Outcomes After Injury to the Thumb Ulnar Collateral Ligament

A Systematic Review

Julie Balch Samora, MD, PhD; Joshua D. Harris, MD; Michael J. Griesser, MD; Michael E. Ruff, MD; Hisham M. Awan, MD

Disclosures

Clin J Sport Med. 2013;23(4):247-254. 

In This Article

Abstract and Introduction

Abstract

Objectives: Rupture of the ulnar collateral ligament (UCL) is a frequent injury of the hand. When untreated, this injury may lead to decreased pinch strength, pain, instability, and osteoarthritis. There is currently no consensus on treatment of acute or chronic UCL injuries. Our primary purpose was to compare nonoperative treatment with surgical repair and surgical reconstruction of thumb UCL injuries. A secondary purpose was to compare graft choice and surgical technique for reconstruction.

Data Sources: A systematic review of multiple medical databases was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines with specific inclusion and exclusion criteria. Clinical outcome studies after nonoperative or operative treatment of thumb UCL injuries, with a minimum of 2 years mean follow-up, were included. Pain, range of motion, key-pinch strength, and stability testing were used as outcome measures.

Main Results: Fourteen articles were included and analyzed (293 thumbs). All but 2 were level IV evidence. Mean Quality Appraisal Tool score was 13.1 (55% overall rating study methodological quality). Thirty-two thumbs were treated nonoperatively and 261 operatively. Mean subject age was 33.9 years. There were 200 acute injuries and 93 chronic injuries. Mean study follow-up was 42.8 months. Nonoperative treatment often failed, necessitating surgery. Acute UCL repair and autograft UCL reconstruction for chronic injury led to excellent clinical outcomes, without a significant difference between the 2 groups. After significant delay to treatment or even failed nonoperative treatment, excellent clinical outcomes can be achieved, without a difference between initially treating the injury surgically. Complications after surgery were rare.

Conclusions: This review has demonstrated excellent clinical outcomes after surgical treatment of both acute and chronic UCL injury, without any significant difference between repair and reconstruction for acute and chronic injury, respectively.

Introduction

Rupture of the thumb ulnar collateral ligament (UCL) is a frequent injury of the hand, commonly caused by sports injuries and falls onto an outstretched hand.[1–5] The mechanism of injury usually involves hyperabduction or hyperextension of the metacarpophalangeal (MP) joint of the thumb.[6] Disruption of the UCL leads to decreased pinch strength, pain, instability, and ultimately osteoarthritis. Some injuries can be associated with a Stener lesion, which is displacement of the ruptured ligament proximal to the adductor aponeurosis, effectively precluding healing without operative treatment.[6]

Acute injuries can be treated with immobilization or surgically with direct repair using bone anchors, direct repair using bone tunnels and pullout sutures, or tension band fixation of bony avulsions.[7–9] If an injury is chronic, there are several operative treatment options, including ligament reconstruction with tendinous autograft or allograft, bone–soft tissue–bone autograft, or even fusion of the MP joint.[10–12]

The evidence regarding operative and nonoperative treatments of acute and chronic thumb UCL insufficiency is primarily limited to level IV retrospective case series and level V expert opinion. Therefore, the purpose of this systematic review is to combine patient outcomes from multiple unique studies and analyze the results of treatment of thumb UCL injury to determine the following:

  1. Whether a difference in clinical outcome exists between operative and nonoperative management of thumb UCL acute injuries;

  2. Whether a difference in clinical outcome exists between operative and nonoperative management of thumb UCL chronic injuries;

  3. Whether a difference in clinical outcome exists between repair and reconstruction of the thumb UCL for acute (less than 3 weeks) UCL injury;

  4. Whether a difference in clinical outcome exists between repair and reconstruction of the thumb UCL for chronic (more than 3 weeks) UCL injury;

  5. Whether a difference in clinical outcome after reconstruction of the thumb UCL exists between different choices of graft;

  6. Whether a difference in clinical outcome after operative treatment exists between acute and chronic UCL injuries.

The authors hypothesized that no difference exists in clinical outcomes between repair and reconstruction for acute UCL injury. However, thumb UCL reconstruction was hypothesized to be significantly better than repair for chronic UCL injury. In addition, operative management was hypothesized to result in greater patient satisfaction versus nonoperative treatment. It was hypothesized that no difference exists between different types of grafts used for thumb UCL reconstruction. It was hypothesized that surgical management results in equivalent outcomes for both acute and chronic UCL injury.

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