition. All of the patients who were operated upon when their injury was chronic, presented with weakness or instability of thumb-index pinch, with pain and weakness of grip being secondary findings. The competitive performance of all of these athletes was hampered because of their in-
jury. However, no surgery was performed because of objective findings alone in the chronic
Each of these patients redue to subjective weakOur indications for surlisted below (Figures 5 and 6). cases.
quested operations ness and disability. gery
are
collateral ligament was torn distally from its attachment to the proximal phalanx, and in the remaining case it had been avulsed with an attached bone fragment from the base of the proximal phalanx. The types of surgical repair employed in this group included: distal re-attachment of the ligament to periosteum and bone with a pull-out wire in twelve cases; distal re-attachment with volar plate repair in two cases; distal repair with adductor pollicis advancement in one case; and Kirschner wire fixation of the avulsion fracture of the base of the proximal phalanx in one case. The incision we routinely used in repairing ulnar collateral ligaments tears is shown in Figure 7. The dissection is started by isolating the adductor aponeurosis (Figure 8). Once the adductor aponeurosis has been divided and retracted, the ulnar collateral ligament is exposed. The palmar flap of the aponeurosis should be retracted so that the accessory collateral ligament and the volar plate can be thoroughly inspected for damage
Figures
5 and 6-Indications for surgery in acute and chronic tears of the ulnar collateral ligament of the
metacarpophalangeal joint of the thumb.
The final result was graded according to the following critena: 1 ) the range of motion of the metacarpophalangeal joint as compared to the other side; 2) strength of the thumb-index pinch as measured with the Jamar dynamometer in the first slot and compared to the uninjured side; 3) the stability of the joint to abduction stress measured in extension and in 20 degrees of flexion; 4) the patient’s symptoms and his ability to perform the functions necessary for him to participate in competitive athletics. Each of these factors was graded on a 10 point scale and the total number of points placed the result in one of four groups;
excellent, good, fair,
or
poor.
TREATMENT
The
mean
time interval from the date of
to the date of surgery in the acute of sixteen patients was 9.8 days. In group
injury
fifteen of these sixteen cases, the ulnar
(Figure 9).
The ligamentous repair or re-attachment is made with the metacarpophalangeal joint in 15% to 20% of flexion so that the collateral ligament proper is under the proper tension, and also to prevent loss of flexion post-operatively. The patients were immobilized four to five weeks post-operatively in a short arm plaster splint or thumb
spica
cast.
The
injury
mean time
interval from the date of
to the date of surgery in
twenty-five
the chronic group was sixty-seven days. Eleven of these athletes were not seen initially or treated by temporary splinting and taping to allow continued athletic participation, and did not receive an adequate trial of conservative therapy as recommended by Bunnell,’ and Coonrad and
patients
in
Goldner.&dquo;6 The remaining 14 patients were treated with 4 weeks of cast immobilization followed by splinting. This method failed in all of these cases and the patients required a subsequent reconstructive procedure because of functional instability. The type of reconstruction varied with the pathology found at the time of surgery, but in 24 of the 25 cases, the repair included distal
conservatively
75
advancement or re-attachment of the torn ligament combined with advancement of the adductor pollicis attachment to the proximal phalanx in a method similar to that of Neviaser and Wilson.’ Eight patients also had the volar plate reconstructed. RESULTS
The surgical result was excellent or good in all 16 of the acute cases. The clinical results of conservative therapy in the chronic group were described previously. In 24 of the 25 chronic cases, the result was either good or excellent. The patients in the chronic group averaged 7 degrees more laxity on abduction stress testing when compared to the acute group of patients. Ten of the chronic cases lost 5 degrees or less of extension of the metacarpophalangeal joint compared with the normal side. Four of these patients also lost 5 degrees or less of flexion compared with the uninjured side. These patients also exhibited slight reduction in strength of
pinch and in grip strength as tested on the Jamar dynamometer. However, this did not alter their ability to return to athletic com-
Figure 76
7-The
surgical
incision most
frequently
petition. Overall, the best results
were obwho had primary ligamentous repair. There was one poor result and this occurred in a fifty-six year old skier who had surgery thirteen weeks after his initial injury and in whom there were obvious degenerative changes in the joint at the time of surgery. He still has a weak, stiff and painful metacarpophalangeal joint and may require arthrodesis in the future. All athletes who participated in team sports subsequently returned to play at the same position without any noticeable change in their functional ability. One patient was a twenty-one year old University of Virginia football player and baseball pitcher who tore the ulnar collateral ligament of his dominant thumb during the latter part of the 1963 football season. He was treated with plaster immobilization for five weeks and did well until the baseball season started. He was unable to pitch because of instability of thumb-index pinch and weakness of grip and played at first base that year. He had a surgical reconstruction following the baseball schedule, some seven months from the
tained
used
in
in
the acute
the chronic
cases
cases.
