User:Mheskes/Rupture to the Ulnar Collateral Ligament (UCL) of the thumb

Abstract here...

Describe your case study
The patient is a 44yo male self employed arborist who has suffered a ruptured ulnar collateral ligament (UCL) injury at work. The rupture occurred after he tripped and fell onto a log, landing on his outstretched right hand putting an acute valgus force on his abducted thumb. The fall has caused a grade II rupture to his UCL; under valgus stress testing as he as over 15 degrees of extra valgus laxity when compared with his sound thumb but with a firm end feel indicating a rupture to the accessory collateral ligament (McKeon, Gelberman & Calfee, 2013; Patel, Potty, Taylor & Sorene, 2010). The degree of laxity in the patients thumb puts him in the higher end of partial UCL tear categorisation with an mri confirming a tear to his accessory collateral ligament (Rhee, Jones & Kakar, 2005; Gagliardi & Agarwal, 2012) Due to the severity of the injury surgical intervention was considered but when given the option the patient opted for a conservative approach due to cost and a need to get back to work.

Evidence
The Metacarpophalangeal joint (MCPJ) functions primarily as the point at which flexion and extension occurs at the thumb. The MCPJ is stabilised by the UCL, radial carpal joint, congruency of the hinge joint as well as the intrinsic and extrinsic muscles of the thumb (Ritting, Baldwin & Rodner, 2010).

The main focus of the UCL is to maintain functional stability on the ulnar side of the MCPJ. In combination with the radial collateral ligament they create lateral and dorsal stability for the proximal phalanx as well as the MCPJ (Patel, Potty, Taylor & Sorene, 2010). This stability stems from the ligamentous structure fanning out across the Ulnar side of the joint in two distinct sections; the MCPJ proper collateral ligament and the MCPJ accessory collateral ligament (Samora, Harris, Griesser, Ruff and Awan, 2013; Arend & Siliva, 2013). At extension the accessory ligament is taut due to the movements of the joints volar plate. Conversely during flexion the proper ligament is taut and the accessory ligament is in a lax state. The MCPJ of the thumb also lacks the proximal extension of the volar plate that other MCPJ's have to check hyper extension injuries.

As the patient fell his thumb was hyper-extended; when the sudden abducting force was applied as he hit the ground the already taut accessory ligament ruptured (Ford, McKee & Szilagyi, 2003; Rhee, Jones & Kakar, 2005; Ritting, Baldwin & Rodner, 2010). This more common mechanism of injury results in UCL tears being far more prevalent than the the opposing radial ulnar collateral ruptures (Edelstein, Kardashian & Lee. 2008).

Muscular structures acting around the MCPJ include the intrinsic abductor pollicis brevis, flexor pollicis brevis and the adductor pollicis muscles. Extrinsic muscles affecting the joint include extensor pollicis longus, extensor pollicis brevis and flexor pollicis brevis. The muscles most related to treatment of the injury are the extrinsic extensors and abductors and the adductor pollicis (Ritting, Baldwin & Rodner, 2010; Rhee, Jones & Kakar, 2005). The extensor and abductor muscles have the potential to exacerbate the rupture by moving in a similar direction to the mechanism of injury and reducing their movement will be one of the goals of orthotic treatment.

Adductor pollicis is the main stabiliser of the MCPJ, it also crosses Carpometacarpal joint inserting at the base of the proximal phalanx and MCPJ sesamoid. Allowing it some movement can lead to more rapid healing of the ligament as well as retaining some functionality of the thumb (McKee, Hannah & Priganc, 2012). Optimal healing of ruptured ligaments requires a period of immobilisation to allow a small amount of repair capable of enduring movement followed by a gradual introduction of stretch (Hardy & Woodall, 1998; McKee, Hannah & Priganc, 2012 ). The gradual stretch and movement is important, not just for allowing the ligaments to regain pre-injury length, but also preventing other tissues from losing their flexibility (Hardy & Woodall, 1998)

Orthotic treatment options
The main orthotic options focus on the immobilisation of the joint followed by a period of physiotherapy and limited mobilisation. The other joints of the thumb should stay functionally mobile to avoid complications and allow pinching and gripping movements to occur. This can be achieved with a number of orthotics over the course of the treatment path. They could be both custom made or generic off the shelf designs but they all follow the general pattern of preventing thumb abduction and extension around the MCPJ.

