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Abstract & Commentary
Synopsis: The suture anchor fixation provided a stable repair if the surgery was performed early.
Source: Zeman C, et al. Acute skier’s thumb repaired with a proximal phalanx suture anchor. Am J Sports Med 1998;265:644-650.
Zeman and colleagues studied the functional outcome of acute surgical repair for injuries of the ulnar collateral ligament of the thumb. Early ulnar collateral ligament repair was performed on 58 patients with grade III complete ruptures of the ligament using a suture anchor. Forty-five patients were interviewed at a minimum postoperative time of 12 months. Forty-four patients (98%) were felt to have a stable repair and were satisfied with their surgery. The same percentage felt that they were not hindered in their day-to-day activities and had a functional range of motion. Mild discomfort was felt in 17%, but only 7% had pain with activities. The average time to return to skiing was 1.7 days. It was felt that the suture anchor fixation provided a stable repair if the surgery was done early.
Comment by James P. Tasto, MD
Mondry first described the unstable thumb in 1940. In 1955, Campbell described the classic "gamekeeper’s thumb" seen in Scottish gamekeepers.1 Schultz, Fox, and Brown coined the phrase "skier’s thumb" in 1973, as skiing appears to be the most common cause of acute rupture.2
Stability of the thumb on the ulnar side is maintained by four anatomical structures. They are the adductor aponeurosis, the adductor pollicis muscle, the proper and accessory ulnar collateral ligament (UCL), and the volar plate. The UCL provides major resistance to a radially applied stress, such as in pinching or holding equipment.
Stener first described some of the pathoanatomy of the ruptured UCL.3 His discussion centered on why failure often occurred with conservative casting. The adductor aponeurosis, when pulled distally, entraps the ruptured ligament and does not allow it to reduce anatomically.
There is some variation in the literature in terms of what degree of angulation is compatible with a full rupture of the UCL. However, if one were to assume that it will occur somewhere between 35-40° of radial deviation of the thumb when a stress is applied to the metacarpophalangeal joint at 30° of flexion, then under most circumstances, this would be compatible with a full rupture and indicate the need for surgical intervention. This test can be done clinically, or it can be done with radiographic assistance for documentation.
There have been any number of different types of repairs documented in the literature, many of which are somewhat more complex than those described here by Zeman et al. In this series, a direct repair with a suture anchor is used, obviating the need for trans-osseous tunnels and tying sutures over buttons.
All methods of repair have been associated with a small percentage of patients who continue to have minor discomfort at the repair site as well as some limitation of motion. In this series, 78% of these patients were felt to have a Stener lesion, which would indicate a probable poor result if conservatively treated.
It is critical to make a diagnosis promptly at the time of injury, and if angulation beyond 35-40° is encountered with the thumb at 30° of flexion, then acute surgical repair appears to yield the best results. The technique described here is simple and seems to work well.
1. Campbell CS. Gamekeeper’s thumb. J Bone Joint Surg 1955;37(B):148-149.
2. Schultz RJ, Fox JM. Gamekeeper’s thumb. Result(s) of skiing injuries. NY State J Med 1973;73:2329-2331.
3. Stener B. Displacement of the ulnar collateral ligament of the metacarpal phalangial joint, the thumb. A clinical and anatomical study. J Bone Joint Surg 1962;44(B):869-879.