Figure
8-The dissection has been started aponeurosis In this illustration
by isolating
the adductor aponeurosis. The
Figure 9-The adductor aponeurosis has been divided and retracted, granulation tissue seen along its distal margin 77
exposing the
torn
probe
is
passed beneath the
ulnar collateral
ligament
with
time of
He returned to level the next year.
injury.
collegiate
pitch
at
the
DISCUSSION
Prior to the reports of Moberg and Stener3 in 1953 and Strande1l4 in 1959, the literature contained very few reports on injury to the collateral ligaments of the metacarpophalangeal joint of the thumb. Although the number of case reports and experimental studies on rupture of the ulnar collateral ligament has increased in recent years, there still is controversy over the proper method of treatment of this injury. No series to date has concerned itself solely with the loss of function and treatment of this injury in athletes. Bunnell’ (1948) noted that the ulnar collateral ligament may be torn by lateral sprains and result in weakness of pinch. He stated that good results would be obtained with 4 weeks of splinting if the injury were recent; in older injuries he advised ligamentous repair and capsulorrhaphy with reinforcement by a fascia lata graft, or arthrodesis. Watson-Jones’ (1955) stressed the importance of long conservative therapy in order to prevent lengthening of the ligament and subsequent recurrent subluxation of the
joint. Moberg and Stener3 (1953) reported good results in 13 out of 14 patients treated by primary ligament repair with the pullout wire technique. Frykman and Johansson9 in 1956 had excellent results in13 of 14 patients treated surgically. Wosnik10 (1958) stated that plaster immobilization
however adequate the will not technique, give satisfactory results in the majority of cases. Strandell’ in 1959 reported the outcome of surgery in 35 consecutive cases: 27 excellent results, 4 good results, and 4 poor results. Kaplanl, 12 described two chronic cases of &dquo;gamekeeper’s thumb&dquo; in which restoration of the ulnar collateral ligament of the thumb failed to result in clinical improvement. He performed experimental investigations on five preserved hand specimens, and stated that forced radial deviation of the 78
by itself,
thumb did not rupture the ulnar collateral ligament of the metacarpophalangeal joint. He concluded that the defect causing radial subluxation of the thumb with ulnar displacement of the head of the first metacarpal was not a rupture of the ulnar collateral ligament, but instead a disruption of the dorsal extensor apparatus between the adductor and extensor tendons and rupture of the dorsal capsule, with secondary displacement of the extensor pollicis longus tendon to the radial side of the metacarpal head where it acts as a deforming force. In his studies the ulnar collateral ligament remained intact but migrated toward the volar aspect of the joint, thus displacing the base of the proximal phalanx volarly and producing radial rotation of the thumb. Stener’ (1962) emphasized the frequency of rupture of the ulnar collateral ligament at its distal attachment with interposition of the adductor aponeurosis between the torn end of the ligament and its site of attachment to the proximal phalanx. He describes the variations in pathology of this injury, and reports good results with early surgical repair in 34 patients. Kessler13 in 1963 stressed that late instability of the metacarpophalangeal joint of the thumb could be prevented by early diagnosis (aided by stress X-rays) and primary ligamentous repair. Coonrad and Goldners (1968) state that ulnar or radial subluxation injuries should be initially treated with immediate immobilization in a plaster cast for 4 weeks and that surgical repair should rarely be considered as initial pnmary treatment. Surgical treatment should be considered if there is pain and functional impairment after an adequate trial of immobilization in a plaster cast.
Our observations concur with Stener’s that tears of the ulnar collateral ligament occur most frequently at its distal attachment. We have excellent or good results in all 16 of the acutely operated cases in athletes and in 24 of the 25 chronic cases. It is our feeling that old injuries which require reconstruction for functional instability should have the adductor pollicis attachment advanced at the time of surgery. The mechanism of injury and resulting func-
ugure
impairment vary with the sport and specific position played by the athlete. In specific situations we feel that temporary taping and splinting may be utilized to allow
is the result if a torn ulnar collateral ligament goes unnoticed or is inadequately treated. In most sports, thumb-index pinch is a vital function for the athlete to perform
continued athletic participation without the final surgical result. The method of taping we use at the University of Virginia is illustrated in Figure 10. The metacarpophalangeal joint of the thumb is stabilized to the hand with the first strips of tape. Then the index finger is taped to the thumb, holding it in adduction, and to prevent abduction at the joint.
competitively.
