There is also significant performance bias, as there are multiple different methods of treatment, providers, graft, suture, and fixation types, as well as methods and duration of immobilization. The major arc of motion of the thumb MP joint is flexion and extension, although there is some abduction, adduction, and rotation. Wong TC, Ip FK, Wu WC. eCollection 2022 May. It was hypothesized that surgical management results in equivalent outcomes for both acute and chronic UCL injury. 13. Baar H, Baar B, Kaplan T, Erol B, Tetik C. Chir Main. Mean Quality Appraisal Tool score was 13.1 (55% overall rating study methodological quality). Epub 2020 Jun 29. *Glickel grading system. There were 6 studies that reported clinical outcomes after autograft UCL reconstruction.11,18,19,21,22,27 Reconstruction techniques (Table 5) and grafts included palmaris longus via bone tunnels with or without K-wire MP joint fixation, palmaris longus with suture anchor fixation, iliac crest boneperiosteumbone graft with cortical screw fixation, and extensor carpi radialis longus bonetendon ligamentoplasty with titanium screw and suture anchor fixation. Roy J, MacDermid J, Woodhouse L. Measuring shoulder function: a systematic review of four questionnaires. An official website of the United States government. abductor pollicis longus (PIN) proximal, dorsal, and radial force on the shaft fragment. Metacarpophalangeal joint injuries of the thumb. Furthermore, it is interesting that our study quality results using the Quality Appraisal Tool were as low as they were (mean 54% with a range of 33%-79%). Commonly, the joint will be permanently enlarged due to the scarring of the healing process. Ford GM, Genuario J, Kinkartz J, Githens T, Noonan T. Am J Sports Med. 415 Ray C Hunt Drive, Suite 3200 Charlottesville, VA 22903 434-982-HAND (4263) The https:// ensures that you are connecting to the ||Injury chronicity not always defined, but we used ,3 weeks for acute injury and .3 weeks for chronic injury. Inclusion criteria included English language studies after nonoperative or operative treatment of thumb UCL injuries with a minimum of 2 years mean follow-up. Epub 2015 Sep 22. A sprained thumb is a common injury among athletes. 2022 Jul;50(8):2324-2338. doi: 10.1177/03635465211023952. After application of all inclusion and exclusion criteria, 14 studies were identified for further analysis and review. Complications, failures, and reoperations are rare after surgical treatment of UCL injury. Van Dommelen BA, Zvirbulis RA. 2022 Jun;54(2):191-196. doi: 10.5152/eurasianjmed.2022.22024. 1999;24:7075. Among cases with concomitant transposition performed, submuscular transposition resulted in a higher rate of reoperation for ulnar neuropathy (12.7%) compared with subcutaneous transposition (0.0%). PMC Mean subject age was 33.9 years. [16] Despite these study limitations, this systematic review is strong in that it analyzes the largest number of studies and subjects in the literature managed with both nonoperative and operative means for acute and chronic UCL injury. eCollection 2021 Nov. Yu JS, Carr JB 2nd, Thomas J, Kostas J, Wang Z, Khilnani T, Liu K, Dines JS. When a broken bone fails to heal it is called a "nonunion." A "delayed union" is when a fracture takes longer than usual to heal. After the nerves exit the spinal cord, they connect from the Axillary (armpit) and upper arm . Rupture of the. Clipboard, Search History, and several other advanced features are temporarily unavailable. In these patients, after failure of nonoperative treatment at anywhere from 1 month to more than 6 years, nearly all patients can achieve complete pain relief, normal pinch and grip strength, joint stability, and range of motion after surgical reconstruction. Range of motion returns much sooner, too. Complications after surgical treatment of UCL injury are rare. A blunt self-retainer is used to retract the musculature, and a small periosteal elevator can be used to clean any remaining muscle fibers from the UCL. Part I of this two-part article focuses on common tendon and . Julie Balch Samora, MD, PhD; Joshua D. Harris, MD; Michael J. Griesser, MD; Michael E. Ruff, MD; Hisham M. Awan, MD. Rao S, D'Amore T, Willier DP 3rd, Gawel R, Jack RA 2nd, Cohen SB, Ciccotti MG. Orthop J Sports Med. 2021 Apr 22;9:20503121211003362. doi: 10.1177/20503121211003362. Our objective was to compare the complication rates after thumb metacarpophalangeal joint (MCP) radial collateral ligament (RCL) versus ulnar collateral ligament (UCL) repair. Wolters Kluwer Health, Inc. and/or its subsidiaries. Kuz JE, Husband JB, Tokar N, et al.. Exercises: Progress to Phase II throwing (once successfully completed Phase I) POST-OPERATIVE WEEK 30-32 . eCollection 2021 Mar. [30,43,44] It has