An initial option for an immediate immobilisation is suggested by Hart, Kleinert and Lyons' 2005 clinical notes for emergency department use. They suggest the use of a modified plaster spica splint that supports the hand in a neutral position. The splint is constructed from a long section of plaster bandage inserted into stockinette before wetting creating a strip long enough to encircle the thumb over and distal to the MCPJ but not further than the inter-phalangeal joint, cross over at the anatomical snuff box and encircle the wrist. The initial application of the stockinette/plaster occurs over the volar surface of the thumb then secured to the wrist with crepe bandage. The advantage of this method of immobilisation, particularly when compared with a solely plaster of Paris splint is the ease of removal in an emergency setting and the low cost when compared with implementing an off the shelf spica splint.

A consideration brought forward by Hart, Kleinert and Lyons and outlined further by Miller and Reinus (2010), in relation to the similar Bowler's thumb, is the potential for mechanical impingement of the ulnar digital nerve. The ulnar nerve runs superficially over bony prominences, particularly the seasamoid bones of the MCPJ and lacks excursion. Compression of the nerve is not painful but can result in residual paresthesia and potential nerve fibrosis if the impingement continues. Reduction of pressure points and an increase accommodation of individual anatomy in all of the orthotics acting around the MCPJ would reduce the risk of this mechanical impingement.

Michaud, Flinn & Seitz's 2010 clinical practice article and an older prospective randomised trial comparing immobilisation with a plaster cast to functional movable bracing in treating MCPJ ligamentous injuries by Sollerman, Abrahamsson, Lundborg & Adalbert (1991) both outline a braces that limit movement but allow enough to assist healing. The orthotic outlined by Michaud, Flinn & Seitz uses a thermoplastic to encompass the MCPJ from along the thenar crease to the most distal portion of the wrist - allowing for wrist flexion, then wrapping around the dorsal aspect of the hand around onto a small extension that wraps around the fifth metatarsal onto the palmar surface. The thenar trim line of the orthotic is attached to the ulnar side via a strap. The plastic runs though the web space of the thumb creating an open area for the thumb to fit through. Between the MCPJ and the inter- phalangeal joint a ring is placed and attached to the rest of the orthotic via two thermoplastic tubes fitted more to the radial side to facilitate the restrictive hinge. A design put forward by Ford, McKee & Szilagyi (2004) is of particular interest as it provides the support required but has been designed to assist sports people to return to play earlier owing to a durable shock absorbing neoprene cover. This can be applied to the patient in this case study as he desires an early return to work in tough conditions that may expose his injury to shock.

The design wraps the MCPJ in closely moulded thermoplastic trimmed to allow movement at the carpometacarpal joint and the inter- phalangeal joint. To hold this rigid section in place over the thumb a neoprene wrap completely covers the thermoplastic then runs across the palmar surface along the proximal palmar crease. Where the crease ends the wrap continues at the same level along the dorsal surface down past the wrist joint wrapping around to be joined via velcro around the wrist. When worn it resembles a glove with the fingers cut off along the line of the proximal palmar crease.

Comparison of orthotic treatment options
The two main orthotic aims that are presented in the literature is one of limited early movement and complete immobilisation. Complete immobilisation has largely been discounted as a viable treatment option owing the increased and more complete healing rates found with controlled early movement (Sollerman, Abrahamsson, Lundborg & Adalbert, 1991; Amini, 2011; Patel, Potty, Taylor & Sorene, 2010; Hardy & Woodall, 1998).

