Introduction
- Mohamed Khalid, MD, MCh, FRCS
Epidemiology
Age
- •
40 years (average)
Sex
- •
Male : female ratio: 3 : 2
Sports
- •
Skiing, snowboarding, ball-handling sports, hockey, cycling, wrestling, break dancing
- •
The incidence is 3% of all skiing injuries. The most common injuries resulting from skiing are knee injuries (medial collateral ligament sprain, anterior cruciate ligament damage, and meniscal injury) 30% to 40%; and shoulder girdle injuries (dislocation of shoulder and acromioclavicular joints, fracture of clavicle, humerus, and wrist) 25% to 30%; followed by ankle sprains 17%; and head injuries 10% to 15%
Position
- •
Sudden forced radial deviation (abduction)
Pathophysiology
Intrinsic Factors
- •
Anatomical: The shallow articulating surfaces of the thumb metacarpophalangeal (MCP) joint provide very little inherent stability.
- •
For its stability the MCP joint relies on muscles (adductor pollicis), static ligaments such as the ulnar collateral ligament, accessory collateral ligament, and volar plate ( Figures 17-1 and 17-2 ). The proper ulnar collateral ligament runs from the head of metacarpal to volar surface of the base of proximal phalanx. It is the primary restraint to an abduction force to the MCP joint and tightens in flexion and relaxes in extension. The accessory ulnar collateral ligament also provides stability to the ulnar aspect of the MCP joint and tightens in extension and relaxes in extension.
FIGURE 17-1
Stabilizers of the metacarpophalangeal joint of the thumb.
FIGURE 17-2
The proper ulnar collateral ligament runs from the head of metacarpal to volar surface of the base of proximal phalanx. It is the primary restraint to an abduction force to the MCPJ and tightens in flexion and relaxes in extension. The accessory ulnar collateral ligament also provides stability to the ulnar aspect of the MCPJ and tightens in extension and relaxes in extension.
(Redrawn from Hand Clinics 25(3):437–442, 2009.)
- •
The ulnar collateral ligament is the key stabilizer of the thumb MCP joint.
Extrinsic Factors
- •
Improper use of ski pole straps ( Figure 17-3 A,B )
FIGURE 17-3
Proper (A) and improper (B) use of ski pole straps.
Traumatic Factors
- •
The mechanism of the injury is forceful abduction of the thumb associated with striking the ground, striking the ski pole handle, or forced abduction of the thumb, which is caught in the ski pole strap.
- •
When a skier falls onto the hand the pole handle in the palm can act as a lever across the MCP joint and force it into abduction/radial deviation ( Figure 17-4 ).
FIGURE 17-4
Mechanism of injury resulting in ulnar collateral ligament damage.
Classic Pathological Findings
- •
Strain, partial tears, or complete rupture of ulnar collateral ligament
- •
The tear is most often at the distal attachment. Ruptures within the substance of the ligament or avulsion of the ligament from the metacarpal ligament can also occur.
- •
Associated lesions might include injury to dorsal capsule, a rent in adductor aponeurosis, extensor expansion, volar plate or avulsion fracture.
Clinical Presentation
History
- •
History of combined hyperextension and forced abduction to the thumb
- •
Acutely painful MCP joint and swelling
Physical Examination
Abnormal Findings
- •
Tenderness, ecchymosis, and swelling along the ulnar border of MCP joint
- •
Laxity in excess of 35° and/or 15° greater than the contralateral thumb on valgus stress testing ( Figure 17-5 )
FIGURE 17-5
Unstable thumb following an ulnar collateral ligament injury.
- •
A weak pincer grip
Pertinent Normal Findings
- •
No tenderness over the radial border of the thumb (vs. radial collateral ligament injury, MCP joint dislocation)
- •
No increased warmth (vs. septic or crystal arthropathy)
Imaging
- •
Plain radiographs, including stress views
- •
Ultrasonography
- •
Magnetic resonance imaging
Differential Diagnosis
- •
MCP joint dislocation
- •
Peri-articular fractures around the MCP joint
Treatment
Nonoperative Management
- •
Rest, ice, compression, and elevation (RICE)
- •
Splinting, functional versus rigid
- •
Casting in a thumb spica
Guidelines for Choosing Among Nonoperative Treatments
- •
Presence of an end point to valgus stress
- •
Absence of a Stener lesion. A Stener lesion is avulsion of the distal attachment of the ulnar collateral ligament with interposition of the adductor aponeurosis between the avulsed ligament and its site of original attachment to the base of the proximal phalanx ( Figure 17-6 ).
FIGURE 17-6
Stener lesion.
