Clinical Grading (Heyman Classification)

Grade I - Sprain (Partial Tear):

• Ligament stretched but intact
• Less than 15° laxity
• Firm endpoint on stress testing
• Treatment: Conservative

Grade II - Partial Tear:

• Some fibers torn
• 15-30° laxity
• Soft but present endpoint
• Treatment: Usually conservative

Grade III - Complete Tear:

• Complete ligament rupture
• Greater than 30° laxity OR greater than 15° vs contralateral
• No firm endpoint
• Treatment: Surgical (especially if Stener)

This classification guides initial treatment decisions.

Anatomic Classification

Based on Location of Tear:

• Proximal avulsion: From metacarpal (less common)
• Midsubstance tear: Within ligament body
• Distal avulsion: From proximal phalanx (most common)

Stener Lesion Present:

• Yes: Mandatory surgery
• No: Consider conservative or surgical
• Uncertain: MRI or surgical exploration

Location and Stener presence determine surgical approach.

Bony Avulsion Classification

Based on Fragment Size/Displacement:

• Non-displaced: May treat conservatively
• Displaced greater than 2mm: Consider ORIF
• Displaced into joint: Requires surgery
• Large fragment (greater than 20% articular): ORIF preferred

Fragment size and displacement guide fixation strategy.

Non-Operative Treatment

Indications:

• Grade I and II injuries (partial tears)
• Complete tear WITHOUT Stener lesion
• Less than 30° absolute laxity
• Less than 15° difference vs contralateral
• Firm endpoint on stress testing
• Non-displaced avulsion fractures

Protocol:

Acute Phase (0-2 weeks):

• Thumb spica cast or splint
• MCP in 20-30° flexion
• IP joint free
• Elevation and ice

Immobilization Phase (2-6 weeks):

• Thumb spica immobilization total 4-6 weeks
• May convert to removable splint at 4 weeks
• Serial clinical assessment

Rehabilitation Phase (6-12 weeks):

• Gentle ROM exercises
• Progressive strengthening
• Splinting for sport/heavy activities
• Return to full activity 10-12 weeks

Expected Outcomes:

• 90% success with appropriate selection
• Must exclude Stener lesion
• Full strength recovery expected

Non-operative treatment succeeds when Stener lesion is excluded.

Operative Treatment

Surgical Indications:

• Complete tear with Stener lesion
• Greater than 30° absolute laxity
• Greater than 15° laxity vs contralateral
• No firm endpoint on examination
• Displaced bony avulsion (greater than 2mm)
• Failed conservative treatment
• High-demand patient (athlete, manual worker)

Timing:

• Acute repair preferred (less than 3 weeks)
• Subacute (3-6 weeks): Repair possible but more difficult
• Chronic (greater than 6 weeks): Consider reconstruction

Surgical Options:

1. Direct Ligament Repair

• Indications: Acute injury with good tissue quality
• Fixation: Suture anchors (2.0-2.4mm) or transosseous sutures

2. Bony Avulsion Repair

• Indications: Displaced avulsion fragment greater than 2mm
• Fixation: K-wire, mini-screw, or tension band

3. Ligament Reconstruction

• Indications: Chronic instability, poor tissue quality
• Graft: Palmaris longus autograft (first choice)

4. MCP Arthrodesis

• Indications: Salvage after failed reconstruction
• Position: 15-20° flexion

Surgical approach depends on acuity and tissue quality.

Preoperative Setup

Patient Positioning:

• Supine on operating table
• Arm on hand table
• Tourniquet on upper arm

Anesthesia:

• General anesthesia OR
• Regional block (axillary/supraclavicular)
• Local infiltration often added

Equipment Needed:

• 2.0-2.4mm suture anchors (typically 1-2)
• Or equipment for transosseous sutures
• Fine hand instruments
• Loupe magnification (2.5x-3.5x)

Proper setup ensures efficient surgical technique.

Surgical Approach

Step 1: Skin Incision

• Mark incision over ulnar MCP joint
• Options:
  • Chevron incision (inverted V)
  • Curvilinear incision along ulnar border
• Length approximately 2-3 cm

Step 2: Superficial Dissection

• Identify and protect dorsal sensory branches of radial nerve
• Multiple small branches in operative field
• Injury causes painful neuroma and numbness
• Careful subcutaneous dissection

Step 3: Expose Adductor Aponeurosis

• Identify adductor pollicis aponeurosis
• Appears as white fibrous band running longitudinally
• In Stener lesion, palpable mass (rolled UCL) beneath aponeurosis

Step 4: Incise Aponeurosis

• Longitudinal incision through aponeurosis
• Reveals torn UCL lying superficial (in Stener)
• Normal UCL would be deep to aponeurosis

Step 5: Identify UCL

• Identify proximal stump (usually retracted, rolled up)
• Identify distal insertion site on proximal phalanx base
• Assess tissue quality
• Remove any scar tissue between ligament and bone

Careful approach protects neurovascular structures.

