Bone-retinaculum-bone reconstruction for chronic posttraumatic instability of the metacarpophalangeal joint of the thumb

PURPOSE: This study presents an autograft technique for the surgical management of chronic posttraumatic instability of the thumb metacarpophalangeal (MCP) joint by using a bone-retinaculum-bone graft from the second compartment of the extensor retinaculum. METHODS: The bone-retinaculum-bone graft was harvested from the second compartment. The graft ends were fixed into the host site with screws. Fourteen patients (12 ulnar, 2 radial collateral ligament tears) had the procedure. All patients were reviewed by an independent observer using objective and subjective criteria, the mean follow-up time was 20 months. RESULTS: Results were satisfactory overall (8 excellent, 4 good, 1 fair, 1 poor that subsequently was fused). All patients returned to their former jobs. All but one had a clinically stable first MCP joint; grasp was 87%, pinch was 80%, MCP joint range of motion (ROM) was 91%, and interphalangeal joint ROM was 98% of the unoperated side. CONCLUSIONS: Early results are encouraging. This procedure preserves ROM of the MCP and interphalangeal joints of the thumb, improves strength, and gives the stability required for proper thumb function.     

Treatment of chronic injuries of the ulnar collateral ligament of the thumb using a free tendon graft and bone suture anchors

We report the results of a simple technique, using bone suture anchors and free tendon graft, for the reconstruction of chronic injuries of the ulnar collateral ligament complex at the thumb metacarpophalangeal (MP) joint. Our series includes 20 patients, with a mean age of 29 years. The mean follow-up period was 42 months. Using the Glickel grading system, 14 patients had excellent results and six had good results. Seventeen patients had no pain and three complained of mild pain with weather changes. Fourteen patients regained full stability of the MP joint and six had mild laxity. The mean loss of pinch strength was 18% compared with the contralateral thumb. The mean loss of motion at the metacarpophalangeal joint was 21%.     

Free tendon grafting to repair the metacarpophalangeal joint of the thumb. Surgical techniques and a review of 70 patients

We report the use of a free tendon graft in 70 patients to repair lesions of the capsuloligamentous complex of the metacarpophalangeal joint of the thumb. Of these 37 had a lesion of the ulnar collateral ligament, 18 of the radial collateral and 11 of the volar plate. Four patients had combined lesions. We outline our techniques and review 51 of the patients. Of those 47 (92%) were satisfied, and all but one had regained full stability. Pinch grip strength was normal in 48. About one-third of the patients had some loss of flexion/extension; this was seldom noticed by the patients and caused no significant disability. Free tendon graft reconstruction is indicated for severe fresh lesions, for old lesions with chronic disability and for lesions which have not responded to conservative management.     

微型骨锚一期重建急性拇指掌指关节尺侧副韧带损伤

目的 评估应用微型骨锚对急性拇指掌指关节尺侧副韧带损伤进行手术修补的临床疗效.方法 2004年7月至2009年5月,对11例急性拇指掌指关节尺侧副韧带完全损伤的患者,采用Mitek micro微型带线骨锚一期植入第一掌骨头或拇指近节指骨基底侧方尺侧副韧带断裂的附着处,用锚尾部的缝合线缝合撕脱的侧副韧带重建起止点.结果 术后随访6个月至4年,平均2.4年.按Saetta标准评定:优7例,良3例,可1例;优良率为90.9%.X线片显示骨锚未见松动、脱落.结论 应用骨锚对急性拇指掌指关节尺侧副韧带损伤进行手术修补不仅操作简便,而且容易掌握,疗效可靠.     

Ultrasonography may be misleading in the diagnosis of ruptured and dislocated ulnar collateral ligaments of the thumb.

To find out if a non-invasive technique (ultrasonography) was able to identify a dislocated ligament of a metacarpophalangeal joint of the thumb with instability of the ulnar collateral ligament, 14 consecutive patients with clinical rupture of the ulnar collateral ligament were examined with ultrasonography before the ligament was explored. At exploration all ligaments were ruptured, and only five out of the 14 were dislocated. Ultrasonography recognised only two of the dislocated ligaments, and in half of the 14 patients the ultrasound scan gave incorrect information about the position of the ligament. We conclude that ultrasonography is not adequate for identifying dislocated ulnar collateral ligaments of the metacarpophalangeal joint of the thumb, and exploration is indicated in those with clinical instability in which palpation either suggests a dislocated ligament or is inconclusive.     

