Evidence-based use of clinical examination, ultrasonography, and MRI for diagnosing ulnar collateral ligament tears of the metacarpophalangeal joint of the thumb: systematic review and meta-analysis

MRI spectrum of injuries to the thumb metacarpophalangeal joint ulnar collateral ligament with a proposed expanded classification of injuries in American football players

Injuries to the ulnar collateral ligament of the thumb metacarpophalangeal joint are of both historic and modern interest for athletes and non-athletes alike. The thumb metacarpophalangeal joint requires stability in both flexion and extension utilizing a combination of static and dynamic stabilizers. This article reviews the magnetic resonance imaging categorization of thumb ulnar collateral ligament injuries and proposes two additional injury patterns seen in high-level and professional athletes who play American football. In addition to the direct magnetic resonance imaging findings in collateral ligament tears, secondary findings of rotation and subluxation can be seen at the thumb metacarpophalangeal joint due to the altered physiologic forces on the joint. Internal brace augmentation via suture tape of a traditional ulnar collateral ligament repair is a novel surgical technique that provides protection during initial healing and the ensuing remodeling phase following repair or reconstruction, resulting in a faster return to play.

Multiaxial 3D MRI of the Ankle: Advanced High-Resolution Visualization of Ligaments, Tendons, and Articular Cartilage

MRI is a valuable tool for diagnosing a broad spectrum of acute and chronic ankle disorders, including ligament tears, tendinopathy, and osteochondral lesions. Traditional two-dimensional (2D) MRI provides a high image signal and contrast of anatomic structures for accurately characterizing articular cartilage, bone marrow, synovium, ligaments, tendons, and nerves. However, 2D MRI limitations are thick slices and fixed slice orientations. In clinical practice, 2D MRI is limited to 2 to 3 mm slice thickness, which can cause blurred contours of oblique structures due to volume averaging effects within the image slice. In addition, image plane orientations are fixated and cannot be changed after the scan, resulting in 2D MRI lacking multiplanar and multiaxial reformation abilities for individualized image plane orientations along oblique and curved anatomic structures, such as ankle ligaments and tendons. In contrast, three-dimensional (3D) MRI is a newer, clinically available MRI technique capable of acquiring high-resolution ankle MRI data sets with isotropic voxel size. The inherently high spatial resolution of 3D MRI permits up to five times thinner (0.5 mm) image slices. In addition, 3D MRI can be acquired image voxel with the same edge length in all three space dimensions (isotropism), permitting unrestricted multiplanar and multiaxial image reformation and postprocessing after the MRI scan. Clinical 3D MRI of the ankle with 0.5 to 0.7 mm isotropic voxel size resolves the smallest anatomic ankle structures and abnormalities of ligament and tendon fibers, osteochondral lesions, and nerves. After acquiring the images, operators can align image planes individually along any anatomic structure of interest, such as ligaments and tendons segments. In addition, curved multiplanar image reformations can unfold the entire course of multiaxially curved structures, such as perimalleolar tendons, into one image plane. We recommend adding 3D MRI pulse sequences to traditional 2D MRI protocols to visualize small and curved ankle structures to better advantage. This article provides an overview of the clinical application of 3D MRI of the ankle, compares diagnostic performances of 2D and 3D MRI for diagnosing ankle abnormalities, and illustrates clinical 3D ankle MRI applications.

Management of Complex Hand and Wrist Ligament Injuries

Ligamentous injuries in the hand and wrist are often underdiagnosed and can present with significant functional limitations if there is untimely recognition of injury. Adequate repair or reconstruction is critical in restoring joint stability and mobility. The purpose of this review is to provide an overview of the metacarpophalangeal joint, scapholunate interosseous ligament (SLIL), and non-SLIL carpal ligament anatomy, diagnosis, imaging, treatment consideration and options, as well as surgical techniques encompassing repair, reconstruction, and fusion.

Ultrasonography in the assessment of hand injuries in children: A systematic review

Despite the frequency of paediatric hand injuries, recommendations for diagnostic investigations are limited due to paucity of published guidelines. This has led to inappropriate diagnoses and therefore inappropriate management. Ultrasonography is a portable, non-ionising imaging modality that allows rapid real-time evaluation of anatomical structures at a low cost and without sedation. In the adult population, ultrasonography has already been shown to improve accuracy in hand injury diagnoses. However, in the paediatric population, only one narrative review focuses on the application of ultrasonography to diagnose hand injury. A systematic search using PubMed, Google Scholar, EMBASE, Scopus, Cochrane database of systematic reviews and University Library of York, Keele, Edinburgh and King's College London was conducted to assess literature surrounding use of ultrasonography as a diagnostic tool for paediatric hand injuries. The literature search yielded 11,860 articles and 21 studies were identified with a total of 30 patients. Ultrasonography was observed to be an accurate tool for diagnosing bone, tendon, ligament and nerve injuries in children. The results of our study suggest that ultrasonography should be considered as an early diagnostic step for paediatric hand injuries.