UCL Repair Steps

Step 6: Prepare Insertion Site

• Identify volar-ulnar base of proximal phalanx
• Debride to bleeding bone
• Create small trough with curette if needed
• Ensure adequate bone stock for anchor

Step 7: Place Suture Anchor

• Insert suture anchor at anatomic UCL insertion
• Usually 2.0-2.4mm anchor
• Direction: angled slightly proximal
• Confirm secure purchase in bone

Step 8: Pass Sutures Through UCL

• Retrieve sutures from anchor
• Pass through UCL using mattress or locking technique
• Ensure good tissue bite
• Options: simple sutures, horizontal mattress, or locking stitch

Step 9: Tension and Tie

• Position thumb in slight flexion (20-30°)
• Tension sutures to reduce UCL to insertion
• Tie securely with multiple throws
• Confirm stable repair with gentle stress

Step 10: Repair Aponeurosis

• Close adductor aponeurosis over UCL
• Use absorbable sutures
• Recreates normal anatomy
• Provides additional support

Alternative: Transosseous Repair

If suture anchors unavailable:

1. Drill small holes through proximal phalanx (volar to dorsal)
2. Pass sutures through UCL
3. Thread sutures through bone tunnels
4. Tie over dorsal cortex or button

Suture anchor technique provides reliable fixation.

Wound Closure

Step 11: Closure

• Subcutaneous layer: 4-0 absorbable
• Skin: 4-0 or 5-0 nylon or Monocryl
• Apply sterile dressing
• Apply thumb spica splint

Splint Application:

• Thumb spica configuration
• MCP in 20-30° flexion
• IP joint free (allows motion)
• Wrist neutral to slight extension
• Forearm included

Proper closure and immobilization protect the repair.

Special Considerations

Bony Avulsion:

• If large fragment with good bone quality: ORIF
• Options: K-wire, mini-screw (1.3-1.5mm), or tension band
• Ensure ligament attached to fragment
• Anatomic reduction critical

Chronic Reconstruction:

• Bone tunnels in metacarpal head and proximal phalanx base
• Palmaris longus graft harvested
• Pass graft figure-of-8 or single bundle
• Tension in slight flexion
• Secure with interference screw or sutures

Technique modifications address specific injury patterns.

Postoperative Care

Immediate Postoperative Period (Day 0-14)

Splint Care:

• Thumb spica splint maintained continuously
• Keep clean and dry
• Elevation above heart level for first 48-72 hours
• Ice packs around splint (avoid getting splint wet)

Wound Care:

• First dressing change at 48-72 hours
• Inspect for hematoma, infection
• Redress with clean dressings
• Suture removal at 10-14 days

Pain Management:

• Expect moderate pain first 24-48 hours
• Paracetamol 1g four times daily
• Ibuprofen 400mg three times daily (if no contraindications)
• Short course opioids if needed (3-5 days maximum)

Complications to Watch:

• Excessive pain (concern for compartment syndrome - rare)
• Numbness in radial nerve distribution (expected, monitor)
• Signs of infection (increasing pain, fever, drainage)

Phase 1: Protected Immobilization (Week 2-6)

Week 2-4:

• Continue thumb spica splint full-time
• May convert to removable splint at week 4 (surgeon preference)
• Maintain MCP in 20-30° flexion
• IP joint should remain free - encourage active IP flexion/extension
• Adjacent finger ROM exercises

Week 4-6:

• Transition to removable thumb spica splint
• Remove only for gentle washing
• NO stress to repair site
• Begin very gentle active ROM (if permitted by surgeon)
• Continue IP joint exercises

Activities:

• No lifting, gripping, pinching
• Shower with waterproof cover
• Desk work acceptable with splint on
• No driving

Phase 2: Early Mobilization (Week 6-8)

Range of Motion:

• Remove splint for exercises 3-4 times daily
• Gentle active MCP flexion/extension
• NO passive stretching
• NO valgus stress
• Therapist-supervised if possible

Exercises:

• Thumb opposition to each fingertip
• Gentle fist making (light grip)
• Tabletop slide exercises
• Tendon gliding exercises

Splint Use:

• Continue splint between exercise sessions
• Night splinting continues
• Splint for any potentially stressful activities

Activities:

• Light activities of daily living
• Computer work
• Writing
• Avoid sports, heavy lifting

Phase 3: Strengthening (Week 8-12)