been well documented that direct suture techniques fail in chronic injuries. Smith RJ. MeSH 1995;18:11611165. The mechanism of UCL injury is a forced abduction or rotation and hyperextension injury of the thumb at the MP joint.32 The most common region of rupture of the UCL is at the distal insertion or in the distal aspect of the ligament, leaving the proximal stump intact.32 Ulnar collateral ligament injuries can involve injuries to the dorsal capsule, palmar plate, and adductor aponeurosis.33 Avulsion fractures of the ulnar base of the proximal phalanx occur 20% to 30% of the time.17,34 Anywhere from 14% to 64% of UCL injuries have associated Stener lesions, which occur when the adductor aponeurosis is interposed between the ruptured end of the UCL and its site of proximal phalanx attachment.32, Nonsurgical treatment has been advocated for nondisplaced, or minimally displaced avulsion fractures of the UCL either with functional bracing35 or via thumb spica casting or splinting.23,3638 Kuz et al recommend that most acute avulsion fractures of the thumb UCL be treated nonsurgically, with the exception of displaced fractures with more than 30% articular involvement or bony Stener lesions. Before Hand Clin. Study data collected and analyzed included subject demographics, number and gender of the subjects, number of nonoperative thumbs, sidedness, dominance, subject age, subject weight, and body mass index, throwing athlete status, mean duration follow-up, UCL injury classification, location of UCL injury (proximal, midsubstance, or distal), number of subjects with Stener lesions, number of subjects with avulsion fractures, mechanism of injury, injury chronicity (defined by 3 weeks based on repair vs reconstruction treatment dichotomy proposed by Smith in 1977),17 length of symptoms, graft type used (autograft or allograft), and implant used. eCollection 2022 Jan. Gnanasekaran D, Raveendranath V, Karupusamy A. J Hand Microsurg. [32], Nonsurgical treatment has been advocated for nondisplaced, or minimally displaced avulsion fractures of the UCL either with functional bracing[35] or via thumb spica casting or splinting. 2. Epub 2016 Jan 13. Thus, the latter group of patients (n = 93) was reported separately as chronically UCL-deficient operatively treated subjects' outcomes (Table 3) with attempted prior nonoperative treatment. Acta Chir Scand. Infection is a rare complication of hand surgery. Purpose. If the tear is diagnosed later a ligament reconstruction might be a better option. The thumb joint may feel loose and unstable, making it difficult to grasp objects between the thumb and index finger. Symptoms are dependent on the cause and severity of injury to the UCL. Bailie DS, Benson LS, Marymont JV. Complications If the UCL is ruptured there is a possibility that the distal end may become interposed by the adductor aponeurosis, which is referred to as a Stener lesion (Figure 5). Positive ulnar variance is used to describe a forearm where the distal ulna is no longer in line with the distal radius, resulting in the ulnar being longer. Click the topic below to receive emails when new articles are available. The following clinical outcome parameters were extracted, if available, from each article identified for further review and scrutinized: pain, range of motion, key-pinch strength, stability testing, number of retears, range of motion posttreatment, prekey-pinch strength and postkey-pinch strength, and complications. Nonoperative treatment of acute UCL injury (with or without a Stener lesion) frequently fails, leading to chronic pain, instability, and weakness, eventually prompting surgical intervention. At this stage, patients should be advised to wear your splint part-time. Glickel SZ, Malerich M, Pearce SM, et al.. Ligament replacement for chronic instability of the, 28. doi: 10.1016/j.asmr.2020.12.004. Alejandro Badia Orthopedic Hand Surgeon Hands, Elbow, Shoulder and Wrist - Badia Hand to Shoulder Ce. Acute rupture of the ulnar collateral ligament (UCL) of the thumb - also known as 'skier's thumb' - is a common injury which may cause long-term complications if inadequately treated. Complications, failures, and reoperations are rare after surgical treatment of UCL injury. I was able to work while wearing the splint. Please use this form to submit your questions or comments on how to make this article more useful to clinicians. J Bone Joint Surg Am. 22. Thirty-two thumbs were treated nonoperatively and 261 operatively. Pain, range of motion, key-pinch strength, and stability testing were used as outcome measures. Tommy John surgery; ulnar collateral ligament reconstruction; ulnar nerve transposition; ulnar neuropathy. Epub 2019 Mar 21. Trends in Patient, Physician, and Public Perception of