ULNAR COLLATERAL LIGAMENT SPRAINS THUMB

ULNAR COLLATERAL LIGAMENT SPRAINS THUMB

COLLATERAL LIGAMENTS Joint capsule reinforced both radially and ulnarly by Proper collateral ligament (PCL) Arise from MC head obliquely distally +palmar insert tubercles on palmar 1/3 proximal phalanx Joined at CC by insertion AddP and APB Accessory collateral ligament (ACL) Arise from MC head more superficial and palmar to PCL Inserts sides of Volar plate and sesamoid bones

THUMB MCPJ ANATOMY

RETTIG 2004 ULNAR Adductor aponeurosis approaches at oblique angle RADIAL Abductor pollicis brevis - approaches joint at parallel plain

SKIER S THUMB GAMEKEEPERS THUMB ULNAR COLLATERAL LIGAMENT

STENER LESION PROXIMAL DISTAL In order for a Stener lesion to be present must have complete tear of both PCL and ACL +/- avulsion#

PHYSICAL EXAMINATION ACUTE INJURIES MCP JOINT UCL Goal is to distinguish between a partial tear (Grade 1 and 2) v complete tear (Grade 3)

PHYSICAL EXAMINATION ACUTE INJURIES MCP JOINT UCL History of significant trauma Pain/Tenderness volar and ulnar aspect MCPJ Extent swelling +/- bruising Resting posture/rom/pronosupination MCPJ/pinch Palpation for displaced UCL Defined as firm, distinct mass on ulnar aspect thumb just proximal to MCP joint (Abrahamson et al 1990) 100% specificity ie each time a mass was noted preoperatively, a Stener s lesion was found at operation. Sensitivity 46% - False-negative rate Stener lesion present without definable mass X-rays/MRI/US Gentle radial stress testing

USEFULNESS OF VALGUS STRESS TESTING Heyman et al 1993 Clin Orthop Rel Res Results of an anatomical and prospective clinical study were collated to determine whether valgus stress testing of the thumb MCP joint was predictive of a torn and displaced UCL

USEFULNESS OF VALGUS STRESS TESTING Anatomical study dividing PCL significantly valgus instability in flexed MCPJ significantly less laxity when tested in extension + dividing ACL + VP complex valgus instab in extension to extent that no longer differed significantly from 30 flexed position Clinical study valgus instability > 35 in extension = consistently indicated presence of tears of PCL + ACL (Stener lesion present 87%) therefore valgus stress testing in extension and 30 flexion = highly predictive of both disruption and displacement of UCL

TREATMENT INDICATIONS HEYMAN ET AL 1993 Disruption considered unlikely conservative management Instability in extension < 35 Instability in flexion 20 > than in extension (ACL intact) Indications that ligament disrupted and displaced (Stener lesion) surgery Presence palpable mass Instability in extension > 35 15 greater laxity in injured v uninjured thumb Differences in instability values in flexion and extension small (ie <20 ) (PCL+ACL) +/- Displaced # noted on x-ray

STABLE V UNSTABLE FRACTURES Kuz 1999

TREATMENT PARTIAL LIGAMENT INJURIES OR NONDISPLACED AND STABLE AVULSION #S Hand-based thumb spica (IP free) 2-4/52 Maintain W + IPJ ROM

TREATMENT PARTIAL LIGAMENT INJURIES OR NONDISPLACED AND STABLE AVULSION #S @ 2-4/52 if pain-free AROM-AAROM MCP Key pinch exercises can be initiated early

TREATMENT PARTIAL LIGAMENT INJURIES OR NONDISPLACED AND STABLE AVULSION #S Tip pinch and wide span grip should be avoided for 8/52

TREATMENT PARTIAL LIGAMENT INJURIES OR NONDISPLACED AND STABLE AVULSION #S Hand-based thumb spica (IP free) 2-4/52 Maintain W + IPJ ROM @ 2-4/52 if pain-free AROM/AAROM MCP Key pinch exercises can be initiated early Tip pinch and wide span grip should be avoided for 8/52. Strengthening (isotonic not isometric due to torsional load) Obtaining terminal ROM is not as important as obtaining a stable, pain -free joint.

