Early Return to Play With Thumb Spica Gauntlet Casting for Ulnar Collateral Ligament Injuries Complicated by Adjacent Joint Dislocations in Collegiate Football Linemen

Abstract

Background: Treatment of thumb ulnar collateral ligament (UCL) ruptures in elite athletes aims to restore thumb stability while minimizing lost playing time. Thus, surgical repair with early protected return to play in a thumb spica cast has been advocated. The purpose of this study was to document adjacent joint dislocations after primary surgical repair sustained during protected return to play with thumb spica casting in elite-level football players. Methods: Three Division I collegiate starting linemen sustaining adjacent joint dislocations in thumb spica casts following acute surgical repair of ipsilateral thumb UCL ruptures were retrospectively reviewed. Demographic data were recorded as well as the timeline for injury, treatment, and subsequent return to sport. Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores were obtained at final follow-up. Results: The mean time from thumb UCL injury to surgical repair was 8.7 days, and the mean return to sport was 13.3 days from surgery. There were 4 simple dislocations including 3 proximal interphalangeal (PIP) joints and 1 elbow. Each PIP dislocation was close reduced and treated with buddy straps with immediate return to play. The elbow dislocation was close reduced and splinted with return to play 22 days after injury. The mean QuickDASH score was 2.3 at 12 month follow-up. Conclusions: This report highlights that while thumb spica casting protects the surgically repaired thumb UCL and allows for earlier return to play, it risks placing additional stress upon adjacent joints and therefore adjacent injury. Appropriate counseling of the risks and benefits of this treatment strategy is essential.

Introduction

Acute thumb ulnar collateral ligament (UCL) ruptures occur with sudden forceful hyperabduction or hyperextension of the thumb metacarpophalangeal (MCP) joint.^{2,10,12,17,21} Complete injuries occur more frequently in elite athletes, particularly in collision sports such as football, as these players experience larger joint forces related to their increased size, speed, and power.^2,12 Long-term sequelae of these injuries include the potential for diminished pinch strength, pain, thumb instability, and secondary osteoarthritis.

Incomplete UCL tears can be treated successfully with cast immobilization of the thumb MCP. However, in the setting of complete injuries, these outcomes are less reliable, particularly in the setting of a “Stener lesion” where the adductor aponeurosis becomes interposed between the torn UCL and its insertion site on the proximal phalanx.¹⁹ Given the potential impact of this injury on a player’s career, surgical repair has become the standard treatment to allow for more reliable return to competitive play.^6,7

The vast majority of clinical studies involving thumb UCL injuries are reported in older, more heterogeneous patient populations.^{1,4-7,9,11,13-15,18,23} Thus, there is a paucity of clinical outcomes data pertaining to elite athletes. A systematic review from 2013 identified only 1 study reporting return to sport; however, this included all athletes.¹⁹ A more recent study by Werner et al in 2014 included only collegiate football players.²² They advocated that in non-skill position players, such as linemen, players could return to practice and games as tolerated 1 week postoperatively in a thumb spica cast and reported no complications with this protocol.

While constraining the thumb and wrist in a thumb spica gauntlet cast protects the surgically repaired thumb UCL and allows for earlier return to play, it risks placing additional stress upon adjacent joints which may subsequently become injured. This may prolong a player’s total recovery time and subsequent return to play. Thus, we report a series of 3 Division I collegiate football linemen sustaining acute adjacent joint dislocations during play in a thumb spica cast after complete rupture of the ipsilateral thumb UCL.

Materials and Methods

Study Cohort and Design

An institutional review board–approved retrospective review was performed including all patients having undergone surgical treatment for thumb UCL rupture performed by a single fellowship-trained hand surgeon over 2 football seasons from August 2014 to November 2015. Inclusion criteria consisted of Division I collegiate football players who underwent primary suture anchor repair (DePuy Mitek, Raynham, Massachusetts) of complete thumb UCL ruptures in the acute setting and subsequently sustained an ipsilateral adjacent joint dislocation following protected return to sport in a thumb spica gauntlet cast. Exclusion criteria included non-starting players, skill position players who would not be able to effectively play with thumb spica gauntlet casting, athletes in sports other than football, and partial thumb UCL ruptures.

Each patient’s medical record was reviewed retrospectively. Variables including demographic data, date of thumb UCL rupture, thumb UCL repair, protected return to play in thumb spica gauntlet cast, adjacent joint dislocation while playing in the gauntlet cast, subsequent interventions, and time to final return to sport were collected and analyzed. Return to sport occurred after receiving clearance from the senior author and was subcategorized based on when the player began full-contact practice as well as game play. The presence of a Stener lesion was confirmed based on the operative report.

All players included in this investigation were subsequently contacted via telephone. The players were asked whether they felt that the gauntlet cast contributed to their ipsilateral adjacent joint dislocations and whether they were able to return to their previous level of competitive play. In addition, the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) outcomes measure questionnaire was administered via telephone, and the results were recorded. Descriptive statistics were calculated and continuous data were reported as the mean ± standard deviation.