Thumb metacarpophalangeal joint ulnar collateral ligament reconstruction using a tendon graft

Chronic instability of the ulnar collateral ligament of the metacarpophalangeal joint of the thumb can cause significant functional disability due to pain and weakness of pinch and grasp. In the absence of adequate ligament to repair, stability of the joint can be restored by reconstruction using a free tendon graft. The technique described here routes the tendon graft through two holes in the proximal phalangeal base and one hole in the metacarpal neck in a triangular configuration, which recapitulates the normal anatomy of the ulnar collateral ligament. The results of reconstruction are good. Stability and strength are restored without sacrificing significant range of motion and with minimal donor site morbidity.     

Treatment of "Gamekeeper's Thumb" by reconstruction of the ulnar collateral ligament

This study examines the treatment of 22 thumbs with symptomatic laxity of the ulnar collateral ligament of the metacarpophalangeal joint by ligament reconstruction 1 week to 10 years after injury. The existing ligament remnants were repaired in 13 thumbs and were re-attached to bone, using a bone anchor, in seven cases. Two ligaments were reconstructed using the extensor pollicis brevis tendon. Patients were reviewed at a mean of 16 months. Functional stability was regained in all patients, but two thumbs had ongoing pain in the metacarpophalangeal joint. All but one patient returned to their original work and recreational pastimes. This study suggests that ligament reconstruction for chronic laxity of the ulnar collateral ligament is likely to achieve painless stability of the metacarpophalangeal joint even when reconstruction is delayed. This makes joint fusion unnecessary in most instances.     

An uncommon injury of the thumb

Ulnar collateral ligament rupture of the thumb is a relatively common injury that is often missed in the emergency department. This in combination with an interphalangeal joint dislocation of the ipsilateral thumb is rare and we report such a case. The importance of looking specifically for an associated ulnar collateral ligament laxity in any injury to the thumb is highlighted. The force producing a combination of ulnar collateral ligament rupture with ipsilateral simultaneous injury to the thumb is often severe enough to cause complete rupture of the ligament, necessitating open repair.     

ULTRASONOGRAPHY MAY BE MISLEADING IN THE DIAGNOSIS OF RUPTURED AND DISLOCATED ULNAR COLLATERAL LIGAMENTS OF THE THUMB

To find out if a non-invasive technique (ultrasonography) was able to identify a dislocated ligament of a metacarpophalangeal joint of the thumb with instability of the ulnar collateral ligament, 14 consecutive patients with clinical rupture of the ulnar collateral ligament were examined with ultrasono-­graphy before the ligament was explored. At exploration all ligaments were ruptured, and only five out of the 14 were dislocated. Ultrasonography recognised only two of the dislocated ligaments, and in half of the 14 patients the ultrasound scan gave incorrect information about the position of the ligament. We conclude that ultrasonography is not adequate for identifying dislocated ulnar collateral ligaments of the metacarpophalangeal joint of the thumb, and exploration is indicated in those with clinical instability in which palpation either suggests a dislocated ligament or is inconclusive.     

Collateral ligament injuries of the thumb metacarpophalangeal joint

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

单孔微型钢板内固定治疗第1掌指关节侧副韧带损伤伴骨折

目的:探讨应用单孔微型钢板内固定治疗第1掌指关节侧副韧带损伤伴骨折的临床效果。方法:应用单孔微型钢板内固定治疗第1掌指关节侧副韧带损伤伴骨折共22例,男16例,女6例;年龄18～53岁,平均28.5岁。受伤至手术时间2 h～2个月,平均6 d.均为第1掌指关节侧副韧带损伤伴骨折,右手13例,左手9例。闭合伤18例,开放伤4例。新鲜损伤(<2周)18例,陈旧损伤(>2周)4例。拇指近节基底尺侧副韧带损伤伴骨折16例,桡侧副韧带损伤伴骨折6例,其中同时伴拇短展肌、拇短屈肌腱止点损伤4例。撕脱骨折块大小为3.0 mm×4.0 mm～6.0 mm×7.0 mm.结果:22例术后切口均Ⅰ期愈合,随访6个月～5年,平均2.5年。根据Saetta等疗效评定标准评价拇指功能,优20例,良2例。结论:应用单孔微型钢板内固定治疗第1掌指关节侧副韧带损伤伴骨折是一种行之有效的方法。     

Comparison of results after surgical repair of acute and chronic ulnar collateral ligament injury of the thumb