WRIST SPRAINS

A KNOWLEDGE OF TOPOGRAPHIC ANATOMY OF THE WRIST IS ESSENTIAL!!!!! Jayasekera N et al (2005) Recruited 32 orthopaedic and 18 accident and emergency surgeons Each was asked to palpate * Proximal pole scaphoid * Waist scaphoid * Tubercle scaphoid * Hook of hamate * Trapezial ridge * Dorsum triquetrum * Pisiform 10% correctly palpated all surface markings. 12% failed to accurately palpate even a single point. Median score = 3/7

DORSAL ASPECT 1. Lister s tubercle 3. Radial styloid process 2. Crucifixion fossa at the level of the scapholunate junction

LISTER S TUBERCLE AND CRUCIFIXION FOSSA LISTER S TUBERCLE CRUCIFISION FOSSA AT THE LEVEL OF THE SCAPHOLUNATE JUNCTION/MIDCARPAL JOINT

SCAPHOLUNATE LIGAMENT If the wrist is now flexed with the tip of the thumb still in the crucifixion fossa one will feel a hard lump coming up into the recess. This is the proximal row and the thumb is now over the area of the scapholunate joint. Ulnarwards, the adjacent radial side of the lunate and radially the proximal pole of the scaphoid can be felt, depending on the degree of ulnar or radial deviation

RADIAL ASPECT 3. Radial styloid 5. Trapezium 4. ANA/waist of Scaphoid 6. Base of the 1 st Metacarpal EPL: extensor pollicis longus APL: abductor pollicis longus and extensor pollicis brevis

ANATOMICAL SNUFFBOX Revealed better with the wrist in ulnar deviation. 3. radial styloid 5. trapezium 4. ANA/waist of scaphoid 6. base of the first metacarpal

PALMAR SURFACE 7. Tubercle of the Scaphoid 9. Pisiform 8. Tubercle of the Trapezium 10. Hook of Hamate

MEDIAL ULNAR SNUFFBOX 12. ulnar styloid 14. extensor carpi ulnaris 13. Triquetrum 15. flexor carpi ulnaris.

(A) (B) Palpation dorsal aspect of triquetrum with wrist in neutral Palpation triquetrum in ulnar snuf f-box with wrist in RD 11. head of ulna 12. ulnar styloid process 13. triquetrum + lunotriquetral joint

CARPAL NOISES GRINDS, SNAPS, CLUNKS Grinding usually caused by two bones rubbing together without good cartilage between them eg unstable scaphoid non-union/oa Snap/Click sharper high-pitch sound most often associated with a subluxing tendon over an osseous ridge eg ECU coming out of its groove on the ulna during active supination, flexion and ulnar deviation when its stabilising tendon sheath is torn or elongated. Clunking low-pitched dull sound produced by sudden subluxation and/or reduction of a partially, or totally, dislocated carpal bone Depending on the level of joint laxity may appear only sporadically as a result of an external force being applied to the joint or occur repeatedly every time the wrist is actively moved in one particular direction without resistance.

RADIAL SIDED WRIST EXAMINATION Scaphoid compression test Clamp gesture Scaphoid shift test Watson s Test Scaphoid thrust test Middle finger extension test

SCAPHOID COMPRESSION TEST & CLAMP GESTURE

SCAPHOID SHIFT TEST WATSON S TEST Patient is seated across from the examiner with flexed elbow resting on table as if to arm-wrestle With the patient's forearm slightly pronated, the examiner grasps the wrist from the radial side, placing his thumb on the palmar scaphoid tubercle and wrapping his fingers around the distal radius. This enables the thumb to push on the scaphoid tubercle with counterpressure provided by the fingers The examiner's other hand grasps at the metacarpal level, controlling wrist position. Important that subject is relaxed Watson et al 1988

SCAPHOID SHIFT TEST WATSON S TEST Starting in UD and slight extension, the wrist is moved radially and slightly flexed, with constant thumb pressure on the scaphoid thus opposing the normal scaphoid flexion with radial deviation With ligamentous laxity or disruption AND under pressure from examiner s thumb the proximal pole of the scaphpid shifts up on the dorsal rim of the radius When the thumb pressure is withdrawn scaphoid returns with a clunk. +ve = reproduces patient s symptoms usually dorsal wrist pain - usually with a painful clunk Watson et al 1988

