Thumb Ulnar Collateral Ligament Tear Repair
Table of Contents
Ulnar collateral ligament (UCL) injuries of the thumb are among the most common injuries of the hand. Whether the injury is acute or chronic, a complete rupture of the ligament is usually managed with operative repair to restore thumb stability with pinch and grip, as well as to avoid arthritic changes. Here we present a patient who underwent UCL repair. We will discuss the natural history, preoperative care, intraoperative technique, and postoperative considerations.
Ulnar collateral ligament (UCL) injuries of the thumb occur when there is an excessive valgus or hyper-abducted force applied to the metacarpophalangeal (MCP) joint. Acute UCL injuries, also known as “skier’s thumb,” usually occur from a fall on an outstretched hand. The name skier’s thumb originated from when a skier fell while holding onto their ski poles. This nomenclature may be misleading because they are noted in multiple sporting activities such as basketball, hockey, football, etc. Furthermore, manual laborers are at risk for these types of injuries. Chronic injuries are more commonly associated with repetitive valgus stress to the UCL and are referred to as “Gamekeeper's thumb.” Any partial tear of the UCL is usually managed conservatively with a splint, whereas a complete tear is indicative of operative intervention. Suturing the torn ligament to its anatomical footprint successfully repairs the ligament and allows restoration of thumb stability.
A 35-year-old male patient presented to the clinic after a fall onto an outstretched hand resulting in forced hyperabduction of the thumb. The patient complained of swelling and pain of the thumb but no numbness.
There was swelling and bruising localized to the injured MCP joint, along with tenderness to palpation along the medial or ulnar side of the thumb MCP joint. The thumb was placed into extension with the application of a valgus force, and the patient exhibited a metacarpal-phalangeal deviation greater than 35 degrees, which is indicative of a complete UCL tear. However, in recent literature, Ritting et al. suggested that the absence of a firm endpoint on physical exam is more indicative of a complete tear.1 If the pain interferes with the quality of the physical exam, local lidocaine may be used. The patient also demonstrated a palpable mass along the medial side of the MCP, which is suggestive of a “Stener’s” lesion (which is representative of a retracted UCL). There was also mild weakness with thumb adduction due to significant pain, but there was no evidence of median or radial nerve injury and the radial pulses were intact.
The first step in evaluating a complete UCL tear is to obtain lateral and anteroposterior view radiographs of the first metacarpal. This is to rule out an avulsion fracture of the proximal phalanx base, which can be associated with UCL injuries.2 Furthermore, stress radiographs may be obtained, but there is a concern for further damaging the UCL so imaging is typically recommended before applying valgus stress on a suspected UCL injury. If an X-ray is inconclusive, alternative imaging modalities include ultrasound, CT, or MRI. MRIs have a 96–100% sensitivity and a 95–100% specificity when diagnosing UCL tears.3 This makes it one of the best imaging techniques to use, but due to its high cost and long waiting times, it may not always be as practical.
A complete tear of the UCL of the thumb can have long term complications without intervention. Patients may report chronic pain and instability in the MCP joint in addition to decreased grip and pinch strength. Furthermore, chronic MCP joint instability can result in osteoarthritis of the MCP as well.
Management of a UCL tear is dependent on whether the tear is complete or partial. Partial tears may be managed conservatively with a splint or cast immobilization. In a study by Landsman et al., 84% of patients treated with a splint after a partial tear for 8–12 weeks healed without significant instability, as opposed to 16% who needed further surgical intervention.4 Surgical repair is considered to be the gold standard for a complete tear of the UCL and has proven to be superior to conservative management such as splinting. Recent studies have shown that without operative intervention for a complete tear, there is an increased risk of instability of the MCP joint in addition to decreased pinch strength.5 However, one study showed promising results for treating an avulsion injury without instability on the exam with conservative management such as splinting, but any instability of the MCP warrants surgical intervention.4
Without surgical repair of a thumb UCL tear, a patient may experience thumb pain, weakness, instability, and osteoarthritis later. Grip and pinch strength is frequently used in occupational or activities of daily living, such as using tools or grabbing smaller objects in one’s typical environment.6 This makes operative repair pragmatic for any range of patients because any decrease in activities of daily living can affect one’s quality of life.