tional
the
jeopardizing
SUMMARY
Injury to the ulnar collateral ligament of metacarpophalangeal joint of the thumb is frequent in competitive sports. All too often, especially in young, poorly supervised athletes, there is a tendency to either overthe
look or minimize this injury thumb-index pinch weakness and
Residual
instability
During the period from 1962 to 1972 at University of Virginia Hospital, there were 41 surgical repairs and reconstructions for ulnar collateral ligament injuries to the the
thumb in athletes In fourteen of the twentyfive chronic cases conservative treatment, consisting of four weeks of cast immobilization, failed. In all twenty-five of the chronic cases the patient requested reconstructive surgery because of functional instability, pain, or weakness of thumb-index pinch. The results obtained with surgical repair or reconstruction were good to excellent in 40 of our 41 1 patients. All patients who participated in team sports returned to competitive athletics at the same team position they played prior to their injury. Temporary splinting and taping may be used to allow continued athletic participation, if this is feasible in the particular athlete’s case, without seriously jeopardizing the final surgical result. The mechanism of injury, diagnosis, indications for surgery, and a means of surgical repair are descnbed. References EB. Functional and Surgical Anatomy of the Hand Philadelphia, J. B. Lippin-
1
Kaplan
2
Stener B collateral
cott Co , 1953 Displacement of the ruptured ulnar ligament of the metacarpophalan-
geal joint anatomical
of the thumb A clinical and . study. J Bone Joint Surg, 44-B
869-879, 1962 3.
Moberg E,
Stener B Injuries to the ligaments of the thumb and fingers Diagnosis, treatment and prognosis Acta Chir Scand, 106
4
Strandell G Total Rupture of the Ulnar Collateral Ligament of the Metacarpophalangeal Joint of the Thumb Results of Surgery in 35 Cases Acta Chir Scand, 118
166-186, 1953
72-80, 1959 5. Bunnell S
Surgery of the Hand Ed. 4, J B Lippincott Co , 1964 Coonrad RW, Goldner JL A Study of the Pathological Findings and Treatment in SoftTissue Injury of the Thumb Metacarpophalangeal Joint With a Clinical Study of the Normal Range of Motion in One Thousand Thumbs and a Study of Post Mortem
Philadelphia,
6.
10-A method
of taping the thumb and hand with ulnar collateral ligament injury.
an
79
Findings of Ligamentous Structures in Relation to Function. J Bone and Joint Surg, 50-A: 439-451, Apnl 1968. 7. Neviaser RJ, Wilson JN, Lievano A. Rupture of the Ulnar Collateral Ligament of the Thumb (Gamekeeper’s Thumb). Correction by Dynamic Repair. J. Bone and Joint Surg, 53-A 1357-1364, Oct., 1971. 8. Watson-Jones R: Fractures and Joint Injuries. Ed. 3, Edinburgh and London, E. and S. Livingstone, 1955. 9. Frykman G, Johansson O: Surgical Repair of Rupture of the Ulnar Collateral Ligament of the Metacarpophalangeal Joint of the Thumb. Acta Chir Scand, 112: 58-64, 1956. Low Back
Pain/Ferguson-Editorial
Continued
from
10. Wosmk H: Die Geschlossenen Bandverletzungen des Daumengrundgelenks. Hefte zur Unfallheilkundr, 56 45 47, 1958. 11. Kaplan EB. Lateral Subluxation of the Metacarpophalangeal Joint of the Thumb: Experimental Study. Bull Hosp Joint Dis, 21:
200-205, 1960. 12.
EB: The Pathology and Treatment of Radial Subluxation of the Thumb with Ulnar Displacement of the Head of the First Metacarpal. J Bone and Joint Surg, 43-A:
Kaplan
541-546, June 1961. 13. Kessler I. Chronic Subluxation of the Metacarpophalangeal Joint of the Thumb. J Bone and Joint Surg, 45-B . 805, Nov. 1963.
Comment
page 69
logical studies (which could
thousands of laboring employees of an industrial plant. Standing films projected in the anteroposterior as well as lateral planes were projected along with routine obliques. There was no justified correlation between the presence of defects and complaints, disabilities, work restrictions, lost work time, or subsequent development of low back
It has not been my privilege to survey college athletes but in over twenty-five years of experience with professional football players plus a significant number of high school and college linemen and linebackers there has not been an impressive correlation of complaints with positive radiological findings. Past experiences have led me to the belief that given a negative history of back pain in spite of positive radiological evidence along the lines of the subject in question we do not reject an athlete unless there is substantive evidence of significant vertebral body changes or slippage. If we find such our experience has been that the history has
problems.
been falsified.
not be afforded) that proper conditioning played the significant role in alleviation of signs and symptoms. That the treatment was empiric is not denied. Furthermore, well over fifteen or even twenty years ago the undersigned was a
participant
80
in
a
study encompassing
many