Ulnar Collateral Ligament Reconstruction Using Social Media Analytics. Non-Fusion. Conflicts of interest The authors report no funding or conflicts of interest. Objectives: No Difference in Complications Between Elbow Ulnar Collateral Ligament Reconstruction With the Docking and Modified Jobe Techniques: A Systematic Review and Meta-analysis. J Hand Surg Am. All but 2 studies were level IV evidence (there was one level II prospective cohort19 and one level III evidence retrospective comparative study20). If your bone is broken, a pin will be used to put it in place. Injuries to the PIP joint remain swollen for long periods of time. This review has demonstrated excellent clinical outcomes after surgical treatment of both acute and chronic UCL injury, without any significant difference between repair and reconstruction for acute and chronic injury, respectively. Chir Main. There are some cases where the fusion is not successful and you will still have pain in . Injury. 25. 21. Further detection bias existed in that not all studies used each clinical outcome (eg, Glickel grade) or radiographic measure postoperatively. Ulnar collateral ligament (UCL) injuries have significantly increased over the past few decades, especially in young throwing athletes. Am J Sports Med. Detection bias was present in the inconsistent use of an invalidated outcomes tool (Glickel grading system), visual measurement of range of motion, different tools for strength and stability measurement, and the subjective nature of reporting weakness and stability. Seventeen articles (n = 1518 cases) met the inclusion criteria, all retrospective cohort studies. All techniques improved clinical outcomes, including pain, motion, strength, and stability. Background:Thumb ulnar collateral ligament (UCL) tears are common in competitive athletes. A chi-square test of independence was performed to examine the relation between UCL versus RCL repair and presence of a complication. No significant difference in the outcome was demonstrated between different types of autograft used for UCL reconstruction. The injury happens when you fall . It is an often-encountered injury and can lead to chronic pain and instability when diagnosed incorrectly. [23,3638] Kuz et al recommend that most acute avulsion fractures of the thumb UCL be treated nonsurgically, with the exception of displaced fractures with more than 30% articular involvement or bony Stener lesions. Background: No study compared different graft types or fixation techniques. An official website of the United States government. Epub 2014 Oct 22. 1-6 weeks: If the ligament is partially torn then a splint or cast is usually worn for six weeks and after its removal a programme of exercises is . Am J Sports Med. *Gender reported in 12 studies (218 subjects). In sports or at work, injuries to the collateral ligament of the thumb's metacarpophalangeal (MCP) joint and the proximal interphalangeal (PIP) joints of the fingers are common [].The most common mechanism for a thumb ulnar collateral ligament (UCL) rupture is the forced abduction and hyperextension of the MCP joint of the thumb [2,3,4,5,6,7], which can occur when someone falls on the thumb . In addition, this study examined how the rate of ulnar nerve complications varied as a function of surgical exposures, graft fixation techniques, and ulnar nerve management strategies. Symptoms of the UCL injury include pain, instability of the MCP joint of the thumb, and weakness in prehension and the chronicity of the injury. The limitations of this systematic review are reliant on the studies analyzed. 2009;61:623632. 44. Pain, range of motion, key-pinch strength, and stability testing were used as outcome measures. Furthermore, the lack of patient-specific data precluded advanced statistical calculations, and weighted means from individual studies were the basis for comparison. The evidence regarding operative and nonoperative treatments of acute and chronic thumb UCL insufficiency is primarily limited to level IV retrospective case series and level V expert opinion. It was hypothesized that no difference exists between different types of grafts used for thumb UCL reconstruction. Accessibility Ulnar collateral ligament tear represents 60 percent of upper limb problems in skiers and is frequently overlooked and underdiagnosed. The doctor won't know if the repair is . There is no uniformly agreed on surgical indication for UCL injuries to the MP joint of the thumb. In these cases, a new graft may be used to perform a second reconstruction. 23. Gamekeepers thumb: a prospective study of functional bracing. 