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Rashidi A, Haj-Mirzaian A, Dalili D, Fritz B, Fritz J. 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. Eur Radiol 2021; 31:5699-5712. [PMID: 33459856 DOI: 10.1007/s00330-020-07666-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 12/10/2020] [Accepted: 12/22/2020] [Indexed: 02/01/2023]
Abstract
OBJECTIVES To determine the performances of clinical examination, ultrasonography, and MRI for diagnosing non-displaced and displaced ulnar collateral ligament (UCL) tears. METHODS Based on a literature search of Medline, ISI Web of Science, Embase, and Scopus between January 1990 and December 2019, all published original articles which met the inclusion criteria were included. We determined the pooled sensitivities, specificities, and accuracies of clinical examination, ultrasonography, and MRI using a meta-analysis based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Diagnostic Test Accuracy (PRISMA-DTA) guidelines. RESULTS A total of 17 studies with 519 subjects reporting diagnostic performances of clinical examination (8), ultrasonography (12), and MRI (5) met the inclusion criteria. For ruling out UCL tears, the pooled sensitivities were similarly high for clinical examination (97% (95% confidence interval [CI], 93-99%)), ultrasonography (96% (95% CI, 94-98%)), and MRI (99% (95% CI, 92-100%)) (p = 0.3). For ruling in UCL tears, the pooled specificities were higher for MRI (100% (95% CI, 87-100%)) when compared to ultrasonography (91% (95% CI, 86-95%)) (p = 0.1) and clinical examination (85% (95% CI, 78-91%)) (p = 0.04). For the diagnosis of displaced UCL tears, MRI had a higher specificity (92% (95% CI, 73-99%)) than ultrasonography (72% (95% CI, 63-80%)) (p = 0.2). CONCLUSIONS Clinical examination, ultrasonography, and MRI have similarly high sensitivities for ruling out UCL tears in patients presenting with a thumb injury. MRI and ultrasonography have high specificities to confirm the presence of suspected UCL tears. MRI performs best for differentiating non-displaced from displaced UCL tears. KEY POINTS • Clinical examination followed by ultrasonography is the most appropriate test for ruling out ulnar collateral ligament (UCL) tears of the thumb. • MRI and ultrasonography both have high specificities to confirm the presence of a suspected UCL tear. • MRI outperforms ultrasonography for differentiating non-displaced from displaced UCL tears.
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Affiliation(s)
- Ali Rashidi
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, 601 North Caroline Street, Baltimore, MD, 21287, USA
| | - Arya Haj-Mirzaian
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, 601 North Caroline Street, Baltimore, MD, 21287, USA
| | - Danoob Dalili
- Nuffield Orthopedic Center, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Benjamin Fritz
- Radiology, Balgrist University Hospital, Zurich, Switzerland.,Faculty of Medicine, University of Zurich, Zurich, Switzerland
| | - Jan Fritz
- Department of Radiology, Musculoskeletal Radiology, New York University Grossman School of Medicine, 660 1st Ave, 3rd Floor, Rm #313, New York, NY, 10016, USA.
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Raheman FJ, Rojoa DM, Dhingra M, Siddiqui S, Macdonald CR. The role of ultrasonography in the assessment of ulnar collateral ligament injury of the thumb - a diagnostic test accuracy meta-analysis. J Plast Surg Hand Surg 2020; 55:83-95. [PMID: 33156740 DOI: 10.1080/2000656x.2020.1838295] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The accurate diagnosis of ulnar collateral ligament (UCL) injuries of the thumb is important in identifying patients requiring surgery. Stener lesion, the most severe form of such injuries, is debilitating and leads to chronic instability if misdiagnosed. We evaluated the diagnostic accuracy of ultrasonography (USS) in UCL injuries. A systematic review of existing literature was performed with a meta-analysis using a bivariate mixed-effects model to estimate summary sensitivity and specificity. All observational studies were assessed, with participants of any age, who sustained UCL injuries of the thumb. A hierarchical model was used to generate a hierarchical summary receiver operating characteristic (HSROC) curves. We identified 17 studies reporting a total of 593 UCL injuries. Pooled estimates for sensitivity and specificity were 0.96 (95% CI 0.89-0.99) and 0.90 (95% CI 0.81-0.94), respectively for the diagnosis of Stener lesions; 0.81 (95% CI 0.66-0.93) and 0.87 (95% CI 0.67-0.96), respectively for non-displaced complete ruptures and 0.82 (95% CI 0.66-0.92) and 0.94 (95% CI 0.85-0.98), respectively for complete ruptures without Stener lesion. The area under the curve (AUC) for Stener diagnosis using USS was 0.98, suggesting excellent diagnostic accuracy. Our meta-analysis suggests that USS is a reliable and accurate method of diagnosis for UCL injuries. Moreover, it has excellent diagnostic accuracy for Stener lesions and may be used in the diagnostic work-up of UCL injuries with magnetic resonance imaging being reserved for ambiguous cases.
