Thumb MP joint

ligamentous injuries
Sylvie Carmes, Hand Center, Guadeloupe
Presentation will be available on www.diuchirurgiemain.org

Six possible lesions

Medial collateral ligament injury: Q ? is there a Stener lesion i.e. is surgical
repair needed ?
Lateral collateral ligament injury: Q ? benign or severe ? if severe, surgery is
needed
Dorsal capsular lesion: Q? Diagnosis and treatment ?
Volar plate injuries: Q ? Indication for surgical treatment in acute injuries ?
Posterior MP dislocation: Q ? How to reduce it ? Is there a surgical indication ?
Anterior MP dislocation: Rare, 17 cases reported in 2011- no question

Ligamentous anatomy of the MP joint

Collateral ligament has two fascicles: main fascicle (1) inserts on the proximal
phalanx and accessory fascicle (2) that inserts on the palmar plate and
sesamoids
The MCL est shorter and thicker than the LCL
Palmar plate is divided in
three parts: the thinner
Metacarpo-sesamoid ligament
(3), thicker sesamoidsphalangeal ligament (4) and
the sesamoids in between

The two fascicles

The accessory ligament is
tense in extension, the main
fascicle in flexion
May help with clinical testing
Limited clinical consequences
from a practical point of view

Ligamentous anatomy of the MP joint

The two sesamoids (U & R) are

deeply inserted (embedded)
into the palmar plate,
posterior to the FPL tendon
sheath (same legends)
Thenar muscles insert on the
sesamoids: Adductor pollicis
(ulnar), FPB (radial)

The thenar muscles, the sesamoids and the sesamoid-phalangeal

ligaments form the active anterior sling
While the metacarpo-sesamoid ligament forms the passive sling

Medial side
The MCL is covered by the
dorsal expansion to the EPL of
the aponeurosis of the
adductor pollicis whose main
insertion is on the ulnar
sesamoid (somewhat like the
interosseous hood at the long
fingers)

Lateral side

The Flexor pollicis brevis inserts on the radial

sesamoid
The joint is covered by the insertions on the thenar
muscles: APB (1), FPB (2) that mix with the EPB
(5) to form a hood (3) that covers the LCL (4) and
the volar plate (8)

Dorsal side
EPL and EPB ( ) are stabilized by
sagittal bands
The EPB blends with the extensor
hood in 70% of cases and does not
insert of the proximal phalanx
(Probably) not involved in thumb MP
joint injuries

Anatomical exercice
Can you name these structures ?

Biomechanical knowledge
Resultant forces at the MP joint is about 10 times
the load at the tip
The MP joint has a huge variation of mobility
between individuals with a bimodal distribution
(750 cases)
Radial laxity averages 6 (0-30) in full extension,
12 (0-45) in 15 of flexion and 1 (0-15) in full
flexion
Hirsch D. J Biomechancis 1974; 7: 343-346
Palmer AK. JHS 1978,3:542-546

Experimental data (200 thumbs)

MP flexion averaged 77 (40126).

MP hyperextension as 35 (0-72)
Total ROM was 110 (55 to 176)
Correlation between metacarpal head shape and
ROM; rounder metacarpal heads had greater
motion (106) compared to flat heads (77)
Yoshida R. J Hand Surg 2003;28A:753757.

Clinical consequences
Patient with limited thumb MP mobility (whether they have a flat
head or a capsular tightness) are more prone to sustain a MP joint
injury (osseous, ligamentous or even soft-tissues injuries)
The stiff thumb cannot escape and protect itself +++
Shaw SJ. J Hand Surg 1992; 17B: 164-166

MCL injuries : the most

frequent

MCL Injuries
Campbell, JBJS 1955, described 24 chronic ulnar instability in Scottish
gamekeepers (they kill hase by holding their neck between thumb and index
and pulling strongly on their legs) Gamekeepers thumb
Bowers, JBJS 1977, reported a 50% failure rate for conservative treatment of
acute ulnar instability
Stener, JBJS 1962, described the anatomical lesion that bears its name (32
surgical cases, 42 anatomical dissections)

Mechanism = sport injuries

24 surgical cases : 18 sport (11 skiing), 3 vehicle,

and 3 other injuries (Swedish study).
1000 surgical cases (France alps): 50 % sport (75%
ski); 38% Work related injuries and 12% domestic
injuries or MVA
What about ski injuries in Qatar ?

Snow only available over 4000 m, ski injuries are less probable !

Question ?
Im Cli
a g nic
in al
g t te
ec sti
hn ng
How to make the diagnosis of a severe lesion ?
iq ?
ue
s?
Is there a Stener lesion that warrants surgical treatment ?

