Assessment of acute ulnar collateral ligament injury of the thumb
Date First Published:
June 18, 2009
Last Updated:
June 18, 2009
Report by:
Katy Guy, ST3 EM (Nevill Hall Hospital Abergavenny)
Search checked by:
Katy Guy, Nevill Hall Hospital Abergavenny
Three-Part Question:
In [patients with suspected injuries to the ulnar collateral ligament of the thumb] does [investigation with ultrasound scanning] help to influence [the choice of treatment]?
Clinical Scenario:
A patient attends the Emergency Department after a hyper abduction injury of his thumb. On examination there is laxity of his ulnar collateral ligament (UCL). You wonder whether conservative treatment is adequate or will the patient require surgery. Would ultrasonography be helpful in assessing UCL ruptures which are going to require surgical input?
Search Strategy:
Search Strategy
OVID medline (R) 1950 to November week 3 2008 was searched. [(collateral ligaments OR ulnar collateral ligaments. Mp. OR rupture OR thumb. Mp.) AND (thumb/in.)AND (Diagnosis/ or diagnosis mp.) AND [ultrasound or ultrasonography ] LIMIT to human AND English. The Cochrane database was also searched which found no papers.
OVID medline (R) 1950 to November week 3 2008 was searched. [(collateral ligaments OR ulnar collateral ligaments. Mp. OR rupture OR thumb. Mp.) AND (thumb/in.)AND (Diagnosis/ or diagnosis mp.) AND [ultrasound or ultrasonography ] LIMIT to human AND English. The Cochrane database was also searched which found no papers.
Outcome:
A total of 10 papers were found. 4 of which were relevant and of sufficient quality to include in the paper.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| “The use of ultrasound in the diagnosis of injuries of the ulnar collateral ligament of the thumb” Jones, MH, England, SJ et al 2000, UK | 60 patients with UCL injuries | Prospective cohort | USS Positive predictive value 94%. Sensitivity 83%, Specificity 75%. | Included patients > 3 weeks after injury. Difficult to pick up undisplaced lesions on USS. | |
| “ Sonographic diagnosis of acute injuries of the ulnar collateral ligament of the metacarpophalangeal joint of the thumb” Shinohara T, Horii, E et al 2006 Japan | 14 patients with acute UCL tear | Retrospective cohort | USS and surgical findings | USS 100% specificity & sensitivity in intra aponeurosis injuries. | Small Numbers |
| “Gamekeeper thumb: Identification of the Stener Lesion with US” O’Callaghan, BI, Kohut G, Hoogewood HM 1994 Switzerland | 20 uninjured volunteers 48 patients with hyperabduction injuries 16 underwent surgery |
Cohort | USS picked up 13/16 dislocations. None with negative scan had instability on review | ||
| “Ulnar collateral ligament: differentiation of displaced and nondisplaced tears with US Noszian IM, Dinkhauser LM et al 1995 Austria | 69 patients with suspected UCL tear (<48 hrs post injury) | USS correct diagnosis 33/39 26/26 conservative treatment were stable on follow up |
Author Commentary:
Correct diagnosis of an ulnar collateral ligament injury is required to determine treatment. Clinical examination is often difficult. There is no consensus on the degree of laxity which signifies a complete ligament rupture.
Non displaced ruptures can be treated conservatively for 6 weeks.
Displaced ligament tears proximal to the aponeurosis are known as Stener lesions. A Stener lesion is unable to regain an anatomical position required for healing; therefore surgical intervention is indicated. Chronic instability of the thumb results if healing cannot occur.
Treatment for suspected UCL rupture is controversial. Some advocate surgical exploration on all patients with a suspected rupture, whilst others advocate conservative treatment for 6 weeks. If instability remains at that time, then surgical repair is performed. However, surgical exploration is difficult when performed more than 3 weeks post injury.
A quick, cheap, accessible imaging modality that could differentiate between lesions requiring surgery and those amenable to conservative treatment would be useful in the treatment and diagnosis of UCL tears.
The papers above appear to show that ultrasound could aid in this differentiation. The benefit would be preventing every suspected lesion undergoing surgical exploration, and patients with definite displaced tears could have access to surgery sooner.
Non displaced ruptures can be treated conservatively for 6 weeks.
Displaced ligament tears proximal to the aponeurosis are known as Stener lesions. A Stener lesion is unable to regain an anatomical position required for healing; therefore surgical intervention is indicated. Chronic instability of the thumb results if healing cannot occur.
Treatment for suspected UCL rupture is controversial. Some advocate surgical exploration on all patients with a suspected rupture, whilst others advocate conservative treatment for 6 weeks. If instability remains at that time, then surgical repair is performed. However, surgical exploration is difficult when performed more than 3 weeks post injury.
A quick, cheap, accessible imaging modality that could differentiate between lesions requiring surgery and those amenable to conservative treatment would be useful in the treatment and diagnosis of UCL tears.
The papers above appear to show that ultrasound could aid in this differentiation. The benefit would be preventing every suspected lesion undergoing surgical exploration, and patients with definite displaced tears could have access to surgery sooner.
Bottom Line:
Once the anatomy of the area is understood, USS appears to be a useful, cheap, adjunct to good clinical examination in acute ulnar collateral ligament injuries. It seems to be an accurate modality in diagnosising those lesions which will require surgical repair.
References:
- Jones, MH, England, SJ et al . “The use of ultrasound in the diagnosis of injuries of the ulnar collateral ligament of the thumb”
- Shinohara T, Horii, E et al . “ Sonographic diagnosis of acute injuries of the ulnar collateral ligament of the metacarpophalangeal joint of the thumb”
- O’Callaghan, BI, Kohut G, Hoogewood HM . “Gamekeeper thumb: Identification of the Stener Lesion with US”
- Noszian IM, Dinkhauser LM et al . “Ulnar collateral ligament: differentiation of displaced and nondisplaced tears with US