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Injuries to the Ulnar Collateral Ligament of the Thumb Metacarpophalangeal Joint

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Injuries to the Ulnar Collateral Ligament of the Thumb Metacarpophalangeal Joint Ballard Office 5350 Tallman Ave NW, Suite 500 Seattle, WA 98107 www.seattlehandandelbow.com Wallingford Office 2409 45th Street, Seattle, WA 98103 Injuries to the Ulnar Collateral Ligament of the Thumb Metacarpophalangeal Joint Philip Heyma n, MD Abstract ment, the palmar plate, and, to a limited extent, the dorsal capsule. Injuries to the ulnar collateral ligament of the metacarpophalangeal (MCP) Biomechanical and clinical studies joint of the thumb are relatively common. When an incomplete rupture is pres- have shown that each of these ent, valgus stress testing with the MCP joint positioned in extension reveals structures contributes to joint sta- minimal or no instability (less than 30 degrees of laxity or less than 15 degrees bility and that their contribution is more laxity than in the noninjured thumb). When a complete rupture is pres- dependent on the position of the ent, valgus stress testing with the MCP joint positioned in extension reveals MCP joint.2,3 In flexion, the taut marked laxity (more than 30 degrees or more than 15 degrees more laxity than proper collateral ligament, which in the noninjured thumb). In this instance, displacement of the ligament proxi- runs from the middle of the mal and superficial to the adductor aponeurosis, which is often termed a Stener metacarpal head to the palmar lesion, is likely. Partial ligament injuries in which the ligament is not displaced aspect of the proximal phalanx, is may be treated nonoperatively. When a Stener lesion is present, however, pri- the primary joint stabilizer (Fig. 1). mary ligament healing cannot occur without operative management. Whether Because of this configuration, it treatment should be operative or nonperative can generally be decided on the also prevents palmar subluxation basis of the findings from the history, the radiographs, and the physical exami- of the proximal phalanx. The dor- nation, which should include valgus stress testing. sal capsule is also taut in flexion; J Am Acad Orthop Surg 1997;5:224-229 however, it is relatively flimsy and thus much less important than the In 1955, Campbell1 described the can injure the ulnar collateral liga- proper collateral ligament in stabi- clinical signs and symptoms of ment. Because stability of the lizing the flexed joint. In addition, ulnar collateral ligament insuffi- thumb is important for prehension, because of its redundancy, the dor- ciency of the metacarpophalangeal treatment is directed toward opti- sal capsule does not play an im- (MCP) joint of the thumb, calling it mizing ligament healing in order to portant role in preventing palmar “gamekeeper’s thumb” because it restore full function. subluxation of the proximal pha- was a frequent occupational injury lanx. The accessory collateral liga- of Scottish gamekeepers. The term ment is palmar to and contiguous described a chronic attritional Anatomy and injury resulting in instability, Biomechanics accompanied by pain and weak- ness of pinch and grasp. The MCP joint is a diarthrodial Dr. Heyman is in private practice with Hand Today, the practicing ortho- joint that is primarily involved in Surgery Associates, PC, Denver. paedist usually sees valgus insta- flexion and extension, but which bility of the thumb MCP joint that also allows some rotation, abduc- Reprint requests: Dr. Heyman, Hand Surgery has been caused by an acute injury. tion, and adduction. Joint stability Associates, PC, Suite 500, Porter Medical Plaza, 2535 South Downing, Denver, CO is provided by static restraints and Because the injury is commonly 80210. caused by a skiing accident, it is dynamic stabilizers. now often referred to as “skier’s The static restraints of the MCP Copyright 1997 by the American Academy of thumb.” However, any severe val- joint are the proper collateral liga- Orthopaedic Surgeons. gus force on the abducted thumb ment, the accessory collateral liga- 224 Journal of the American Academy of Orthopaedic Surgeons Philip Heyma n, MD Accessory collateral ligament Proper collateral ligament Palmar ligaments Palmar ligaments Sesamoid bone Sesamoid bone Fig. 1 Left, In flexion, the proper collateral ligament and the dorsal capsule are tight. Right, In extension, the proper collateral ligament and the dorsal capsule are loose, and the accessory collateral ligament and palmar plate are tight. with the proper collateral liga- joint may hyperextend, or it may Pathologic Anatomy ment. It extends palmarward and lack full extension. The amount of attaches to the volar plate. valgus laxity is also variable in A wide spectrum of pathologic dis- In extension, the accessory col- normal thumbs. In full extension, orders have been reported after lateral ligament and the palmar valgus laxity averages 6 degrees. acute valgus injuries to the thumb plate are taut and are the primary Valgus laxity increases to an aver- MCP