Acute Thumb Metacarpophalangeal Joint Ulnar Collateral Ligament Injury: Diagnosis, Management, and Return to Sports Considerations

ABSTRACT

Thumb metacarpophalangeal joint ulnar collateral ligament injuries are common in athletes and range from mild sprains to complete retracted tears. The typical injury mechanism of a valgus force directed onto an abducted or extended thumb is frequently seen in certain sporting activities, such as skiing, football, and baseball. Ultrasound and magnetic resonance imaging are excellent imaging supplements to the clinical evaluation for diagnosis confirmation. Positive treatment outcomes have been demonstrated when these injuries are appropriately managed both nonoperatively and surgically. When deciding on a treatment plan, it is paramount to take the athlete's injury severity and sport-specific factors into account. The aim of this review is to summarize the sport epidemiology, diagnosis, treatment options, and return to play considerations for athletes who sustain an acute thumb metacarpophalangeal joint ulnar collateral ligament injury.

MR Imaging of Acute Knee Injuries: Systematic Evaluation and Reporting

Acute knee injury ranges among the most common joint injuries in professional and recreational athletes. Radiographs can detect joint effusion, fractures, deformities, and malalignment; however, MR imaging is most accurate for radiographically occult fractures, chondral injury, and soft tissue injuries. Using a structured checklist approach for systematic MR imaging evaluation and reporting, this article reviews the MR imaging appearances of the spectrum of traumatic knee injuries, including osteochondral injuries, cruciate ligament tears, meniscus tears and ramp lesions, anterolateral complex and collateral ligament injuries, patellofemoral translation, extensor mechanism tears, and nerve and vascular injuries.

Thumb Metacarpophalangeal Joint Ulnar Collateral Ligament Injuries: Management and Biomechanical Evaluation

First described in 1955 as "gamekeeper's thumb," injuries to the ulnar collateral ligament (UCL) of the thumb metacarpophalangeal joint are common and can cause pain and instability, especially during key pinch and grasp. Although primarily diagnosed on physical examination, stress radiographs, ultrasonography, and magnetic resonance imaging can be used to diagnose UCL injuries and distinguish partial from complete tears. If complete rupture occurs, the adductor aponeurosis can become interposed between the retracted UCL stump and its insertion on the proximal phalanx, known as a "Stener lesion." When instability persists after a trial of nonsurgical management or in the setting of complete rupture, there are various methods of repair or reconstruction. Biomechanically, there are no treatments of repair or reconstruction using native tissues that provide equivalent strength to the preinjured ligament. Recently, suture tape augmentation has been used for the repair or reconstruction with excellent short-term results and earlier return to function, although there is a paucity of literature on longer term outcomes. The various methods of surgical treatment yield excellent outcomes with a low incidence of complications.

The Accuracy and Cost-Effectiveness of MRI Assessment of Collateral Ligament Injuries of the Lesser Digits’ Proximal Interphalangeal Joints

Background

Collateral ligament injuries of the thumb and lesser digits are simple injuries, but they may lead to disabilities in hand function. This study aimed to evaluate the accuracy and cost-effectiveness of magnetic resonance imaging (MRI) in diagnosing proximal interphalangeal (PIP) collateral ligament injuries of lesser digits.

Methods

A retrospective evaluation was conducted on 18 fingers that had undergone surgery for PIP joint complete collateral ligament injury. Pre-operative MRI results were compared with the intra-operative findings. The data from MRI and direct intraoperative findings were analyzed by the Chi-square test in paired groups. The McNemar test analyzed the accuracy of the MRI test for detecting volar plate injuries. Statistical Packages for Social Sciences (SPSS) version 25 (IBM Inc., Armonk, New York) software program was used for the analysis. 

Results

In digits other than the thumb, the accuracy of MRI for detecting collateral injuries was 38.89%, and detection was incorrect in 11 (61.11%) of 18 patients. There are significant differences between MRI and Intraoperative results (p<0.001). MRI findings for seven fingers (38.89%) of the 18 fingers involved were compatible with the surgery results (38.88%). By comparison, the MRI findings of 11 fingers (61.11%) were inconsistent with the intra-operative results. Eight patients (44.44%) were diagnosed preoperatively with MRI as having volar plate ruptures, three patients (16.67%) were diagnosed with open surgery, but only three of the volar plate diagnosed patients with MRI were verified as ruptures during open surgery (38.0%). In addition, preoperatively undetected volar plate injuries by MRI (n=10) were detected intra-operatively in three cases (30.0%). Therefore, the accuracy of MRI was found not to be statistically significant for the detection of volar plate injuries (p=0.727).

Conclusion

This study concluded that a 1.5-Tesla MRI with a slice thickness of 2-3 mm should not be relied on as a decisive tool for diagnosing collateral ligament injuries of the PIP joint of the lesser digits. Additionally, MRI was found insufficient for diagnosing volar plate injuries that accompanied collateral ligament injuries. Given these findings, one might conclude that MRI is not cost-effective in diagnosing collateral ligament injuries of the lesser digits PIP joint.