With this patient being on the higher end of level II rupture the main comparison would be with a surgical intervention. Operative treatment is generally successful in regard to pain relief, pinch strength and stability of the joint. It is, however, more commonly reserved for more serious complete ruptures of both the proper and accessory ligaments. Studies focusing on the comparative treatment outcomes have predominantly found lower range UCL injuries heal well with a conservative treatment plan involving early movement and splinting. Higher level complete ruptures with greater laxity are better treated with surgical intervention and a period of splinting and physiotherapy (Rhee, Jones & Kakar, 2005; Samora, Harris, Griesser, Ruff and Awan. 2013). The potential surgical techniques available for ligament repair have extend beyond suture based surgery to biological scaffolding embedded with growth factors to encourage rapid repair and autograft tendon replacement of ligamentous structures (Kiapour & Murray, 2014).Complete reconstructions using autograft tendons taken from other locations are more common in complete, unstable UCL ruptures though the majority are still treated with dissolving sutures (Patel, Potty, Taylor & Sorene, 2010). As the newer techniques are not being applied and the process of ligament repair is well established much of the research into UCL repair is much older than would be optimal. Much of this early research has been collated into some systematic reviews but far more commonly into reviews of clinical experience.

Functional Aims and Goals
The patient would like to return to his business; unfortunately even with job modifications the nature of the work means there are very few tasks that do not put his thumb’s MCPJ at great risk of re-injury. Operating a chainsaw is a major part of his work; it is gripped with his left hand forward holding a handle above the engine, with his injured right hand positioned rearward controlling the throttle and the movement of the saw through the timber. Although experienced operators try to avoid the situation, if a log is cut in the wrong manner chainsaws can jam and/or kickback with great force with any unforseen movement generally absorbed by the hands. Vibration from the engine is also an issue particularly with the hard plastic or POP of the orthotic resting on the handle (Husqvarna 2011).

Both the POP/high temperature thermo plastic (HTT) and the LTT orthotics aim to hold the MCPJ in enough flexion to allow the gripping of objects while preventing a repeat of the mechanism of injury while working. Given the environment it would have to survive in and the need for early movement a POP cast would be unsuitable for this application and the temporary nature of the injury would preclude the HTT.

As suggested by Ford, McKee & Szilagyi (2004) the use of a neoprene glove to both suspend the orthotic as well as offering impact protection would suit the functional goals in an environment where it is exposed to dirt, shock and vibration. If fabricated as suggested by the article only the MCPJ is immobilised allowing greater functional ROM in the thumb as it allows movement at the carpometacarpal joint. A preferable version in this case study would be to extend around the dorsal and palmar surfaces, with Velcro attachment on the medial side, to provide a greater lever arm against abducting and extending forces. The additional immobilisation the carpometacarpal joint will require the thumb to be positioned in a neutrally adducted posture, allowing the thumb and fingers to still meet their functional requirements.

Design
Design The design aims to prevent the MCPJ from moving during work activities that could potentially repeat the mechanism of injury- mainly abduction but also extension. As it is being used during specific activities it also has to hold the rest of the thumb in a functional position that allows it to perform the required tasks and oppose the other digits.

The available area to apply force is limited around the thumb, particularly distally to the MCPJ, so to create a longer lever arm to oppose any abduction the orthosis needs extend medially along the palmar and dorsal surfaces as possible (fig 1,2,3). The glove is designed to reduce the impact of vibration from machinery and soften any sudden impact. It holds the LTT firmly to the hand by slipping over the thumb, attaching via Velcro on the palmar surface then wrapping around the medial side of the hand to the dorsal section of the glove. The dorsal section of the glove is attached to the LTT via Velcro also.

LTT would be the ideal material as this is a temporary orthosis; it is quick and easy to produce and holds a firm but contoured position to the soft tissue of the hand. Neoprene was chosen as it is light, durable and has some stretch to hold the LTT portion firmly to the hand. It was also recommended by Ford, McKee & Szilagyi (2004) (fig 7).