SST INTERPRETATION OF RESULTS Not an all or none test but rather a spectrum of mobility Grading 0 - rigid ligamentous support and no palpable translation +1 shift - mild generalized displacement of the carpus without a palpable subluxation of the scaphoid +2 shift - true scaphoid subluxation from the scaphoid fossa, with a palpable, and occasionally audible clunk as the scaphoid reduced on release of force Wolfe SW (1994) Validity 69% sensitivity 66% specificity Indicates approx 1/3 SLL injuries missed Approx 1/3 who did not have injury tested positively La Stayo & Howell 1995

ULNAR SIDED WRIST EXAMINATION ULNOCARPAL STRESS TESTS Ulnocarpal stress test (Lichtman) Ulna fovea sign TILT sign Lunotriquetral Ballottement Test (Reagan Shuck Test) Lunotriquetral Compression Test Lunotriquetral Shear Test (Kleinman) Lunotriquetral ligament tests (Christodoulou) Ulnomeniscotriquetral dorsal glide test Pisotriquetral tests grind, apprehension, stress GRIT test ECU tenodesis test

ULNAR SIDED WRIST EXAMINATION DISTAL RADIOULNAR JOINT Piano-key sign Table press test Relocation test DRUJ ballottement test DRUJ Grind and Rotate test

ULNOCARPAL STRESS TEST NAKAMURA ET AL 1997 Place the wrist in maximum UD Axially load the wrist Passively rotate forearm through supination to pronation Sensitive for ulnar-sided pathology but not very specific Ulnar impaction Lunotriquetral ligament TFCC injury Isolated arthritis Positive test = patient s typical pain is reproduced

REAGAN SHUCK TEST One hand is placed with the thumb and index on the triquetrum and pisiform while the other hand is placed on the lunate and radial wrist. The 2 hands are moved in opposite volar-dorsal directions creating stress across the lunotriquetral joint. Modification Because triquetro-hamate joint is spiral - to achieve max anterior stress of triquetrum on lunate need to pronate triquetrum on hamate whilst applying palmar stress

ULNA FOVEA SIGN Elbow flex 90 - rests on table patients upper limb relaxed, examiner supports wrist and forearm neutral Examiner presses thumb distally and deep into interval ( soft spot ) between ulnar styloid process and FCU tendon, between volar surface of ulnar head and the pisiform +ve detecting foveal disruptions and/or UT ligament injuries = exquisite tenderness that patient claims replicates their pain, compared with contralateral side Sensitivity = 95.2% Specificity = 86.5% Tay S-C et al 2007, Tay et al 2010

RELOCATION TEST / PISIFORM BOOST TEST Technique similar to articular shear test but rather addresses the volar sag and supination of the carpus rather than articular disc Fingers over dorsum of distal ulnar and thumb over pisotriquetral complex the ulnar carpus are relocated into normal alignment upon the TFC with a combined volar -to-dorsal glide and pronation Tip to avoid shear of the articular disc a distal distraction on the pisiform is usually applied in combination with the dor sal glide Test positive if the relocation of the subluxed ulnar carpus reduces wrist pain Prosser 1995

ECU TENDON ECU synergy test

TABLE PRESS AND LIFT TESTS With both hands flat resting on the examination table in a pronated position ask patient to push into the examination table DRUJ instability - ulna more prominent dorsally and seems to sublux volar with pressure, creating a dorsal hollow. 100% sensitivity for a TFCC tear Lester et al 1995 Adams and Berger 1997 Long lever load to fingers-palm to undersurface of table with forearm in supination (Supination Lift Test) Compare bilaterally Increased motion of ulna head and pain indicative of DRUJ disruption

DRUJ INSTABILITY TEST AKA DRUJ BALLOTTEMENT TEST Radius stabilised by examiner Distal ulna fixed between examiners thumb and index finger moved in dorsal-palmar direction with respect to radius Perform initially in neutral forearm rotation, where up to 5 mm of translation may be noted. Abnormal translation of ulnar head suggests a complete TFCC disruption Repeat at extremes of both supination and pronation where less translation should normally be noticed and to ascertain which limb of TFCC af fected If translation of the ulna at the extremes of rotation = that of neutral translation, DRUJ instability is present

ULNOCARPAL WRIST SUPPORTS

THERMOPLASTIC

SOFT CAST

FABRIFOAM NEOPRENE

DART-THROWING ARC SPLINT ULNAR BOOST

TIGER PAWS Gymnast s wrist