Clinical testing should be made after taking an x-rays to eliminate an undisplayed

avulsion-fracture that could be displaced during testing

Fracture-avulsion
injuries
30% of cases present with
an avulsion of the MCL
insertion
Sometimes you make the
diagnosis of a Steners lesion

bony skiers thumb injuries

Series of 30 cases: Good results in all
patients with a avulsion-fracture; however
a 25% non-union rate; the biggest and
most rotated fragments tend to show less
good results
Most authors do favor surgery if
fragment is over 30% of the articular
surface, displaced > 2 mm, or rotated >
45
Kuz JE. J Hand Surg 1999;24A:275282

Without fracture, experimental data shows

that clinical testing should be made in full
flexion which needs local anesthesia at least

Position

Nothing
cut

Capsule
ACL & PP
UCL cut
cut
cut

AA cut

Full
extension

15
flexion

10

14

Full
flexion

12

28

>90

The good
position
for
32
>90
testing
42

> 90

Palmer AK. JHS 1978,3:542-546

Clinical testing
Others have proposed > 30 of
valgus instability or > 15 compared
to the controlateral side
French mountain doctors have
described the bottle test: if you
cannot hold a full bottle between
thumb and index, this is a severe
lesion
Heyman P. Injuries of the ulnar collateral ligament of the thumb metacarpophalangeal joint: biomechanical
and prospective clinical studies on the usefulness of valgus stress testing. Clin Orthop Rel Res 1993;292:16571.

Radiological testing
Same limitations
Need anesthesia
Need to do it yourself
In which position (full flexion)

From a practical point of view !

Diagnosis is easy
Either the joint, w/o anesthesia, is grossly stable with a clear stop
Or it is grossly unstable with a limpness felt toward the end of the range of
motion, and you know it is severe ( A discrete hematoma on the dorsal aspect
of the thumb IP signifies capsulo-ligamentous rupture and hemarthrosis
diffusion along the thumb EPL is also indicative of a severe lesion).

2nd question: is there a Stener

lesion ?
The MCL usually ruptures (90%) at its phalangeal
insertion
During a fall, the thumb is forced in valgus and
flexion as it thrust into soft snow (it is not the
strap of the ski pole which is responsable but the
quality of snow)
When the thumb goes back in extension, the
dorsal aponeurosis interposes between the two
ends of the ligament which cannot heal +++

How frequent are

Steners lesions ?
Nobody really knows
Stener stated that is could be present in up to 64% of
severe MCL injuries (15-64% according to surgical
series)
Palpation was proposed to make the diagnosis
Most surgeons consider that all severe lesions should
be treated surgically in case of a Steners lesion
At least 30% could be treated conservatively

Can imaging technique may help

to make the diagnosis ?
X-rays are usually normal
Indirect signs of severity: Spontaneous joint
opening, Anterior subluxation,
Loss of parallelism between the line tangent
to the base of the proximal phalanx and the
line tangent to the sesamoid bones signes
an avulsion of the MCL
Rochet S. Rupture of the thumb ulnar collateral ligament of the metacarpophalangeal
joint: is it possible to operate according to the position of sesamoides on dynamic Xray.
Chir Main 2007;26:2005.

Other imaging techniques

MRI
Sensibility 63-100%, specificity
50-100%
Not available everywhere,
takes some time,.
Many artefacts

Sonography ?
Static sonography: Sensibility 88%,
specificity 83-91%
However structures are difficult to
see for an average physician,
especially the adductor aponeurosis
+++
All series reported false negative

Sonography ?

We described Dynamic Sonography: You see

easily the ligament and, by flexing the IP you
make the aponeurosis moving and you can say
easily if it is over or under the ligament

Pluot, Gurini, Dumontier, Drap,

Rupture w/o a Steners lesion

Rupture with a Steners lesion

In the first part of the study we were able

to correlate the MRI imaging to
sonography and anatomy

Rupture with Stener

Rupture w/o Stener

In the second part o the study, correlation were made for experimental injuries

Correlation was possible in

the two different planes
(axial and longitudinal)

Treatment

Benign: Nothing or a 10 days strapping for

pain relief
Severe: 3 to 6 weeks in a thumb spica cast
Stener : Surgery

Surgical
technique
Local or regional anesthesia
V (seagull) type incision
Respect the dorsal sensory branch
Incise the dorsal aponeurosis close to the EPL
tendon
At exploration, the dorsal capsule and part of
the volar plate are frequently torn

Surgical
technique
Reinsertion of the medial ligament on the
phalanx (periosteal suture, anchors,...)
A small bony piece is excised, otherwise fixed
The dorsal aponeurosis is closed over the
ligament
Cast immobilization for 1 month, then
rehabilitation

Results
80-90% are pain-free after 6 months
Loss of motion of 5-10% (Kapandji
9-10)
60-70% regain normal grip and pinch
strength
The MP is enlarged definitively

Results (1000 cases)

Very good: normal thumb
:

Good: thumbs which are stable, pain-free, but with

web space opening and/or MCP range of motion
reduced from 10 % to 15 % in comparison with the
opposite side.
:

Average thumbs exhibit 20 % to 30 % stiffness either

in flexion-extension or in web space opening.
:

Poor: painful and/or unstable cases.