The trim lines have to allow flexion and extension at the wrist, inter phalangeal joint of the thumb and the MCPJ’s of the fingers but also enough surface area to attach Velcro and provide enough of a lever to immobilise and resist movement around the MCPJ (fig -4,5,6). Similar trim lines would be used for a POP device.


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Manufacturing process
Materials: LTT, heating pan, water, towels, curved scissors, shears, first aid kit, heat gun, Velcro, neoprene, sewing machine, thread and bias binding.
 * LTT
 * 1. From an approximately 160mm by 150mm sheet of LTT cut, with shears, a basic thumb spica splint shape (fig 8)
 * 2. Heat in pan of water at 60-70C.
 * 3. When soft, pat off excess water on towels
 * 4. With client resting on elbow, hand up and thumb in a neutral, slightly flexed position lay the LTT into the web space of the thumb (fig9).
 * 5. Pinch a seam along lateral edge of thumb.
 * 6. Pull dorsal and palmar tabs until they meet on medial side.
 * 7. Apply pressure around the thumb and palmar surface to closely form LTT to the hand.
 * 8. Mark distal trim line for the thumb between interphalangeal joint and MCPJ adding enough to allow a later rollover of the edge.
 * 9. Remove while still soft and trim palmar and dorsal tabs
 * 10. Reheat thumb section till soft enough to cut the distal thumb trim line and thumb seam with curved scissors (fig 10).
 * 11. Reheat distal thumb trim lines and roll over to smooth edge
 * 12. Reheat palmar trim lines to roll over and smooth area around the palmar crease (fig 11)
 * 13. Allow to harden to check for sharp edges; if any heat and roll over or trim neatly with shears.
 * 14. Trial fit, if loose reheat and re-form to hand
 * 15. Attach hook sections of Velcro to palmar and dorsal tabs by heating LTT and back of Velcro with heat gun (fig 12).




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 * Glove.
 * 1. Basic pattern two and a half palm sizes wide can be used (fig. 13)
 * 2. A cotton trial pattern works best to locate and size darts for concave sections and a better fit (fig 14)
 * 3. Shape cotton to hand from basic pattern and cut and number for ease of reassembly (fig 15)
 * 4. Cut neoprene based on cotton pattern
 * 5. Sew joints with a wide zigzag stitch, double back for strength.
 * 6. Sew thumb section together by hand.
 * 7. Either over-lock edges or add bias binding.
 * 8. Sew loop Velcro on inside surface of glove to correspond with hooks on LTT (fig 16)
 * 9. Sew Velcro on dorsal surface and corresponding section on wrap around portion so the glove can be secured on (fig 16).
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 * Glove.
 * 1. Basic pattern two and a half palm sizes wide can be used (fig. 13)
 * 2. A cotton trial pattern works best to locate and size darts for concave sections and a better fit (fig 14)
 * 3. Shape cotton to hand from basic pattern and cut and number for ease of reassembly (fig 15)
 * 4. Cut neoprene based on cotton pattern
 * 5. Sew joints with a wide zigzag stitch, double back for strength.
 * 6. Sew thumb section together by hand.
 * 7. Either over-lock edges or add bias binding.
 * 8. Sew loop Velcro on inside surface of glove to correspond with hooks on LTT (fig 16)
 * 9. Sew Velcro on dorsal surface and corresponding section on wrap around portion so the glove can be secured on (fig 16).
 * 7. Either over-lock edges or add bias binding.
 * 8. Sew loop Velcro on inside surface of glove to correspond with hooks on LTT (fig 16)
 * 9. Sew Velcro on dorsal surface and corresponding section on wrap around portion so the glove can be secured on (fig 16).