- •
Absence of displaced fractures
Surgical Indications
Absolute Indications
- •
Complete avulsion with interposition of adductor aponeurosis (Stener lesion)
- •
Displaced (greater than 2 mm) avulsion fractures (ulnar base of the proximal phalanx, metacarpal head, and shearing fractures of the volar surface of the radial condyle of the metacarpal head) ( Figure 17-7 )
FIGURE 17-7
Displaced avulsion fracture.
Relative Indication
- •
Minimally displaced intraarticular avulsion fracture
Aspects of History, Demographics, or Exam Findings That Affect Choice of Treatment
- •
Weak pincer grip
- •
Lack of end point on abduction stressing
Aspects of Clinical Decision Making When Surgery Is Indicated
- •
Complete versus incomplete rupture/strain (definite end point or not on abduction stressing
- •
30° laxity of the ulnar side of the joint when stressed radially in extension and 40° of flexion (the latter is more reliable)
- •
15° more laxity compared with contralateral thumb
- •
Presence of a Stener lesion
- •
Presence of a palpable “tumor” (mass) at the level of UCL just proximal to the MCP joint
- •
Retracted ligament on ultrasonography or MRI
- •
Greater than 2 mm displacement of fracture
- •
Joint incongruity
- •
Rotated fragment
Evidence
Multiple Choice Questions
- QUESTION 1.
Thumb ulnar collateral ligament injury is common in all the following injuries except
- A.
skiing.
- B.
break dancing.
- C.
netball.
- D.
table tennis.
- A.
- QUESTION 2.
Ulnar collateral ligament injuries constitute what percentage of all skiing injuries?
- A.
5%
- B.
3%
- C.
40%
- D.
8%
- A.
- QUESTION 3.
Stabilizers of thumb MCP joint include all of the following except
- A.
adductor pollicis.
- B.
abductor pollicis.
- C.
ulnar collateral ligament.
- D.
volar plate.
- A.
- QUESTION 4.
The ulnar collateral ligament commonly avulses off of what attachment?
- A.
Distal
- B.
Midsubstance
- C.
Proximal
- D.
b+c
- A.
- QUESTION 5.
The most sensitive and specific modality of diagnosing an unstable UCL injury is
- A.
history.
- B.
clinical examination.
- C.
ultrasonography.
- D.
MRI.
- A.
Answer Key
- QUESTION 1.
Correct answer: D (see Epidemiology)
- QUESTION 2.
Correct answer: B (see Epidemiology)
- QUESTION 3.
Correct answer: B (see Anatomy)
- QUESTION 4.
Correct answer: A (see Pathological findings)
- QUESTION 5.
Correct answer: D (see Evidence)
Nonoperative Rehabilitation of Thumb Ulnar Collateral Ligament Injuries
- Mohamed Khalid, MD, MCh, FRCS
- Bradley Kent Earnest, OTR/L, CHT
- Mark Simenson, OTR/L, CHT
- Bradley Kent Earnest, OTR/L, CHT
- •
Protect
- •
Monitor pain, edema, and range of motion
- •
Maximizing strength and activities of daily living (ADLs) independence
Phase I (weeks 0 to 4)
Protection
- •
Hand-based IP free thumb spica splint with no more than 30° of abduction ( Figure 17-8 ).
FIGURE 17-8
Static hand-based splint.
| PHASE I (weeks 1 to 4) | PHASE II (weeks 4 to 6) | PHASE III (weeks 6 to 10) | PHASE IV (weeks 10 to 12) |
|---|---|---|---|
|
|
|
|
Management of Pain and Swelling
- •
Compression
- •
Ice
- •
Elevation
Techniques for Progressive Increase in Range of Motion
Stretching and Flexibility Techniques for the Musculotendinous Unit
- •
Allow active flexion/extension of thumb MP joint (10 reps, three times per day) but no opposition movements at this time.
Functional Exercises
- •
Gentle/light hygiene (avoid radial MP joint stress)
Milestones for Progression to the Next Phase
- •
Decreased pain per patient report
- •
Decreased tenderness to palpation and edema
- •
Increased stability (within 15 degrees radial deviation (MP joint) of noninjured thumb
- •
If not progressing continue phase I for 2 more weeks and if criteria is still not met refer back to MD for further evaluation
Phase II (weeks 4 to 6)
Protection
- •
Continue splinting with heavy use and while sleeping.
- •
Splint may be removed for light ADL (2 lb or less).
Management of Pain and Swelling
- •
Continue as for Phase I.
- •
Retrograde massage may be added if needed for edema.
Techniques for Progressive Increase in Range of Motion
Manual Therapy Technique
- •
Retrograde massage
Stretching and Flexibility Techniques for the Musculotendinous Unit
- •
Continue with active MP joint flexion and extension exercises as in Phase I.