This is a 35-year-old patient who presented with a complete UCL tear of the right thumb. This patient underwent repair of the UCL with the use of a 3-0 suture anchor placed in the anatomical footprint. The author typically uses a “mini” anchor with either a 3-0 or 4-0 non-absorbable suture with a tapered needle placed at the volar base of the ulnar aspect of the proximal phalanx. The ligament was held down to the anatomical footprint and was subsequently repaired. The repair was subsequently augmented with a temporary 0.045 K-wire across the MCP joint to reinforce the UCL repair.
Application of a 0.045 K-wire was used prior to UCL repair to stabilize the MCP joint and protect the repair. The K-wire is left in place for 3–4 weeks, after which it will be subsequently removed in the office upon follow-up. In a prospective study conducted by Picard et al., they found that the application of a K-wire resulted in a decreased recovery time and an early return to work. However, it is significant to note that manual laborers were not included in this study.6 K-wire immobilization has proved to be effective in treating avulsion injuries, whereas free tendon reconstruction has been just as effective for UCL ruptures. Thus, it seems that the use of a K-wire depends on the type of UCL injury (avulsion vs rupture) and is up to the surgeon's discretion.7
In this case, we are using a suture augmentation to help expedite the healing process. The benefits of faster healing time and increased stability of repair make suture augmentation one of the most effective treatments to date. Historically, the UCL was repaired using wire or suture pull-out techniques through a bone tunnel.8 Suture tape is also a popular technique used because it removes the need for drilling a bone tunnel or exposing the suture material as required in suture/wire pull‐out techniques.9 The suture augmentation tape allows for a faster clinical recovery in addition to a decreased postoperative time in an immobilization cast. Another factor that makes this tape appealing is the increased stability and ability to withstand a higher workload as opposed to repair without suture augmentation.10
It is important to note that partial tears are treated conservatively with a plaster cast or splint. One study showed that there was no difference in time or efficiency in recovery between the two, which leaves it to the discretion of the patient if one is more comfortable than the other.11
A complete tear of the UCL is best managed operatively. There runs some risk with operative intervention, such as neuropraxia (sensory branch of the radial nerve), stiffness, persistent pain, the persistent weakness of grip, and cold intolerance.7 Unfortunately, without an experienced clinician, a complete UCL tear can easily be missed on a physical exam. Any delay in operative intervention may interfere with postoperative outcomes such as the return of MCP stability. Studies have shown that repair within 1–3 weeks of an acute UCL tear clinical diagnosis yielded better recovery time in addition to increased stability of the UCL when compared with those who received a delay in diagnosis.7, 12 Therefore, any inaccuracy or missed diagnosis could become crucial to the prognosis of the patient.
This patient will return to the clinic in approximately 4–6 weeks to assess the healing of the UCL repair. After the cast is removed, patients typically participate in physical therapy exercises such as range of motion and grip strength exercises. Once the pain has subsided and the range of motion is restored, the hand can be completely used again.13 Unfortunately, some follow-up studies have shown some degree of osteoarthritis in patients who underwent ligamentous repair.14 However, all of these patients had a chronic UCL injury as opposed to an acute injury. It seems that there is insufficient literature on postoperative osteoarthritis following the repair of acute tears, and it would be beneficial to further investigate.
- 3-0 suture anchor
- 0.045 K-wire (optional)
Nothing to disclose.
The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.