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Critique of fit
Critique
 * -	44yo male with a ruptured ulnar collateral ligament, works as self employed arborist.
 * -	The client’s main focus is protection of the injury while working.
 * -	Initial swelling has reduced.
 * -	Tender around joint with limited movement without pain.
 * -	Client apprehensive about thumb being passively moved.
 * -	Client can maintain functional position without pain.
 * -	Orthotic aims to prevent a repeat of the mechanism of injury by providing the longest comfortable leaver arm to oppose an abduction movement at the thumb.
 * -	The device is firm around the target joint but too tight over the interphalangeal joint when donning and doffing. The tightness is fixed with a reheating and remodelling of the distal thumb trim line.
 * -	The dorsal strapping is unnecessarily large on the glove. By moving the base attachment points more medially the over-wrapping section can be shortened.
 * -	 Client can maintain a functional position to hold chainsaw and other tools as well as being able to oppose all digits with the thumb.
 * -	The trim lines allow for opposition of the digits and full flexion at the MCPJ’s of the fingers and PIP joint of the thumb.
 * -	The edges around the distal palmar crease and thumb are well rolled over.
 * -	The thumb is well positioned though the angle in the finger to thumb web space looks too severe but does not seem to cause issues.
 * -	The glove changed from being edged with bias binding to being over-locked for durability and ease of adjustment. It also took considerably less time to produce.
 * -	The LTT is pulled too thin on the dorsal section of the medial side. In the future applying a broader pulling force or allowing more material would prevent this.


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Outcome measures
The main function of this orthosis to protect against re-injury while the ligament heals; the injury also has the potential to heal with normal rest and no orthotic. Accordingly it makes it difficult to record before and after outcome measures in a direct gauging of the orthotics effect on improved functionality. What can be measured is his ability to perform similar manual tasks he could do before the orthotic while wearing the device whilst protecting the ligament as well as basic tests such as thumb opposition with the digits and pinch strength tests.

His physical recovery can be tracked with by using a function scale like the Quick Disabilities of the Arm, Hand and Shoulder (quickDASH) or an MRI and/or a palpation and strength test to see if the ligament has healed. The quickDASH, as the name suggests, is a shortened version of a general upper limb function test with a good re-test reliability and takes about 2 min to complete. It has been widely used since its publication in 1996 using a Likert scale to allow a patient to rate their ability to perform tasks with their upper limb (Angst, Schwyzer, Aeschlimann, Simmen & Goldhahn, 2011). We would be looking for a reduction in the DASH score as the injury heals.

Sample Referral
From: M Heskes 48-50 Edwardes St Reservoir, VIC 3073

18 May 2014

RE: Occupational Therapy for Mr John Smith

Dear Mr Willem de Ergotherapie,

My client wishes to return to work after experiencing an injury to the ulnar collateral ligament in his right thumb, and requires some help assistance with his rehabilitation.

Subject to your availability for a consultation, I believe he requires some assistance in modifying his current work practices (he is a self employed arborist) to reduce his risk of re-injury. The involved limb is his dominant side and he holds a very hands-on role as the primary worker in his business.

My treatment of John Smith to date has consisted of providing him with a low-temperature thermoplastic thumb brace, which holds his thumb in a neutral, slightly flexed functional position, which allows him to still use the chainsaws essential to his work. In addition to the hard plastic brace, I have provided him with a glove that covers the orthotic to reduce shock and the effects of the vibration from the machinery.

At the present time resting the thumb would be his best option, but as he is firm in his decision to return to actively work as an arborist. I am asking for your assistance in evaluating his work practices, as from what he has told me about his job there is a high risk of re-injury. In addition to a possible modifications of his work practices, it is likely that Mr Smith’s injury will need to be carefully monitored, and for Mr Smith to be educated as to injury aggravators and early warning signs of re-injury.

It is my goal for the brace to sufficiently protect Mr Smith’s ulnar collateral ligament so as to enable it to heal, while enabling him to work safely within his business. I hope we can work together and with Mr Smith to achieve his goals and help him heal safely. If, after any consultations you feel there could be any modifications the brace, please do not hesitate to contact me.

I can be freely contacted via dummyemail@fakeorthoticclinic.com.au or 03 9888 8888 should you wish to discuss Mr John Smith’s case in further detail.

Regards

M Heskes

Orthotist

Fake Orthotic Clinic