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Open injury, ulnar nerve — Clinical Guidelines

Overview

Ulnar collateral ligament (UCL) injuries commonly occur in overhead athletes, particularly pitchers, leading to significant functional impairment and necessitating careful evaluation and management to optimize return-to-play outcomes. 5

Diagnosis

Clinical Examination: Stress testing and physical examination are crucial but can be limited without local anesthetic infiltration to reduce pain-related guarding 4.

Imaging: Magnetic Resonance Imaging (MRI) grading is used to assess severity (I: intact with edema; IIA: partial tear; IIB: chronic healed; III: complete tear) 2.

Stress Radiography: Serves as the gold standard for diagnosing UCL instability 4.

Management

Nonoperative Treatment: Rehabilitation protocols are employed, especially for partial tears or lower MRI grades, aiming return to play 2.

Surgical Intervention: Ulnar collateral ligament reconstruction (UCLR) is common for complete tears, utilizing techniques like docking or modified Jobe, often with palmaris longus autograft 3.

Ulnar Nerve Considerations: Routine transposition of the ulnar nerve is not typically performed unless preoperative symptoms are present 3.

Special Populations

Professional Athletes: Return-to-play rates vary; operative treatment generally shows higher RTP rates compared to nonoperative, though economic impacts are substantial 2 1.

Key Recommendations

Utilize local anesthetic infiltration to enhance the accuracy of clinical examination for UCL injuries (Evidence: Moderate 4).

Consider MRI grading for assessing the severity of UCL injuries and guiding treatment decisions (Evidence: Moderate 2).

For complete UCL tears in professional athletes, surgical reconstruction is often recommended to optimize return-to-play outcomes, despite significant economic costs (Evidence: Moderate 2 1).

References

1 Meldau JE, Srivastava K, Okoroha KR, Ahmad CS, Moutzouros V, Makhni EC. Cost analysis of Tommy John surgery for Major League Baseball teams. Journal of shoulder and elbow surgery 2020. link 2 Ford GM, Genuario J, Kinkartz J, Githens T, Noonan T. 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. The American journal of sports medicine 2016. link 3 Erickson BJ, Harris JD, Fillingham YA, Cvetanovich GL, Bush-Joseph CA, Bach BR et al.. Treatment of Ulnar Collateral Ligament Injuries and Superior Labral Tears by Major League Baseball Team Physicians. Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association 2016. link 4 Cooper JG, Johnstone AJ, Hider P, Ardagh MW. Local anaesthetic infiltration increases the accuracy of assessment of ulnar collateral ligament injuries. Emergency medicine Australasia : EMA 2005. link 5 Safran MR. Ulnar collateral ligament injury in the overhead athlete: diagnosis and treatment. Clinics in sports medicine 2004. link 6 Musharafieh RS, Bassim YR, Atiyeh BS. Ulnar collateral ligament rupture of the first metacarpophalangeal joint: a frequently missed injury in the emergency department. The Journal of emergency medicine 1997. link00346-0)

Open injury, ulnar nerve