- Ritting AW, Baldwin PC, Rodner CM. Ulnar collateral ligament injury of the thumb metacarpophalangeal joint. Clin J Sport Med. 2010;6(2):106–112. https://doi.org/10.1097/JSM.0b013e3181d23710
- Mahajan M, Rhemrev SJ. Rupture of the ulnar collateral ligament of the thumb - a review. Int J Emerg Med. 2013;6(1):31. Published 2013 Aug 12. https://doi.org/10.1186/1865-1380-6-31
- Plancher KD, Ho CP, Cofield SS, Viola R, Hawkins RJ. Role of MR imaging in the management of "skier's thumb" injuries. Magnetic Resonance Imaging Clinics of North America. 1999 Feb;7(1):73-84, viii. Retrieved from https://europepmc.org/article/med/10067224.
- Landsman JC, Seitz WH Jr, Froimson AI, Leb RB, Bachner EJ. Splint immobilization of gamekeeper's thumb. Orthopedics. 1995;18(12):1161-1165. https://doi.org/10.3928/0147-7447-19951201-06
- Schroeder NS, Goldfarb CA. Thumb ulnar collateral and radial collateral ligament injuries. Clin Sports Med. 2015;34(1):117-126. https://doi.org/10.1016/j.csm.2014.09.004
- Picard F, Khalifa H, Dubert T. Duration of sick leave after surgical repair of the ulnar collateral ligament of the thumb metacarpophalangeal joint with K-wire immobilization: Prospective case series of 21 patients. Hand Surgery & Rehabilitation. 2016 Apr;35(2):122-126. https://doi.org/10.1016/j.hansur.2015.12.007
- Başar H, Başar B, Kaplan T, Erol B, Tetik C. Comparison of results after surgical repair of acute and chronic ulnar collateral ligament injury of the thumb. Chir Main. 2014;33(6):384-389. https://doi.org/10.1016/j.main.2014.10.003
- Madan SS, Pai DR, Kaur A, Dixit R. Injury to ulnar collateral ligament of thumb. Orthop Surg. 2014;6(1):1-7. https://doi.org/10.1111/os.12084
- Huber J, Bickert B, Germann G. The Mitek mini anchor in the treatment of the gamekeeper's thumb. Eur J Plast Surg, 1997, 20: 251–255. https://doi.org/10.1007/BF01159486
- Shin SS, van Eck CF, Uquillas C. Suture Tape Augmentation of the Thumb Ulnar Collateral Ligament Repair: A Biomechanical Study. The Journal of Hand Surgery. 2018 Sep;43(9):868.e1-868.e6. https://doi.org/10.1016/j.jhsa.2018.02.002
- Sollerman C, Abrahamsson SO, Lundborg G, Adalbert K. Functional splinting versus plaster cast for ruptures of the ulnar collateral ligament of the thumb: a prospective randomized study of 63 cases. Acta Orthop Scand, 1991, 62: 524–526. https://doi.org/10.3109/17453679108994487
- Hung CY, Varacallo M, Chang KV. Gamekeepers Thumb (Skiers, Ulnar Collateral Ligament Tear) [Updated 2020 Apr 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-.
- Baskies MA, Lee SK. Evaluation and treatment of the ulnar collateral ligament of the thumb metacarpophalangeal joint. Bull NYU Hosp Jt Dis. 2009;6:68–74. Retrieved from http://www.nyuhjdbulletin.org.
- Christensen T, Sarfani S, Shin AY, Kakar S. Long-Term Outcomes of Primary Repair of Chronic Thumb Ulnar Collateral Ligament Injuries. Hand (N Y). 2016;11(3):303-309. https://doi.org/10.1177/1558944716628482
Cite this article
Selsky AD, Ilyas AM. Thumb ulnar collateral ligament tear repair. J Med Insight. 2021;2021(303). doi:10.24296/jomi/303.