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Affiliation(s)
- Firas J Raheman
- The Leicester Royal Infirmary, University Hospitals of Leicester, Leicester, UK
| | - Djamila M Rojoa
- The Leicester Royal Infirmary, University Hospitals of Leicester, Leicester, UK
| | - Mohit Dhingra
- The Leicester Royal Infirmary, University Hospitals of Leicester, Leicester, UK
| | - Saad Siddiqui
- The Leicester Royal Infirmary, University Hospitals of Leicester, Leicester, UK
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3
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Spies CK, Langer M, Müller LP, Oppermann J, Löw S, Unglaub F. [Ligamentous lesions and instability of the finger joints]. DER ORTHOPADE 2017; 47:175-188. [PMID: 29264616 DOI: 10.1007/s00132-017-3510-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Joint capsule and ligamentous lesions are common injuries of the upper extremities. Athletes are particularly inclined to suffer from these injuries. Clinical and radiological examinations are the cornerstone of an adequate treatment. Ultrasound-based diagnostics as a non-invasive and dynamic investigation method are gaining increasing relevance based on the development of high resolution probes. A correct interpretation of the findings is only feasible with a comprehensive knowledge of the anatomy. The most important goal is stability as a prerequisite for early active and passive motion with unrestricted range of motion.
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Affiliation(s)
- C K Spies
- Abteilung für Handchirurgie, Vulpius Klinik, Vulpiusstr. 29, 74906, Bad Rappenau, Deutschland.
| | - M Langer
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Waldeyerstr. 1, 48149, Münster, Deutschland
| | - L P Müller
- Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Köln, Kerpener Str. 62, 50937, Köln, Deutschland
| | - J Oppermann
- Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Köln, Kerpener Str. 62, 50937, Köln, Deutschland
| | - S Löw
- Praxis für Handchirurgie und Unfallchirurgie, Wolfgangstr. 2, 97980, Bad Mergentheim, Deutschland
| | - F Unglaub
- Abteilung für Handchirurgie, Vulpius Klinik, Vulpiusstr. 29, 74906, Bad Rappenau, Deutschland.,Medizinische Fakultät Mannheim, Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
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4
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Ziegler C, Neshkova I, Schmidt K, Meffert R, Jakubietz M, Jakubietz R. [Surgical treatment of ulnar collateral ligament injuries of the thumb metacarpophalangeal joint]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2016; 28:111-26; quiz 127. [PMID: 26769008 DOI: 10.1007/s00064-015-0436-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Revised: 10/08/2015] [Accepted: 10/10/2015] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Reconstruction of the ruptured ulnar collateral ligament of the metacarpophalangeal (MP) joint of the thumb. INDICATIONS Ruptured ulnar collateral ligament of the thumb MP joint with instability: joint opening of more than 30° in flexion and more than 20° in extension, Stener lesion, displaced avulsion fractures. CONTRAINDICATIONS Abrasions, wound-healing disturbance, skin disease, osteoarthritis. SURGICAL TECHNIQUE Curved skin incision dorsoulnar above the thumb MP joint. Protection of the branches of the superficial radial nerve. Incision of the adductor aponeurosis. Exposing the ulnar collateral ligament; opening and examination of the joint. Depending on the injury, primary suture repair, transosseous suture, repair with a bone anchor, osteosynthesis with K-wires or small screws in avulsion fracture, ligament reconstruction in chronic instability or older injury. POSTOPERATIVE TREATMENT Cast splint of the MP joint until swelling subsides; cast immobilization for 6 weeks; range-of-motion exercises, avoiding forced radial deviation of the MP joint for 3 months. RESULTS Complete joint stability 3 months postoperatively in all 34 patients with rupture of the ulnar collateral ligament.