This study sought to demonstrate that successful outcomes can be achieved with the new technique presented here for chronic ulnar collateral ligament (UCL) injury of the thumb metacarpophalangeal (MCP) joint, as well as with K-wire pinning for acute UCL injury. We followed 19 patients who suffered an UCL rupture (mean follow-up: 14.26 ± 4.65 months) and 32 patients who presented with UCL avulsion fracture (mean follow-up: 16.81 ± 7.54 months). We used a free tendon graft for UCL reconstruction in the UCL rupture group. Both ends of the graft were stabilized with bioabsorbable suture anchors, which were used as biotenodesis interference screws. Closed reduction and K-wire fixation was used in UCL avulsion fracture group. There were no statistically significant differences between operated and contralateral healthy thumb MCP joint in both groups in the grip strength, tip pinch strength, flexion, extension, ulnar deviation, and radial deviation movements at final follow-up. Grip strength, tip pinch strength, ulnar deviation and radial deviation were significantly better in the avulsion group than the rupture group. All patients regained full stability at the MCP joint in avulsion group; 16 patients regained full stability and 3 patients presented with mild laxity (less than 10° laxity) in rupture group. Glickel grading scale used as a functional score was excellent for 30 patients and good for 2 patients in avulsion group; it was excellent for 17 patients and good for 2 patients in rupture group. Our study shows that closed reduction and percutaneous K-wire fixation of acute displaced large UCL avulsion fracture is a simple technique and achieves adequate stability of UCL. For UCL rupture, free tendon reconstruction with bioabsorbable suture anchors provides adequate stability and stable fixation within the tunnels.     

Ultrasonographic stress test of the metacarpophalangeal joint of the thumb

The purpose of this study was to evaluate functional ultrasound as a tool for detecting an ulnar collateral ligament injury of the thumb. The feasability of using ultrasound for imaging the thumb joint space was tested in a pilot study, using ultrasound and dissection in 14 cadaveric hand specimens. To test this method clinically, both metacarpophalangeal joints of the thumb in 461 healthy volunteers were examined using ultrasound (11 MHz) under radial stress. The distance between the innominate tubercle of the first metacarpal head to the proximal phalanx was measured. The mean distance between the first metacarpal head and the proximal phalanx (n = 461) was 4.5 mm (standard deviation, 0.65 mm) on the right side and 4.6 mm (standard deviation, 0.61 mm) on the left side. These data were compared with data of 25 patients with an operative diagnosis of rupture of the ulnar collateral ligament of the thumb. The difference in joint space between the injured and uninjured sides was 2.25 mm (standard deviation, 0.46 mm). The metacarpophalangeal joint space can be reproducibly detected on high-frequency ultrasound. An increased gap seen on ultrasound is indicative of a rupture of the ulnar collateral ligament of the thumb.     

Rupture of the radial collateral ligament of a metacarpophalangeal joint to one of the ulnar three fingers.

In six patients rupture of the radial collateral ligament of the metacarpophalangeal joint of one of the three ulnar fingers, surgical reconstruction was successful using local tissues in five and a tendon graft in one. Operative treatment of this injury is indicated only when significant instability is present.     

Injuries to the Ulnar Collateral Ligament of the Thumb Metacarpophalangeal Joint

Injuries to the ulnar collateral ligament of the metacarpophalangeal (MCP) joint of the thumb are relatively common. When an incomplete rupture is present, valgus stress testing with the MCP joint positioned in extension reveals minimal or no instability (less than 30 degrees of laxity or less than 15 degrees more laxity than in the noninjured thumb). When a complete rupture is present, valgus stress testing with the MCP joint positioned in extension reveals marked laxity (more than 30 degrees or more than 15 degrees more laxity than in the noninjured thumb). In this instance, displacement of the ligament proximal and superficial to the adductor aponeurosis, which is often termed a Stener lesion, is likely. Partial ligament injuries in which the ligament is not displaced may be treated nonoperatively. When a Stener lesion is present, however, primary ligament healing cannot occur without operative management. Whether treatment should be operative or nonperative can generally be decided on the basis of the findings from the history, the radiographs, and the physical examination, which should include valgus stress testing.     

Reconstruction of the rheumatoid thumb.