Progressive Loading:

• Gradual increase in grip activities
• Putty exercises (soft → medium → firm)
• Pinch strengthening exercises
• Key pinch, tip pinch, lateral pinch
• Progress resistance as tolerated

ROM Goals:

• Achieve full active ROM
• MCP flexion 50-60°
• Full extension to neutral or near-neutral
• No extension lag acceptable

Functional Training:

• Simulate work/sport-specific activities
• Graded return to daily tasks
• May use taping for support during activities
• Continue night splinting for protection

Activities:

• Return to most activities of daily living
• May begin light recreational activities
• No contact sports yet
• Gradual return to manual work

Phase 4: Return to Full Activity (Week 12+)

Criteria for Return to Sport:

• Pain-free ROM
• Strength at least 80% of contralateral side
• No instability on stress testing
• Patient confidence in stability
• Surgeon clearance

Sport-Specific Training:

• Gradual return to sport protocol
• May need protective taping or brace initially
• Position-specific training for athletes
• Full clearance usually 3-4 months post-op

Long-Term:

• Most patients achieve full recovery by 4-6 months
• Strength may continue improving up to 12 months
• Annual review recommended first year
• Monitor for late instability or arthritis

Rehabilitation Milestones Summary

Red Flags Requiring Immediate Review

• Sudden increase in pain
• Loss of motion after initial gains
• Recurrent instability sensation
• Signs of infection
• Persistent weakness at 3 months
• Donor site problems (if graft used)

Viva Scenarios

MCQ Practice Points

High-Yield Exam Facts

Terminology Tricks:

• Gamekeeper's thumb = chronic (repetitive injury from rabbit neck breaking)
• Skier's thumb = acute (traumatic fall with pole strap)
• Both refer to same anatomic injury (UCL of thumb MCP)

Anatomic Details:

• UCL inserts on volar-ulnar base of proximal phalanx
• Proper collateral: dorsal origin, taut in flexion
• Accessory collateral: volar origin, taut in extension
• Adductor aponeurosis runs superficial to UCL insertion

Treatment Timelines:

• Acute repair: less than 3 weeks (best results)
• Subacute: 3-6 weeks (repair still possible)
• Chronic: greater than 6 weeks (reconstruction usually needed)
• Conservative: thumb spica 4-6 weeks
• Return to sport: 12-16 weeks post-op

Outcomes Numbers:

• Acute repair success: 90-95%
• Chronic reconstruction success: 70-80%
• Conservative treatment (partial tears): 85-90%
• Pinch strength recovery: 85-95% after acute repair
• Long-term arthritis risk: 10-20% at 10 years

Common MCQ Distractors:

• RCL injury (radial collateral) - much less common than UCL
• IP joint instability - different entity
• De Quervain's tenosynovitis - radial wrist pain, not MCP
• CMC joint arthritis - base of thumb, not MCP
• Trigger thumb - different pathology

Imaging Pearls:

• X-ray to exclude bony avulsion (mandatory before stress testing)
• MRI: 100% sensitivity for Stener lesion
• Ultrasound: dynamic assessment possible, operator-dependent
• Stress radiographs controversial (risk converting partial to complete)

Surgical Technique Points:

• Approach: chevron or curvilinear incision over ulnar MCP
• Must protect dorsal sensory branches of radial nerve
• Incise adductor aponeurosis to access UCL
• Fixation: suture anchors (2.0-2.4mm) most common
• Alternative: transosseous sutures through bone tunnels
• Graft for reconstruction: palmaris longus first choice

Complications:

• Most common: temporary numbness (radial nerve branches)
• Most significant: chronic instability (from missed Stener)
• Late complication: post-traumatic arthritis (10-20%)
• Surgical: nerve injury, infection, anchor pullout

Common Exam Scenarios

Scenario 1: Acute Injury with Stener

• Young skier, fall with pole strap
• Palpable mass, greater than 30° laxity, no endpoint
• Management: Surgical repair with suture anchors
• Key teaching point: Stener lesion cannot heal conservatively

Scenario 2: Partial Tear vs Complete

• Patient with 25° laxity, 10° vs contralateral, firm endpoint
• Management: Conservative with thumb spica 4-6 weeks
• Key teaching point: Firm endpoint suggests partial tear

Scenario 3: Chronic Presentation

• 3-month history, persistent instability, weak pinch
• Management: Ligament reconstruction with tendon graft
• Key teaching point: Greater than 6 weeks = primary repair usually not possible

Scenario 4: Bony Avulsion

• X-ray shows 3mm displaced avulsion fragment
• Management: ORIF with mini-screw or K-wire
• Key teaching point: Greater than 2mm displacement = operative indication