joint. There may be rupture joint stabilizers against valgus age of 12 degrees when the joint is of the dorsal capsule, adductor stress.2,3 When a traumatic valgus positioned in 15 degrees of flex- mechanism, and extensor pollicis force is applied to the thumb MCP ion.6,7 brevis.10 Anatomic, biomechanical, joint, the proper collateral liga- and clinical studies have shown ment, the accessory collateral liga- that when the injury is limited to ment, and the palmar plate provide Mechanism of Injury these structures, the thumb will be joint stability when the dynamic stable on valgus stress testing.3 stabilizers are overcome.2-4 Any extreme valgus stress to the More severe injuries involve rup- The dynamic stabilizers include thumb can result in ligamentous ture of the proper collateral liga- the thumb extrinsic muscles (exten- disruption. The most common ment. sor pollicis longus, extensor pollicis mechanism is a fall on the abduct- When the proper collateral liga- brevis, and flexor pollicis longus) ed thumb. In skiing, it has long ment is ruptured, instability will be and intrinsic muscles (abductor been thought that the ski pole plays present when the thumb is tested pollicis brevis, flexor pollicis bre- an important role in the pathogene- in flexion.4 When the accessory vis, and adductor pollicis). The sis of this injury. In the 1960s, most collateral ligament is also torn, the adductor mechanism is of particu- ski-pole handles had a strap that tear is considered complete, and lar importance as a dynamic stabi- passed between the thumb and the there is instability in extension as lizer.5 It inserts into the extensor index finger and wrapped around well as flexion.3 Rupture of the expansion through its aponeurosis, the wrist. With increased aware- ulnar collateral ligament is typical- which lies superficial to the joint ness of this injury, many new grip ly at its distal insertion site on the capsule and the ulnar collateral lig- designs were subsequently devel- base of the proximal phalanx. ament. The adductor also has a oped. These include strapless grips Occasionally, however, the rupture deep insertion into the palmar with molded hand pieces, with or is in the midsubstance or more aspect of the proximal phalanx by without a platform for the hand. proximal.4,6,9 way of the ulnar sesamoid. However, newer design modifica- Displacement of the distal end There is considerable variation tions have not had any detectable of the completely ruptured liga- in the range of flexion and exten- effect on preventing this injury.8 ment can occur such that it comes sion of the thumb MCP joint. Some have suggested that the ski to lie superficial and proximal to Some normal joints demonstrate as pole prevents adduction of the the adductor aponeurosis (Fig. 2). little as 5 degrees of motion, while thumb, which normally occurs dur- This pathologic entity was first others have a range of as much as ing a fall, thus making the thumb described by Stener in his classic 115 degrees.6,7 The normal MCP more exposed to injury.9 paper in 1962.4 There is general Vol 5, No 4, July/August 1997 225 Ulnar Collateral Ligament Injuries of the Thumb Ruptured collateral ligament Adductor aponeurosis Adductor aponeurosis (retracted) Fig. 2 Left, When a complete rupture of the ulnar collateral ligament is present, the distal end of the torn ligament is usually displaced proximal and superficial to the proximal edge of the intact adductor aponeurosis. Right, Division of the adductor aponeurosis is required for repair of the ligament. agreement that, due to the interpo- seen on the posteroanterior view, patients will usually demonstrate sition of the adductor aponeurosis, which is highly indicative of a com- guarding; therefore, local anesthet- these injuries do not heal with non- plete rupture. However, in most ic should be infiltrated into the operative treatment. Because the cases of partial or complete liga- ulnar aspect of the joint before proper collateral ligament is ment ruptures, plain films appear stress testing. Some authors sug- anatomically contiguous with the normal. gest a median and/or ulnar nerve accessory collateral ligament along block at the wrist to negate the sta- their common edge, isolated prop- bilizing effect of the intrinsic mus- er collateral ligament tears are pre- Evaluation cles.5 However, if pain is relieved vented from complete displace- by an injection into the joint alone, ment by the intact accessory collat- Patients with suspected ulnar col- these nerve blocks are not neces- eral ligament.3 lateral ligament injuries will pre- sary. Occasionally, radiographs will sent with a history of valgus injury The integrity of the proper col- show an avulsion fracture from the followed by pain and swelling on lateral ligament is then assessed by ulnar aspect of the base of the prox- the ulnar aspect of the MCP joint. carrying out valgus stress testing imal phalanx (Fig. 3). This frag- Ecchymosis is frequently seen as with the MCP joint in 30 degrees of ment may be a small fleck or may well.
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