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Affiliation(s)
- C Ziegler
- Klinik für Unfall-, Hand-, Plastische und Wiederherstellungschirurgie, Universität Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Deutschland.
| | - I Neshkova
- Klinik für Unfall-, Hand-, Plastische und Wiederherstellungschirurgie, Universität Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Deutschland
| | - K Schmidt
- Klinik für Unfall-, Hand-, Plastische und Wiederherstellungschirurgie, Universität Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Deutschland
| | - R Meffert
- Klinik für Unfall-, Hand-, Plastische und Wiederherstellungschirurgie, Universität Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Deutschland
| | - M Jakubietz
- Klinik für Unfall-, Hand-, Plastische und Wiederherstellungschirurgie, Universität Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Deutschland
| | - R Jakubietz
- Klinik für Unfall-, Hand-, Plastische und Wiederherstellungschirurgie, Universität Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Deutschland
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6
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Adler T, Eisenbarth I, Hirschmann MT, Müller-Gerbl M, Fricker R. Can clinical examination cause a Stener lesion in patients with skier's thumb?: a cadaveric study. Clin Anat 2011; 25:762-6. [PMID: 22109689 DOI: 10.1002/ca.22005] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2011] [Revised: 10/25/2011] [Accepted: 10/26/2011] [Indexed: 11/09/2022]
Abstract
Approximately one-third of all injuries of the upper limb and 7% of all injuries in skiing affect the ulnar collateral ligaments of the thumb metacarpophalangeal joint (skier's thumb). In some patients the collateral ligaments are displaced proximally over the adductor aponeurosis, resulting in a so-called Stener lesion. In these cases surgical treatment is indicated. We hypothesized that a Stener lesion could be provoked by clinical stability testing in patients with a skiers thumb and performed a cadaveric study on 10 Thiel fixated cadaver hands. For clinical stability testing, the thumb was manually deviated in radial direction in both 30° flexion and extension of the MP-joint. It was performed with maximum strength by two hand surgeons after sequential detachment of the ulnar collateral ligaments. After every sequence, it was assessed if the clinical stability testing had caused a Stener lesion. All of the 10 cadavers showed identical results while testing the clinical stability. A decreased stability was only found after cutting both parts of the ulnar collateral ligaments. A Stener lesion could not be provoked in any of the cadavers at any time by clinical stability testing. Summarizing our findings we conclude that a proper performed clinical stability testing of the thumb MP joint is a safe maneuver, which does not lead to a Stener lesion in patients with skier's thumb.
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Affiliation(s)
- Tom Adler
- Hand Surgery Unit, Department of Orthopaedic Surgery and Traumatology, Kantonsspital Bruderholz, Bruderholz, Switzerland.
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Meier R, Jansen H, Uhl M. [Radiological procedures in the traumatised wrist]. DER ORTHOPADE 2010; 39:801-21, quiz 822. [PMID: 20694752 DOI: 10.1007/s00132-010-1660-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Injuries of the wrist are difficult to diagnose because of the complex and narrow anatomic structures. On the basis of precise clinical examination, X-rays, CT and MRI are valuable additional tools that can be used. In the case of bone injury, spiral computer tomography with multiplanar reformatting is currently the method of choice. MRI is indicated for the identification of soft tissue or ligamentous injury and avital fragments or necrosis. Other diagnostic tools for the wrist are currently of minor importance. Technical and methodological innovations allow ever better visualisation and classification of lesions, as well as their extent, thus enabling more targeted therapy. However, prerequisites of effective use include differential assessment and precise knowledge of the procedures.
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Affiliation(s)
- R Meier
- Klinik und Poliklinik für Unfall-, Hand-, Plastische- und Wiederherstellungschirurgie, Universitätsklinikum Würzburg, Würzburg.
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8
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Abstract
Injuries of the wrist are difficult to diagnose because of the complex and narrow anatomic structures. On the basis of precise clinical examination, X-rays, CT and MRI are valuable additional tools that can be used. In the case of bone injury, spiral computer tomography with multiplanar reformatting is currently the method of choice. MRI is indicated for the identification of soft tissue or ligamentous injury and avital fragments or necrosis. Other diagnostic tools for the wrist are currently of minor importance. Technical and methodological innovations allow ever better visualisation and classification of lesions, as well as their extent, thus enabling more targeted therapy. However, prerequisites of effective use include differential assessment and precise knowledge of the procedures.
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Affiliation(s)
- R Meier
- Klinik und Poliklinik für Unfall-, Hand-, Plastische- und Wiederherstellungschirurgie, Universitätsklinikum Würzburg, Oberdürrbacher Strasse 6, 97080 Würzburg.
