J. Matthew Cage

Radial Collateral Ligament Injuries of the Thumb Metacarpophalangeal Joint: Epidemiology in a Military Population

PURPOSE The reasons for variation in the reported incidence rates between thumb metacarpophalangeal joint radial collateral ligament (RCL) and ulnar collateral ligament (UCL) injuries are unclear. Delay in diagnosis of injury to the RCL leads to greater time of patient disability. The purpose of this study was to define the demographics and presentation of patients with RCL injuries in a military health care system. METHODS We performed a retrospective review of electronic medical records over a 5-year period to determine the incidence and epidemiology related to patients with instability of the thumb metacarpophalangeal joint resulting from injury of the radial or ulnar collateral ligaments. RESULTS A total of 56 patients presented with thumb metacarpophalangeal joint instability. Of these, 18 (32%) had an RCL injury. Patients with an RCL injury were, on average, younger than those with UCL injuries. Those with RCL injuries were more likely to require surgery than were those with UCL injuries (67% vs 40%). With regard to time to presentation, most patients with UCL injuries presented 2 to 10 weeks after injury, whereas nearly all patients with RCL injuries presented greater than 10 weeks after injury. Radial collateral ligament injuries were more likely than UCL injuries to have resulted from an axial load (56% vs 16%), whereas UCL injuries were more likely to have been caused by an abduction-adduction moment (50% vs 22%). CONCLUSIONS In this series, patients sustaining injuries to the RCL were younger and presented later than their counterparts with UCL instability. Close attention to subtle or frank instability presenting as pain in younger patients with axial loading injury mechanisms may allow early diagnosis and appropriate treatment of this injury.

Successful Conservative Therapy in Rockwood Type V Acromioclavicular Dislocations

Objectives: Acromioclavicular (AC) joint injuries are common and constitute approximately 9% of all shoulder injuries. Traditionally Rockwood Types IV, V, and VI AC dislocations are indicated for surgery, type III dislocations are controversial, and type I and II are treated non-operatively. Our objective is to determine the success of non-operative treatment in Type V AC dislocations in active duty service members who must continue to do push-ups, pull-ups, bear weight, and wear ruck-sacks among other demanding activities requiring upper body strength in order to maintain current employment and lifestyle. Methods: A retrospective review was conducted using an automated search of electronic patient medical records from March 2007 through March 2012 for patients diagnosed with an AC dislocation in the Tripler Army Medical Center Department of Orthopedics. Patients were excluded who were not active military at the time of injury or who were tertiary referrals. Radiographs were reviewed and comparison was made to the contralateral shoulder. A Type V injury was defined as greater than 100% increase in the coracoclavicular distance compared to the contralateral side or greater than 2cm of displacement unilaterally. Acute repair was defined as repair within 90 days without a trial of conservative therapy. Failure of conservative therapy was defined as being unable to return to full duty. A good outcome was defined as a return to full duty without limitations. Results: 103 patients were identified with 60 patients having a bilateral shoulder films. Normal CC distances of the uninjured shoulder ranged from 4.3 mm to 18.66 mm with a mean of 9.09 mm and a standard deviation of 2.30 mm. 34 patients were Type V dislocations. 5 patients were tertiary referrals and were excluded. Acute surgical AC reconstruction was selected in 8 patients, initial conservative therapy in 21. In the conservative group: 11 patients (61%) returned to duty without surgery (average 97.8 days); 5 patients had delayed surgery and returned to full duty (average 135.2 days after surgery, 1 revision); 1 was medically separated for this injury; 1 was considered a failure and elected to change his career; and 3 patients were lost to follow up. In the acute surgical group: 6 patients returned to full duty in an average of 169.3 days after surgery(mean time to surgery 28.29 days) with 3 of those requiring revision surgery; 1 patient was lost to follow up, 1 patient failed to return to full duty. In the conservatively treated group, there was no association between failure rates and increase in CC distance or mm of displacement (p= 0.32 and 0.69 respectively). Conclusion: While numerous studies have evaluated the operative versus non-operative treatment of type III injuries in both a prospective and retrospective manner, no study to date has reported on the conservative treatment of type V AC dislocations. In this study we report on conservative treatment being successful in a majority of patients and that the average time to return to duty was not improved in an acute versus delayed surgical intervention. While more study is needed, this suggests that type V AC dislocations may be given a trial of conservative therapy. Secondarily we report on an increased range of the normal CC interspace (previously reported 1.1-1.3cm).

The Displacement of the Clavicle is a Better Predictor of Surgical Intervention in the Non-Operatively Treated Acromioclavicular Dislocation than the Increase in Coracoclavicular Distance

Objectives: Acromioclavicular (AC) joint injuries are common and constitute approximately 3.2% of all shoulder injuries. Traditionally Rockwood Types I and II are treated conservatively, Type III dislocations are controversial, and Types IV, V, and VI AC dislocations are indicated for surgery. Little is known about nonoperative treatment of Type V AC dislocations especially in active populations. The purpose of this study was to compare the outcomes between Type V AC dislocations treated initially with acute surgical intervention versus those treated conservatively and to identify potential risk factors associated with failure of non-operative treatment. Methods: A retrospective review was conducted using an automated search of electronic patient medical records from January 2007 through December 2012 for patients diagnosed with an AC dislocation in the Tripler Army Medical Center Department of Orthopedics. A Type V injury was defined as greater than 100% increase in the coracoclavicular (CC) distance compared to the contralateral side. Patients were excluded if there were no bilateral radiographs, who did not present acutely or who were tertiary referrals. Results: 25 patients were identified as having acute Type V dislocations. Acute surgical AC reconstruction was selected in 8 patients and initial conservative therapy 17. In the conservative group: 8 patients (57%) returned to duty without surgery (average 90.3 days); 4 patients had delayed surgery and returned to full duty (average 238.75 days from initial injury); 2 refused surgery and changed careers; and 3 patients were lost to follow up. In the acute surgical group: 6 patients (75%) returned to full duty in an average of 207 days with 3 of those requiring revision surgery; 1 patient was lost to follow up, and 1 patient failed to return to full duty. There was no significant difference in time to return to duty between the acute surgical group and those who underwent delayed surgical reconstruction (p=0.62). In the conservatively treated group, patients who failed conservative treatment and elected for surgery had a mean increase in CC distance of 144% (range 118%-166%) with a mean 22.5mm displacement of the clavicle above the acromion (19.3- 25.1 mm). In conservative group that did not undergo surgery there was an average 141% increase in CC distance (range 102% - 217%) with a mean 17.3mm displacement (12.5-24.22 mm). There was a significant difference in mm of displacement of the clavicle above the acromion in conservatively treated patients who underwent surgical correction and those who did not (p=.035) while there was no significant difference between the CC distance in this same group (p=0.9). Conclusion: No study has compared initial conservative vs. operative management in type V AC joint dislocations. This study demonstrates that initial nonoperative treatment returns a majority of active patients to full duty faster than acute surgical reconstruction. Patients who undergo early operative management do not return at a higher rate, experience a similar rate of revision surgery, and time to return to duty is not significantly shorter than their initial conservative counterparts. Thus, we recommend that type 5 AC joint injuries, even in an active population, should be managed initially conservatively, as it is effective in the majority of patients, and initial surgery offers no advantage.