- •
Active opposition added to treatment and home program
Other Therapeutic Exercises
- •
ADL (2 lb or less) with splint removed
Activation of Primary Muscles Involved
- •
Same as for Phase I
Functional Exercises
- •
ADL (2 lb or less) with splint removed
Milestones for Progression to the Next Phase
- •
Pain at rest 0/10. Pain/tenderness 2/10 or less with palpation over UCL and with gentle use.
- •
MP joint stable with flexion, extension, and active opposition
Phase III (weeks 6 to 10)
Protection
- •
Wean from splint for ADL and nighttime use. Continue splinting with heavy use.
Management of Pain and Swelling
- •
Continue with ice, retrograde massage, and compression.
- •
Modalities such as ultrasound and neuromuscular electrical stimulation (NMES) may be added.
Techniques for Progressive Increase in Range of Motion
Manual Therapy Techniques
- •
Joint mobilization and passive range of motion initiated to MP joint
Soft Tissue Techniques
- •
Scar massage initiated over UCL for internal scarring management
Stretching and Flexibility Techniques for the Musculotendinous Unit
- •
Initiate place and hold exercises in MP flexion, extension and opposition.
Other Therapeutic Exercises
- •
If UCL is stable and pain free outside of splint with ADL then extra-soft (yellow) Theraputty exercises are initiated for flexion, extension and opposition.
Activation of Primary Muscles Involved
- •
Same as for Phase I
Techniques to Increase Muscle Strength, Power, and Endurance
- •
Yellow Theraputty activities of pinch and grip initiated three times per day for 5-minute sessions.
Functional Exercises
- •
Resisted three-jaw chuck, palmar, and tip pinch initiated under therapist supervision.
Milestones for Progression to the Next Phase
- •
No tenderness to palpation over UCL ligament
- •
Minimal pain with activities outside of splint
Phase IV (weeks 10 to 12)
Protection
- •
Continue splinting with heavy use.
- •
Taping may be initiated for protection with sport related activities ( Figure 17-9 A-D ).
FIGURE 17-9
A–D, Taping for protection during sporting activity.
Management of Pain and Swelling
- •
Same as for Phase III
Techniques for Progressive Increase in Range of Motion
Manual Therapy Techniques
- •
Increase aggressiveness of joint mobilization and active/passive range of motion.
Soft Tissue Techniques
- •
Manual and vibration scar massage.
Stretching and Flexibility Techniques for the Musculotendinous Unit
- •
Dynamic splinting to increase MP joint flexion and thumb opposition ( Figure 17-10 ) as needed
FIGURE 17-10
Dynamic splinting.
Other Therapeutic Exercises
- •
Increase resistance grade of Theraputty
- •
Power web, upper body exerciser, and graded clothes pins
- •
NMES
Activation of Primary Muscles Involved
- •
Same as for Phase I
Techniques to Increase Muscle Strength, Power, and Endurance
- •
Same as above
Functional Exercises
- •
Use for all ADL outside of splint.
Sport-Specific Exercises
- •
Trainer input
Milestones for Progression to Advanced Sport-Specific Training and Conditioning
- •
No reported pain (rest/general use)
- •
UCL stability
- •
Functional pinch/grip strength
Criteria for Abandoning Nonoperative Treatment and Proceeding to Surgery or More Intensive Intervention
- •
Significant pain outside of splint
- •
Instability of UCL
- •
Stener lesion
Tips and Guidelines for Transitioning to Performance Enhancement
- •
Trainer input
Performance Enhancement and Beyond Rehabilitation: Training/Trainer and
- •
Trainer input
Optimization of Athletic Performance
- •
Trainer input
Evidence
Multiple Choice Questions
- QUESTION 1.
What splint would best protect the UCL in the first 4 weeks of injury?
- A.
Wrist cock-up
- B.
Hand base thumb spica
- C.
Neoprene thumb wrap
- D.
Mallet
- A.
- QUESTION 2.
What degree of thumb abduction is advised in the splint?
- A.
0
- B.
30
- C.
60
- D.
90
- A.
- QUESTION 3.
What active thumb motion is introduced in week 5?
- A.
Flexion
- B.
Extension
- C.
Adduction
- D.
Opposition
- A.
- QUESTION 4.
When are modalities (ultrasound/NMES) added to the treatment plan?
- A.
Phase I
- B.
Phase II
- C.
Phase III
- D.
Phase IV
- A.
- QUESTION 5.
What type of splint is added in Phase IV?
- A.
Dynamic
- B.
Static progressive
- C.
No splint
- D.
Silver ring
- A.
Answer Key
- QUESTION 1.
Correct answer: B (see Phase I)
- QUESTION 2.
Correct answer: B (see Phase I)
- QUESTION 3.
Correct answer: D (see Phase II)
- QUESTION 4.
Correct answer: C (see Phase III)
- QUESTION 5.
Correct answer: A (see Phase IV)
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