8. Quantitative outcome of surgical repair. Accurate diagnosis of finger injuries can often be difficult, given the complicated soft-tissue anatomy of the hand and the diverse spectrum of injuries that can occur. important to begin moving your fingers right after surgery and keep them moving to avoid stiffness. Clinical outcome studies after nonoperative or operative treatment of thumb UCL injuries, with a minimum of 2 years mean follow-up, were included. No significant difference in the outcome was demonstrated between different types of autograft used for UCL reconstruction. Pain Swelling Bruising A weaker pinch or problems grabbing things when you use your thumb If surgery is needed, the ligament is reconnected to the bone. Main results: Jackson M, McQueen MM. 45. [17,34] Anywhere from 14% to 64% of UCL injuries have associated Stener lesions, which occur when the adductor aponeurosis is interposed between the ruptured end of the UCL and its site of proximal phalanx attachment. Am J Sports Med. By nature of the definition of chronic UCL deficiency, patients with remote UCL injury have either been untreated or have failed prior nonoperative treatment (for various reasons such as pain, weakness, or instability) and gone on to necessitate surgical intervention. The triangular fibrocartilage complex (TFCC) is an important stabilizer of the distal radioulnar joint (DRUJ). Consensus was obtained between the authors on assignment of study quality scores with any score dispute being decided by default assignment of the lower of the 2 disputing scores, as originally reported and recommended in the original study using the Quality Appraisal Tool.16. may email you for journal alerts and information, but is committed Re-rupture occurred in 1 patient, chronic subluxation occurred in 1 patient, and chronic pain/stiffness occurred in 5 patients. I had a UCL injury (incomplete, didn't require surgery) with a small avulsion fracture to my right thumb in 2015 at the age of 36. Most times, they won't know until they're in the surgery if the internal brace is appropriate. Eventually this abnormal movement will wear out the joint and it will become arthritic. Despite a perception that UCLR has minimal morbidity, a review of all published literature revealed that 12.0% of UCLR surgeries result in postoperative ulnar nerve complications. Although many injuries can be managed conservatively, some require more invasive interventions to prevent complications and loss of function. Please try after some time. Ritting et al30 assert that operative management of acute injuries is indicated when the thumb is without an endpoint to valgus stress testing. No study directly compared the different types of graft for UCL reconstruction. The original study using this tool had a mean quality score range of 25% to 96% but had more than half of the studies scoring >75%. The rate of complications after RCL primary repair was higher than UCL repair, however not statistically significant. When untreated, this injury may lead to decreased pinch strength, pain, instability, and osteoarthritis. Therefore, these patients were included in the surgical group for analysis, as they did have more than 2 years minimum clinical follow-up after surgical treatment. 35. Griffith TB, Ahmad CS, Gorroochurn P, D'Angelo J, Ciccotti MG, Dines JS, Altchek DW, Camp CL. Orthop J Sports Med. HHS Vulnerability Disclosure, Help Bone-periosteum-bone graft reconstruction for chronic ulnar instability of the metacarpophalangeal joint of the thumbminimum 5-year follow-up evaluation. You may be trying to access this site from a secured browser on the server. It is the result of repetitive stretching and abduction stresses of the ulnar collateral . 12. 1992;8:713732. When untreated, this injury may lead to decreased pinch strength, pain, instability, and osteoarthritis. The range of motion of the MP joint of the thumb following operative repair of the. When evaluating the relationship between ulnar and radial ligamentous injury and the presence or absence of complication, there was no significant difference, however trends were noted, X. A broken thumb can also cause numbness or tingling. Conclusion: eCollection 2021. Purpose: Abstract Objectives: Rupture of the ulnar collateral ligament (UCL) is a frequent injury of the hand. Careers. If you log out, you will be required to enter your username and password the next time you visit. Abstract. [30] The stability of the MP joint derives from joint congruity, the true and accessory collateral ligaments, the volar plate, and the surrounding intrinsic muscles. Simmons underwent surgery, also performed by Shin, to repair a torn UCL in his left thumb (like Trout, Simmons injured his non-dominant thumb). abduction-adduction motion. [32] The most common region of rupture of the UCL is at the distal insertion or in the distal aspect of the ligament, leaving the proximal stump intact. 