Diagnosis of Acute Complete Thumb UCL Rupture

Each patient included in this investigation was diagnosed with an acute complete rupture of the thumb UCL by the fellowship-trained hand surgeon based on the presence of pain and swelling localized to the ulnar aspect of the thumb MCP joint with associated instability upon stress testing. Instability was defined as the lack of a firm end point with radial deviation of the thumb MCP at full extension and 30^o of flexion. Fluoroscopic examination was also utilized to confirm the diagnosis. The presence of a palpable mass in the first web space was noted on physical examination as was recognition of a Stener lesion at the time of surgery.

Surgical Repair Technique

Primary suture repair of the thumb UCL was performed utilizing suture anchor fixation in each case. A curvilinear incision was centered over the dorsoulnar aspect of the thumb MCP joint. The superficial radial nerve was visualized and protected throughout the duration of the procedure. The adductor aponeurosis was inspected for the presence of a Stener lesion and was subsequently incised to expose the dorsoulnar joint capsule. A capsulotomy exposed the UCL ligament rupture from the proximal phalanx in each case. A rongeur was used to prepare the bony bed at the insertion site for placement of a Mini QUICKANCHOR (DePuy Mitek, Raynham, Massachusetts) suture anchor. Care was taken to remain extra-articular by aiming away from the joint surface. Holding the MCP joint reduced, a 2-0 braided high-tensile strength polyester suture was used to secure and restore the anatomy of the UCL at its insertion. The volar plate was incorporated into the repair when adequate tissue was present and when indicated. The capsule, adductor aponeurosis, and skin were repaired in layers followed by application of a thumb spica splint.

Postoperative Care

Patients were maintained non-weight-bearing in a thumb spica splint immediately postoperatively. Evaluation of the wound was performed at 1 week, and players were transitioned into a removable gamekeeper splint. Guided gentle range of motion exercises were initiated at this time.³ In addition, players were cleared to return to practice and game play as tolerated with the use of a removable thumb spica gauntlet cast. Thumb strengthening was initiated 4 weeks postoperatively, and players were allowed to play without the gauntlet cast at 3 months postoperatively.

Results

Three Division I collegiate linemen were included in this study (Table 1). Each player started at his respective position and sustained a hyperextension injury to the thumb resulting in complete rupture of the thumb UCL. A Stener lesion was present in 2 of 3 cases. The mean time from thumb UCL rupture to suture anchor repair was 8.7 ± 4.6 days (range: 6-14 days). Following surgical intervention, the mean time to return to game play was 13.3 ± 2.9 days (range: 10-15 days). Of note, 1 player opted to practice and play in a cast prior to surgical intervention given the importance of the upcoming game to the season.

Table 1.

Demographic Data.

Player	Age	Position	Dominant hand	Mechanism	Stener lesion	Follow-up, mo
1	20	Offensive lineman (OL)	No	Thumb hyperextension injury during game	No	12
2	22	Defensive tackle (DT)	No	Thumb hyperextension falling to ground during practice	Yes	12
3	22	Defensive end (DE)	No	Thumb hyperextension while tackling during game	Yes	12

A total of 4 adjacent joint dislocations occurred in the 3 linemen at a mean time of 20.5 ± 9.2 days from the date of thumb UCL rupture (range: 8-30 days). One player sustained 2 dislocations of the ipsilateral long finger proximal interphalangeal (PIP) joint in 2 subsequent games at 17 and 24 days postoperatively. A second sustained a single ipsilateral ring finger PIP joint dislocation 15 days following surgical repair. In each case, the player close reduced his own finger and continued to play with buddy strapping in addition to the thumb spica gauntlet cast. Radiographs in each case were negative for fracture, and each injury was treated nonoperatively. The third player opted to delay surgical intervention, practicing, and playing in a cast given the importance of the upcoming game to the season. He sustained an in-game elbow dislocation that weekend, 6 days prior to surgical fixation of his thumb UCL. He was removed from play, close reduced, and splinted by team physicians on the sideline. Radiographic and fluoroscopic examination in the clinic demonstrated a concentrically reduced elbow without fracture. Range of motion was stable without apprehension or significant discomfort from 30° to 130° of flexion. This player’s elbow was treated nonoperatively. He subsequently underwent surgical fixation of his thumb UCL and was able to return to sport 22 days after his elbow dislocation (15 days postoperatively) in a hinged elbow brace in addition to a thumb spica gauntlet cast. Each player was able to return to sport at his preinjury level. The mean QuickDASH score and sport subscore were 2.3 and 12.5, respectively (on a scale from 0 [best] to 100 [worst], with scores below 10.1 considered normal for the general population⁸) at 12 month follow-up. A summary of this data can be found in Table 2.

Table 2.

Clinical Data.