75% very good,

15 % good,
8 % average,
2 % poor

Is surgery an
emergency : YES
Clinical results decline after
8-10 days
After 3 weeks, a ligamentous
suture may not be possible
and a ligamentoplasty may be
needed

Take home message

Rather frequent injury
Do not operate on every patient
BUT do not miss the patient that should be operated on i.e. the
one with a Steners lesion: clinical suspicion, dynamic sonography
(or even MRI) will help to choose the right treatment

If you miss the diagnosis

Due to the high loads on the joint

Instability will increase
Joint will become painful and later,
arthritic
Surgery is needed (either ligamentous
reconstruction, or arthrodesis)

LCL injuries : less frequent

Radial instability
Ten times less frequent
No Steners lesion
Postero-lateral (rotatory) instability
Less impressive clinically but very
poorly tolerated
Surgical treatment is mandatory in
severe injuries

Clinical examination, the same

Radiological examination, the same
No need for other imaging techniques
Surgical principles and techniques are similar

Dorso-Radial capsular
injuries

Dorso-radial capsular injuries

In association with LCL injuries most
often

Isolated injury
Clinical diagnosis: all patients exhibit tenderness to palpation specifically at the
dorsoradial aspect of the MP joint of the thumb; there is no laxity of the
collateral ligament tested at 0 and 30 of flexion. Some patients lack full
active extension of the proximal phalanx
In some patients, mild palmar subluxation of the proximal phalanx on xray
films.
Krause JO. (J Hand Surg 1996;21 A:428-433.)

Posterior MP dislocation

Posterior MP dislocation

Bears the name of Louis Hubert

FARABEUF (1841-190), French
surgeon who described the
anatomical lesion; the way to
reduce it, and the instrumentation
you needed to

Posterior MP dislocation
Hyperextension injury + some pronation
and internal rotation Metacarpal head
twists around the FPL which is trapped in
the joint
The metacarpal head then enters the
thenar muscles
The MCL is usually intact (taught in
flexion only)

Posterior MP dislocation

Clinical diagnosis is usually easy

X-rays will confirm dislocation but are difficult to
analyse
2 types described: simple and complex injuries

Simple dislocation

Pain
Functional limitation
Thumb hyperextended
X-rays: sesamoid are still in contact with
the metacarpal head

Complex dislocation

Pain
Functional limitation
Thumb not hyperextended but parallel
to the metacarpal
X-rays: sesamoid are posterior to the
metacarpal head

Take home message

A faulty maneuver will transform a simple dislocation into a
complex one, or even an irreducible one
There is only one reduction technique that should be performed
under regional anesthesia
After reduction, a radiological testing is mandatory (fluoroscopy)

The technique of reduction according to Farabeuf

NO TRACTION
Increase the deformity
and push the phalanx
against the metacarpal in
order to prevent
irreducibility

Closed reduction of a dorsal dislocation of the joint is easier if the insertions of the
intrinsic muscles in the sesamoids are intact, since these muscles will guide the volar
plate back into its proper position (Weeks, 1981).

Faulty maneuver
(traction) leading to
entrapment of sesamoid
bones

Post-reduction testing: Two parts

Clinical testing in the frontal plane

If there is a severe lesion of one of
the collateral ligament (i.e. radial or
ulnar instability)
Surgery is indicated

Post-reduction testing: Two parts

Testing under fluoroscopy to

better understand the lesions
and the potential for chronic
instability

Stable lesions = passive sling

injury = metacarpo-sesamoid
ligament injury (3)
The most frequent injury (> 80%)
Stable after reduction
During extension, the sesamoids stay
with the phalanx
Orthopedic treatment (cast) for 1
month

If
Rupture of the
active restraints
Rupture of the sesamodo-phalangeal ligament
Fracture of a sesamoid bone
Rupture of the flexor pollicis brevis tendon

Surgical treatment is
to be considered

Rupture of the sesamoidophalangeal ligament

The sesamoid bones do not follow
the phalanx during extension

Fracture of a sesamoid bone

Difficult to see

Sesamoid is derived from the flat and oval seeds of the sesame indicum an ancient east
indian plant used by Greek physicians as a purgative.

Two types of sesamoid fractures

First described in 1915

Type 1: Without rupture of the palmar plate: stable, non treatment required
Type 2: With rupture of the PP (also described by Stener): unstable, may
need surgical repair. Three clinical signs: (1) hyperextension injury, (2)
ecchymosis on the flexor side of the MP joint extending to the thenar
eminence, (3) tenderness over one or both sesamoid bones.

Rupture of the flexor policies

brevis tendon
Hematoma, proximal pain,
increased pain during resisted
flexion if seen late

Anterior MP dislocation

Anterior MP dislocation
If sesamoids are interposed; EPL tendon not
palpable; radial or ulnar displacement of EPL
or EPB; paradoxical MP flexion and IP
extension when attempting to extend the MP
joint tissues interposition
Most cases 15/17 required open reduction due
to interposition of volar plate, dorsal capsule
or tendons
Beware of MCL or LCL injuries that require
surgical repair

Conclusion
Rather rare injuries
Severe injuries should be treated surgically
A thorough clinical examination with a meticulous
ligamentous testing is the key to a good treatment
option
Sequelae are very disabling

Choukran