1 An injury to the ulnar collateral ligament occurs when this structure is stretched too far. Meta-analysis of the pooled data was completed. Federal government websites often end in .gov or .mil. 1,5,9,10 In acute cases of complete tears involving high-level . Despite 11 of these patients (34%) remaining symptomatic, 5 remaining clinically unstable, and a 25% (n = 8 patients) nonunion rate, all 32 were satisfied with their clinical outcome (mean, 3 years follow-up). Pain reduction was significantly improved in all subjects (P < 0.05). Before Complications after this procedure may include nerve or blood vessel damage. PMC Surgical management of chronic, 42. Arthrosc Sports Med Rehabil. There is currently no consensus on treatment of acute or chronic UCL injuries. Nonoperative treatment of acute UCL injury (with or without a Stener lesion) frequently fails, leading to chronic pain, instability, and weakness, eventually prompting surgical intervention. The ulnar collateral ligament (UCL) of the thumb is commonly injured by falling onto an outstretched hand or in sports where the thumb metacarpal phalangeal joint (MP) is hyperextended or hyper-abducted. The injury involves the ulnar collateral ligament (UCL) of the thumb. Subject, surgical, and study data were compared using 2-sample and 2-proportion Z-test calculators with alpha 0.05 because of the difference in sample sizes between the compared groups. All continuous data for independent and dependent variables were assimilated with weighted means and SDs based on the number of subjects or thumbs and the applicable means and SDs. Background:Thumb ulnar collateral ligament (UCL) tears are common in competitive athletes. Would you like email updates of new search results? Further detection bias existed in that not all studies used each clinical outcome (eg, Glickel grade) or radiographic measure postoperatively. This systematic review has demonstrated excellent clinical outcomes (pain, strength, motion, and stability) after surgical treatment (repair and autograft reconstruction) of both acute and chronic UCL injury, without any significant difference between repair and reconstruction for acute and chronic injury, respectively. Only prospective studies can determine this injury course. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). National Library of Medicine Figure 46-2 Approach to the ulnar collateral ligament. PLoS Med. The ECRL bone-tendon ligamentoplasty for chronic ulnar instability of the metacarpophalangeal joint of the thumb. **Stener lesion status reported in 6 studies (145 thumbs). Acute UCL repair and autograft UCL reconstruction for chronic injury led to excellent clinical outcomes, without a significant difference between the 2 groups. Some injuries can be associated with a Stener lesion, which is displacement of the ruptured ligament proximal to the adductor aponeurosis, effectively precluding healing without operative treatment.6, Acute injuries can be treated with immobilization or surgically with direct repair using bone anchors, direct repair using bone tunnels and pullout sutures, or tension band fixation of bony avulsions.79 If an injury is chronic, there are several operative treatment options, including ligament reconstruction with tendinous autograft or allograft, bonesoft tissuebone autograft, or even fusion of the MP joint.1012. Am J Sports Med. After the surgery you will lose some mobility in the thumb, but you are still able to grasp objects. Eurasian J Med. Highlight selected keywords in the article text. Ulnar collateral ligament injuries of the thumb (gamekeeper or skier thumb) are more common than the radial side but both can cause significant disability. 1998;23:503506. and transmitted securely. Search terms included thumb, ulna(r), collateral, ligament, UCL, repair, reconstruction, and treatment. Return-to-Play Outcomes in Professional Baseball Players After Medial Ulnar Collateral Ligament Injuries: Comparison of Operative Versus Nonoperative Treatment Based on Magnetic Resonance Imaging Findings. 