Player	Time from UCL rupture to surgery, days	RTP from surgery, days	Dislocation	Time from UCL rupture to dislocation, days	RTP following adjacent joint dislocation, days	QuickDASH score (sport subscore)
1	6	10	Long finger PIP	23	0	0 (0)
			Long finger PIP	30	0
2	6	15	Ring finger PIP	21	0	0 (0)
3	14	15	Elbow	8	22	6.8 (37.5)
Mean	8.7	13.3		20.5	5.5	2.3 (12.5)

Note. UCL = ulnar collateral ligament; RTP = return to play; QuickDASH = Quick Disabilities of the Arm, Shoulder and Hand; PIP = proximal interphalangeal.

Discussion

In this study, we evaluated the postoperative course of 3 Division I collegiate starting linemen sustaining 4 adjacent joint dislocations following primary surgical repair for acute complete thumb UCL ruptures. Each was cleared for return to competitive sport as tolerated with the thumb protected in a custom, removable thumb spica gauntlet cast and subsequently sustained an ipsilateral joint dislocation during game play. Two players sustained PIP joint dislocations that were closed reduced on the field and buddy-taped, allowing for immediate return to play. The third player sustained a simple elbow dislocation, necessitating closed reduction on the sideline and removal from competition for 3 weeks. No additional surgical procedures were required related to these injuries. This report highlights an important complication of immobilization and early return to sport following surgical stabilization of thumb UCL ruptures that should be considered when counseling and treating competitive athletes sustaining upper extremity injuries.

Complete ruptures of the thumb UCL are common injuries in Division I football players.²² Primary surgical repair is advocated within 3 to 6 weeks of injury as delayed repair yields unreliable outcomes. Otherwise, reconstructive rather than reparative procedures become necessary.^16,20,21 Similarly, nonoperative management risks chronic instability and pain, particularly with the presence of a Stener lesion.¹⁹ In elite-level athletes, treatment strategies aiming to minimize lost playing time while maximizing the prognosis for full recovery are paramount as both can have significant short-term and potentially long-term career implications.²² Despite this, there is a clear paucity of evidence to advise proper treatment.

To our knowledge, a single study exists reporting clinical outcomes of college football athletes after acute primary thumb UCL repair.²² Players were defined as skill position players (quarterback, running back, wide receiver, tight end) versus non-skill position players (linemen and linebackers) based on the need to use of their hands to catch and throw the football. Skill position players were not allowed to play following injury, and surgery was immediately scheduled. Conversely, non-skill position players were protected in a cast or rigid orthosis and allowed to continue playing as tolerated with surgical fixation at the end of the season or training period. Non-skill position players, such as linemen, tended to undergo surgery later than skill position players (43 vs 12 days); however, they returned to play earlier (4 weeks postoperatively vs 7 weeks). Ultimately, all 18 players included in the study returned to at least the same level of play after primary surgical repair using suture anchor fixation.

Given these findings, the 3 players in this report (all of whom were non-skill position players) were offered primary surgical fixation using a suture anchor construct as well as a thumb spica gauntlet cast to allow for protected return to play as tolerated at 1 week postoperatively. Each player achieved a stable thumb without pain or dysfunction, indicating successful repair in each case. While they were allowed to return to full play within 2 weeks, each player felt that the use of a cast, which minimized time away from the playing field, contributed to their sustaining adjacent joint injuries. Each PIP joint dislocation occurred during a hyperextension moment that the wrist was not able to accommodate in the cast. In each case, closed reduction was performed on the field and players returned to immediate play with buddy strapping of the fingers; however, 1 player sustained 2 separate dislocations of the same finger in 2 separate games. In each case, the player felt that being immobilized at the wrist placed additional stress on the finger, resulting in injury.

The player sustaining the elbow dislocation recounted contorting his arm in an awkward position, which was the only way he had a chance to grab an opposing ball carrier’s jersey. However, this left his arm vulnerable in an extended position. An opposing lineman’s helmet subsequently struck his posterior elbow in this position, resulting in hyperextension and dislocation of his elbow. This resulted in him being unable to return for 3 additional games, which was a significant portion of his senior season and ultimately impacted his prospects as a professional player.

There are several limitations to the current study inherent to a retrospective review, including recall bias as each player was interviewed several months after their injuries. In addition, the small sample size, while potentially reflective of the rare nature of this complication, limits the ability to make generalized recommendations in support of or against the described treatment protocol in elite-level athletes. However, this report does bring to light the potential for adjacent joint injuries, which may further complicate or delay a player’s return to preinjury levels of play. While this report focuses on injuries sustained during protected early return to play in a thumb spica gauntlet cast following surgical repair of acute complete thumb UCL ruptures, these results may be extrapolated to other splinted or braced sporting injuries where early protected return to play is possible.

Conclusions

While elite-level football players are most likely to opt for earlier return to play protected in a cast, this report documents the occurrence of adjacent joint dislocation in 3 starting Division I collegiate linemen who underwent surgical repair of thumb UCL ruptures. While a subjective measure, these players attributed their injuries to limitations inherent in playing with cast immobilization, and in 1 case, this resulted in the player missing a significant portion of his season. These findings highlight the importance of counseling these patients regarding the preoperative and postoperative risks including adjacent injuries as well as potential short- and long-term consequences related to these injuries.