Table of Contents
- 1. Introduction and Surgical Approach
- 2. Incision and Dissection to Extensor Mechanism
- 3. Identification and Preservation of Branches of Radial Sensory Nerve
- 4. Identification of Possible Stener Lesion
- 5. Exposure of UCL Footprint and MP Joint Capsule
- 6. Mobilization of UCL and Confirmation of Ligament Length
- 7. Placement of K-Wire in MP Joint
- 8. UCL Repair
- 9. Closure
- Release Adductor Aponeurosis Longitudinally
- Elevate Extensor Mechanism Dorsally
- Prepare Footprint with Rongeur
- Place Suture Anchor
- Primary Repair of UCL to Footprint
- Augment Repair to Incorporate MP Joint Capsule
- Inspect and Confirm Repair and Reinforcement
- Reinforce Repair Further with Sutures Between UCL and MP Joint Capsule
Prior to beginning an examination under anesthesia with a valgus load to the MP joint should yield frank instability of the MP joint as shown here. See how the metacarpal is stabilized, and the proximal phalanx is loaded. The incision is placed on the ulnar border of the MP joint beginning at the level of the metacarpal head and extending towards the proximal phalanx space. The key is to avoid incision placement within the webspace. Prior to skin incision, the surgical site is infiltrated with a local anesthetic.
An incision is placed. Care is taken to not injure any of the crossing radial sensory nerve branches below the skin incision. Blunt dissection is then performed down to the extensor mechanism.
Branches of the radial sensory nerve will be evident within the surgical field. They should be adequately mobilized and then retracted either volarly or dorsally out of the surgical field.
If a Stener lesion is present, it will be evident at this point as demonstrated here with the ulnar collateral ligament sitting avulsed and on top of the adductor aponeurosis.
In order to expose the footprint of the ulnar collateral ligament, the adductor aponeurosis is released longitudinally, and the extensor mechanism elevated dorsally.
The plane between the extensor mechanism and the MP joint capsule is developed as shown here. Once that plane is developed, the extensor mechanism is elevated dorsally and a retractor placed behind it. This will protect both the extensor mechanism and any branches of the radial sensory nerve above it.
With the footprint of the ulnar collateral ligament exposed and debrided down to bleeding bone, the ligament is then mobilized and confirmed to be able to reach its footprint for subsequent repair.
Optionally, the MP joint can be pinned using a 0.045 K-wire as shown here to stabilize the joint and protect the repair prior to performing the actual repair. This K-wire can then be removed in the office approximately 3 to 4 weeks postoperatively.
The repair will be performed with a suture anchor placed in the footprint. Prior to placing the suture anchor, the footprint is freshened up using a Rongeur as shown here.
With the ligament mobilized, the joint pinned, and the footprint freshened up, the suture anchor is placed. The suture anchor used is one that can carry a 2-0 or 3-0 non-absorbable, braided suture as shown here.
Once anchored, the sutures are then loaded on a needle driver. Either a locking or a non-locking stitch is placed through the ligament. Here, a non-locking box stitch is placed through the ligament and then repaired in simple fashion. With the ligament held down against the footprint of the repair site by an assistant, the ligament is subsequently repaired.
With the primary repair completed, the repair is then augmented by taking the two suture ends and sewing them distally to the MP joint capsule as shown here. This will further reinforce repair as well as increase the distal translation of the ligament relative to the MP joint.
Here, closer inspection of the repair site confirms excellent coverage of the ligament to its footprint, as well as reinforcement to the MP joint capsule while not sewing in the extensor mechanism or branches of the radial sensory nerve.
If so desired, the repair can be augmented with sutures placed from the capsule into the ligament as shown here being placed along the dorsal border of the ulnar collateral ligament. This can also be performed on the volar side as well.
Once satisfied with the repair, the closure begins with repair of the adductor aponeurosis as shown here. It is mobilized and then repaired back to the extensor hood. An absorbable, monofilament suture is being used for the repair. Lastly, the wound is washed, and the skin closed next. Care is taken not to inadvertently capture any branches of the radial sensory nerve during closure. Postoperatively, a bulky soft dressing is applied that's left in place until the office visit. The patient is then converted to a removable splint. The pin is kept in for 4 weeks. After 4 weeks, the pin is pulled, and therapy is initiated. Thank you.