Most rheumatoid patients will present with one or more thumb deformities at some stage of their clinical history. The goal of treatment is restoration and maintenance of stable and painless motion. Treatment is based on the type and stage of the deformity. The boutonniere thumb is the most common deformity. Metacarpophalangeal arthrodesis is preferred for isolated metacarpophalangeal involvement. For advanced cases in a low-demand patient, metacarpophalangeal arthroplasty with interphalangeal arthrodesis is performed. In the higher demand hand with an uninvolved carpometacarpal joint, arthrodesis of both metacarpophalangeal and interphalangeal joints may be considered. The less common swan neck is approached by treating the carpometacarpal joint with a hemiarthroplasty or a total resection with capsulodesis or arthrodesis of the metacarpophalangeal joint. Adduction contracture is treated by Z-plasty of the skin of the first web space and release of the adductor aponeurosis. Gamekeeper's deformity is treated with reconstruction of the ulnar collateral ligament. Arthrodesis is recommended for those patients with articular erosion of the metacarpophalangeal joint. Flexor pollicis longus and extensor pollicis longus tendon ruptures are common in rheumatoid patients. Extensor pollicis longus ruptures are usually treated with EIP transfer or observation. Flexor pollicis longus ruptures are more disabling and usually require a tendon transfer, tendon graft, or an interphalangeal joint fusion in patients with radiographic destruction of that joint.     

Fractures of the sesamoid bones of the thumb

Sesamoid fractures of the metacarpophalangeal joint of the thumb may be classified into two types: (1) with palmar plate intact, and (2) with palmar plate ruptured. In type 1, the patient maintains a normal flexion posture of the metacarpophalangeal joint as well as the ability to flex the metacarpophalangeal joint and interphalangeal joint. In type 2, the metacarpophalangeal joint assumes a hyperextension posture and the patient is unable to flex the metacarpophalangeal joint. Three cases are described to illustrate the two types of the injury. An open fracture of a thumb sesamoid associated with laceration of the palmar plate in a child was treated by reapproximating the palmar plate and the fracture fragments with sutures. Two additional closed fractures of the thumb sesamoid were treated by splinting the metacarpophalangeal joint in comfortable flexion for 2 to 3 weeks. Normal hand function was restored in all the three patients.     

Combined reconstruction of volar and radial instability of a thumb metacarpo-phalangeal joint

The purpose of this paper is to present a case of the combined volar and radial ligament instability of a thumb metacarpophalangeal joint secondary to trauma. A successful reconstruction of the volar capsule and the radial collateral ligament was achieved using the tendon of the extensor pollicis brevis.     

Rupture of the radial collateral ligament of the fifth metacarpophalangeal joint

Isolated rupture of the radial collateral ligament of the metacarpophalangeal joint of the fifth digit is a rare but disabling injury. Treatment is complicated by the influence of the hypothenar musculature, which deviates toward the ulna and flexes the digit. We have managed two cases, one chronic and one acute, by open reduction and repair. Both cases demonstrated distraction of the collateral ligament ends by the extensor sagittal band. This operative finding is not too dissimilar from the interposition of the adductor pollicis tendon between the ends of a ruptured ulnar collateral ligament in a gamekeeper's thumb injury. Because of this finding, we believe that open reduction and repair of a ruptured radial collateral ligament of the metacarpophalangeal joint of the fifth digit is indicated.     

Radial collateral ligament injury of the thumb with a Stener-like lesion

The original Stener lesion, described in 1962, refers to an ulnar collateral ligament tear of the thumb metacarpophalangeal joint with adductor aponeurosis interposition. The adductor aponeurosis serves as a mechanical block to healing by preventing apposition of the torn ends of the ulnar collateral ligament. This article presents a case of a 27-year-old woman with painful swelling of the thumb metacarpophalangeal joint following a car accident. Complete tear of the radial collateral ligament was diagnosed based on physical and radiographic examinations. Radial collateral ligament injuries are reported to be less common than ulnar collateral ligament injuries, and, in the past, radial collateral ligament tears were thought to be innocuous, requiring little intervention. More recently, the significance of these injuries has been well documented, and there is support for acute surgical management of complete radial collateral ligament tears. During surgical intervention in our case, we found an intrasubstance tear of the radial collateral ligament with the proximal portion of the ligament retracted and lying superficial to the abductor aponeurosis, thereby producing a Stener-like lesion on the radial side of the joint. The incidence of a Stener-like lesion to the radial collateral ligament is unknown, but it has only been reported once in the literature. Although a primary radial collateral ligament tear may heal by soft tissue apposition, we felt that conservative management in our patient would unlikely lead to healing due to interposition of the abductor aponeurosis. This case supports current recommendations for surgical intervention of complete radial collateral ligament injuries due to the possibility of a Stener-like lesion with soft tissue interposition recurring in the future.