Ulna collateral ligament

 

Definition

 

Injury to ulnar collateral ligament of thumb MCPJ

 

Interferes with pinch grip and grasp and thumb is ineffective as a post

 

Gamekeeper 2Gamekeeper 1

 

Aetiology

 

Valgus / forced abduction

 

10 x more common than injuries to radial collateral ligament

 

Gamekeeper's thumb's

- secondary to repetitive breaking pheasant's neck

- chronic injury

 

Skier's thumb

- acute injury

 

Anatomy

 

UCL anatomy

 

Ulna collateral ligament

 

Proper

- origin dorsal metacarpal head

- passes to volar aspect proximal phalanx

 

Accessory

- volar side of proper ligament

- attaches to volar plate

 

Adductor aponeurosis 

 

Superficial to ulna collateral ligament

- inserts into ulna border thumb extensor mechanism

- via the ulna sesamoid

 

Pathology

 

Stener lesion

- distal end of UCL flipped superficially over adductor aponeurosis

- will not heal

- may be able to palpate a lump

- use MRI to diagnose

 

Stener lesion

 

Examination

 

Gamekeepers

 

Painful, swollen MCPJ

 

Tenderness along UCL

 

Abduction Stress Test

 

Game exam

 

In full extension and 30° compared to other side

- increased opening at 30o - injury to ulna collateral ligament proper only

- increased opening at 30 and full extension - injury to both accessory and ulna collateral ligament

 

X-ray

 

Bony avulsion

 

1. Small fragment pulled away from proximal phalanx

 

Bony gamekeepersBony gamekeepers

 

2. Large intra-articular fracture involving >1/4 articular surface

 

Bony gamekeepers largeBony ORIF

 

3. Salter Harris III in pediatric population

 

MRI

 

Anatomy

 

MRI Anatomy

 

A.  Undisplaced

 

Game MRIGamekeepers MRI

Distal tear of ulna collateral ligament on coronal MRI

 

MRI gameMRI game

Distal tear of ulna collateral ligament on coronal MRI

 

B.  Displaced UCL

 

UCL dispUCL disp 2

Coronal MRI demonstrating displaced distal UCL avulsion

 

Management

 

Non operative

 

Indications

 

Partial tear

Undisplaced complete tear

Undisplaced bony fragment

 

Management

 

6/52 thumb spica

 

Operative

 

Indications for surgery

 

Stener lesion

Complete tear with displacement

Displaced bony fragment

Salter Harris III

Chronic injury with instability

 

Acute injury

 

Results

 

Milner et al J Hand Surg Am 2015

- 43 cases acute UCL injury with MRI

- all partial tears / minimally displaced / displaced < 3 mm healed with immobilisation

- tears displaced > 3 mm failed immobilisation

 

Dar et al J Hand Surg Am 2021

- biomechanical study

- primary repair + suture tape augmentation > primary repair > ligament reconstruction

 

Gibbs et al Orthop J Sports Med 2020

- 18 thumbs in athletes

- primary repair of acute UCL injury augmented with suture tape

- average return to sport 5 weeks

 

Surgical technique

 

Gamekeepers repair

 

AO foundation surgical approach

 

Vumedi primary repair with suture anchor

 

Arthrex internal brace surgical technique PDF

 

Vumedi primary repair augmented with internal brace

 

Dorso-ulnar approach to the MCPJ of the thumb

- dorsal incision along ulna border MCPJ

- divide Adductor pollicis aponeurosis

- leave cuff for lateral repair

- identify UCL

 

Fixation options

- bony anchors for proximal or distal tears +/- internal brace

- direct repair of midsubstance +/- internal brace

- screw fixation of bony avulsions

 

Post operative management

- 6/52 thumb spica

 

Chronic Injuries

 

Options

 

Primary UCL repair +/- suture tape augmentation

Adductor advancement

Tendon reconstruction

MCPJ fusion

 

Results

 

Agout et al Ortho Traumatol Surg Res 2017

- 55 chronic injuries

- compared repair when able with reconstruction and fusion

- primary repair > fusion > reconstruction

 

Tendon reconstruction

 

UCL reconstructionUCL recon suture anchor

Figure 8 reconstruction                                         Single bundle reconstruction with suture tape augmentation

 

Graft options

- palmaris longus

- strip of FCR if palmaris absent

- fourth toe extensor tendon

 

Technique

- figure of 8 through drill holes

- suture anchor fixation +/- suture tape augmentation

 

Vumedi tendon reconstruction with suture anchors and suture tape augmentation

 

MCPJ fusion

 

Thumb fusion