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ABSTRACT
Thirty-nine patients diagnosed with 40 acute complete ruptures of the ulnar collateral ligament of the thumb metacarpophalangeal joint were treated primarily with thumb spica splint immobilization. Duration of splinting ranged from 8 to 12 weeks. Thirtyfour of these injuries (85%) followed for 1 to 5 years (average 2.4 years) healed without significant instability, arthrosis, pain, or stiffness (range of motion within 80% of the contralateral hand). Six ruptures (15%) demonstrated persistent instability and pain at 12 weeks and were treated with surgical reconstruction. Currently accepted guidelines for surgical intervention as primary treatment for ligamentous disruption at the thumb metacarpophalangeal joint may need revision. This study suggests that splint immobilization is an effective primary treatment modality. The minority of patients who demonstrate persistent laxity can be successfully treated surgically with excellent results.
The term "gamekeeper's thumb" has evolved over the years to encompass instability of the metacarpophalangeal (MCP) joint of the thumb resulting from both acute and chronic insults to the ulnar collateral ligament. The understanding of the pathologic anatomy has unified the thinking that complete rupture of the ulnar collateral ligament is responsible for the instability in pinch.13 Methods of diagnosis of injury involve various stress testing maneuvers with sufficient reliability to correlate well with findings at surgery.2,4 Currently it is recommended that stress testing be performed in as much flexion as possible to completely isolate the ulnar collateral ligament.4 Arthrography and stress roentgenography may be performed to aid in diagnosis if needed.5 Little controversy arises as to the closed management of incomplete lesions. On the other hand, 30° of angulation, 30% articular "uncovering" or the presence of a displaced bony avulsion fragment have all been described as hallmarks of the unstable complete collateral ligament injury requiring surgical intervention. Reports range from 15% to 60% that the ruptured end of the collateral ligament is displaced by the adductor aponeurosis with the implication that closed management will fail to restore the normal anatomy.4,6 Failure rates as high as 50% have been described with closed management of complete ruptures.5 Combined with this are reports that early (within 2 weeks of injury) vs delayed reconstruction will achieve better results.3,7
The purpose of this article is to reexamine the treatment protocol for acute, complete ruptures of...