1976;58:106112. Physical examination of the thumb demonstrates the instability of the MCP joint, impossibility of opposition of the thumb, and the weakening of gripping force.5,6 This includes, but not limited to, self-retrograde massage, cold therapy, and extremity elevation. Keywords: Downey DJ, Moneim MS, Omer GE Jr. Clipboard, Search History, and several other advanced features are temporarily unavailable. Corresponding Author: Hisham M. Awan, MD, The Ohio State University Hand and Upper Extremity Center, 915 Olentangy River Rd, Suite 3200, Columbus, OH 43212 ([emailprotected]). They may even tear completely. All authors independently performed the search. Usually it is pulled off of the bone (proximal phalanx) on the nail side of the joint. Bookshelf After three to four weeks, the joint should heal enough to remove the splint and begin strengthening exercises. Hand Surg. J Bone Joint Surg Am. This systematic review has demonstrated excellent clinical outcomes (pain, strength, motion, and stability) after surgical treatment (repair and autograft reconstruction) of both acute and chronic UCL injury, without any significant difference between repair and reconstruction for acute and chronic injury, respectively. Catalano LW III, Cardon L, Patenaude N, et al.. Surgery has been recommended for fracture displacement, significant articular involvement, clinical instability, or fragment rotation. 2006;31:6875. [6] Treatment [ edit] A post-operative photo of repair of a complete rupture of the ulnar collateral ligament. [33] Avulsion fractures of the ulnar base of the proximal phalanx occur 20% to 30% of the time. 2013;23(4):247-254. The fixation technique associated with the highest rate of neuropathy was the modified Jobe (16.9%) versus DANE TJ (9.1%), figure-of-8 (9.0%), interference screw (5.0%), docking technique (3.3%), hybrid suture anchor-bone tunnel (2.9%), and modified docking (2.5%). Of the 262 potentially relevant studies, 14 studies were identified for review11,15,1829 (Figure 1). Pearl: ensure slight adduction of thumb when placing the thumb spica splint for skier's thumb to reduce stress on the UCL. Abstract Objectives: Rupture of the ulnar collateral ligament (UCL) is a frequent injury of the hand. 1999;24:275282. Bostock S, Morris MA. Methodological quality of the study was assessed using the Quality Appraisal Tool (Table 1). Rupture of the ulnar collateral ligament (UCL) is a frequent injury of the hand. Nonoperative treatment of acute UCL injury (with or without a Stener lesion) frequently fails, leading to chronic pain, instability, and weakness, eventually prompting surgical intervention.. doi: 10.1097/JSA.0000000000000322. Fusetti C, Papaloizos M, Meyer H, et al.. There were 61 studies eliminated as secondary for being in a language other than English. Your thumb will be immobilized in a splint and should not be moved until follow up. Meta-analysis of the pooled data was completed. Furthermore, it is interesting that our study quality results using the Quality Appraisal Tool were as low as they were (mean 54% with a range of 33%-79%). Please confirm that you would like to log out of Medscape. Am J Sports Med. 1989;14:567573. The diagnosis is best established clinically, though MRI is the imaging modality of choice. The rate of complications after RCL primary repair was higher than UCL repair, however not statistically significant. Thumb sidedness reported in 3 studies (51 thumbs). Both x-ray and magnetic resonance imaging evidence confirmed no increase in MP joint osteoarthritis at up to 75 months, postoperatively. The mean prevalence of postoperative ulnar neuropathy was 12.0% overall after any UCLR procedure at a mean follow-up of 3.3 years, and 0.8% of cases required reoperation to address ulnar neuropathy. Potentially inclusive articles were manually reviewed, discussed among the authors, and a decision was made regarding inclusion or exclusion. Unauthorized use of these marks is strictly prohibited. Docs Struggle to Keep Up With the Flood of New Medical Knowledge. Am J Orthop (Belle Mead NJ). Study design: Both purely ligamentous and bony avulsion injuries were included. In a recent study, 49% of UCL disruptions of the thumb were caused by a fall onto an outstretched hand. Rupture of the thumb ulnar collateral ligament (UCL) is a frequent injury of the hand, commonly caused by sports injuries and falls onto an outstretched hand.15 The mechanism of injury usually involves hyperabduction or hyperextension of the metacarpophalangeal (MP) joint of the thumb.6 Disruption of the UCL leads to decreased pinch strength, pain, instability, and ultimately osteoarthritis. Mean study follow-up was 42.8 months. He too had the internal brace augmentation. A p-value of 0.05 was considered statistically significant. TREATMENT: Treatment consists of either a period of splintage or if completely torn,a repair of the ligament with an operation. Thumb Metacarpophalangeal Joint Ulnar Collateral Ligament: Early Outcomes of Suture Anchor Repair with Suture Tape Augmentation. Methods: The authors report no funding or conflicts of interest. Surgical treatment has been advocated for all avulsion fractures of the UCL, as the area of articular cartilage is always greater than the fragment size.41 Abrahamsson et al42 maintain that a proximally displaced ligament, palpated proximal to the MP joint, is a more specific indication for surgery.

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