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Winkler FJ, Heers G, Hartung W, Grifka J. [Examination of the painful wrist]. DER ORTHOPADE 2009; 38:213-27; quiz 228. [PMID: 19194693 DOI: 10.1007/s00132-008-1392-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The anatomy of the wrist is complex. Mechanical, neurological or systemic causes are responsible for a painful wrist. In many cases a specific diagnosis can already be made by taking a precise medical history. Physical examination includes inspection, palpation of landmarks and a dynamic examination in regard to joint regions. Plane X-Ray examinations are the basic tools in diagnostic imaging. Additional radiographic adjustments, ultrasound-, MRI- and CT-examinations may lead to more detailed information in special cases. A diagnostic arthroscopy is accomplished, if a pathological cause for wrist-pain with non-invasive methods cannot be found.
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Affiliation(s)
- F J Winkler
- Orthopädische Klinik der Universität Regensburg, Asklepios Klinikum, Bad Abbach, Deutschland.
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Rochet S, Gallinet D, Garbuio P, Tropet Y, Obert L. Entorse grave du pouce: opérer selon la position des sésamoïdes lors des clichés en stress. ACTA ACUST UNITED AC 2007; 26:200-5. [PMID: 17897862 DOI: 10.1016/j.main.2007.08.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2007] [Accepted: 08/17/2007] [Indexed: 11/18/2022]
Abstract
AIM Acute complete ruptures of the ulnar collateral ligament should be treated with surgical repair of the ligament. But diagnosis using ultrasound, dynamic X ray and magnetic resonance imaging are unable to diagnose surely the complete rupture. According to Rotella and Urpi if the radiograph shows no parallelism between the sesamoid bones and the metacarpal head, the injury of ulnar collateral ligament is total and complete and requires surgical reparation. The aim of this work was to verify the finding of Rotella and Urpi and the relationship between the lost of parallelism and the Stener lesion (interposition of adductor aponeurosis between the ruptured ulnar collateral ligament and its site of insertion on the base of the proximal phalanx). MATERIAL AND METHODS Embalmed anatomical specimens were used to systematically investigate and document the role played in joint stability by each of the anatomical elements. Each ligament was sectioned and instability documented. A retrospective radiological study was performed on 93 patients who had an history of injured ulnar collateral ligament of the thumb. RESULTS The anatomical study confirmed the result of Rotella and Urpi in showing that the loss of parallelism between the sesamoid bones and the metacarpal head was associated with complete rupture of ulbnar collateral ligement The clinical study showed that the lost of parallelism was associated with a Stener lesion (N=23). CONCLUSION The association between the lost of parallelism of sesamoid bones and Stener lesion confirm that the rupture of all elements of the ulnar collateral ligament. This anatomical and clinical findings have to be confirmed by a prospective clinical study.
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Affiliation(s)
- S Rochet
- Service de traumatologie, d'orthopédie, de chirurgie plastique et reconstructrice, hôpital Jean-Minjoz, CHU de Besançon, 3, boulevard Fleming, 25000 Besançon, France.
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Koslowsky TC, Mader K, Gausepohl T, Heidemann J, Pennig D, Koebke J. Ultrasonographic stress test of the metacarpophalangeal joint of the thumb. Clin Orthop Relat Res 2004:115-9. [PMID: 15552146 DOI: 10.1097/01.blo.0000136907.90559.5c] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The purpose of this study was to evaluate functional ultrasound as a tool for detecting an ulnar collateral ligament injury of the thumb. The feasability of using ultrasound for imaging the thumb joint space was tested in a pilot study, using ultrasound and dissection in 14 cadaveric hand specimens. To test this method clinically, both metacarpophalangeal joints of the thumb in 461 healthy volunteers were examined using ultrasound (11 MHz) under radial stress. The distance between the innominate tubercle of the first metacarpal head to the proximal phalanx was measured. The mean distance between the first metacarpal head and the proximal phalanx (n = 461) was 4.5 mm (standard deviation, 0.65 mm) on the right side and 4.6 mm (standard deviation, 0.61 mm) on the left side. These data were compared with data of 25 patients with an operative diagnosis of rupture of the ulnar collateral ligament of the thumb. The difference in joint space between the injured and uninjured sides was 2.25 mm (standard deviation, 0.46 mm). The metacarpophalangeal joint space can be reproducibly detected on high-frequency ultrasound. An increased gap seen on ultrasound is indicative of a rupture of the ulnar collateral ligament of the thumb.
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Affiliation(s)
- T C Koslowsky
- Department of Trauma Surgery, Hand and Reconstructive Surgery, St. Vinzenz-Hospital, Köln, Germany
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