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Simultaneous Bilateral Functional Radiography in Ulnar Collateral Ligament Lesion of the Thumb: An Original Technique

Am J Orthop. 2015 August;44(8):359-362

References

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2. Stener B. Displacement of the ruptured ulnar collateral ligament of the metacarpophalangeal joint of the thumb: a clinical and anatomic study. J Bone Joint Surg Br. 1962;44(4):869-879.

3. Stener B. Hyperextension injuries to the metacarpophalangeal joint of the thumb: rupture of ligaments, fracture of sesamoid bones, rupture of flexor pollicis brevis. An anatomical and clinical study. Acta Chir Scand. 1963;125:275-293.

4. Coonrad RW, Goldner JL. A study of the pathological findings and treatment in soft-tissue injury of the thumb metacarpophalangeal joint. With a clinical study of the normal range of motion in one thousand thumbs and a study of post mortem findings of ligamentous structures in relation to function. J Bone Joint Surg Am. 1968;50(3):439-451.

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A 44-year-old woman experienced forced traction from a dog leash and presented to the ED with pain in the right thumb region. Radiographs showed no bone damage (Figure 7). Thumb UCL injury was suspected. A bilateral simultaneous functional radiographic projection showed slight joint laxity, a sprain was diagnosed, and plaster bandaging was applied. Figures 8A–8D show the accurate thumb positions for performing the functional radiograph in forced valgus. We call the technique J.J.’s thumb radiographic projection.

Discussion

Examination using the stress test to cause joint tilt is crucial in making an accurate diagnosis and deciding on the most appropriate therapeutic approach.¹⁰ Most authors accept that surgical management is required in joint tilts over 30º, as these involve complete UCL rupture.^10-12

The MCP joint must be examined in flexion, when the main fascicle of the UCL is tight, and not in extension, when the main fascicle of the UCL is relaxed. If we examine the thumb in extension, radial deviations may occur that are not caused by joint instability. Tilt here must be compared with that of the healthy side.¹¹

Early diagnosis and adequate management are essential, as unnoticed or undervalued injuries can progress to painful sequelae, associated with stiffness, instability, and osteoarthritis, with evident harm to the grip and pinch functions of the hand. In many cases, clinical evidence of MCP joint instability is difficult. The radiologic diagnosis is usually obtained with comparative radiographs in forced valgus of both thumbs.

The forced valgus maneuver typically is performed by the examiner, who must stay with the patient in the radiography room and wear radiologic protection. Incredibly, some patients must force the valgus themselves.

The maneuver we have described clearly has complications, as it is painful, and some patients are uncooperative. Usually the thumb is anesthetized, and the examiner assumes the exposure to x-rays. The valgus deviation force that can be applied during stability testing may lead to further disruption of a partially torn ligament or displacement of a ruptured ligament if the overforced maneuver is performed.^13,14 That does not occur with our technique. On the other hand, the forces applied to the thumbs must be symmetrical for comparison purposes. The way to prevent these inconveniences is to perform the forced valgus maneuver over both thumbs simultaneously, under the same force application conditions and on a single radiograph, without requiring the examiner to remain with the patient in the radiography room.

Heim¹⁵ designed a system for simultaneous functional radiographs, but an apparatus must be built to adapt it to the frame of the radiography table, and the technique involves hyperpronating both hands and bandaging them to the forearm—which is uncomfortable and bothersome for patients and, in our opinion, has a poor application in high-volume EDs.

The technique of having the patient hold a bandage roll (J.J.’s thumb radiographic projection) offers several advantages:

1. The thumb can be placed in flexion, tightening the main fascicle of the UCL, which is how the UCL must be examined.

2. Forced valgus is allowed. Holding a water glass involves opening the thumb and the necessary stability of the MCP joint of the thumb (grip function of thumb); this radiographic technique is functional.

3. The examiner need not stay with the patient in the radiography room or be exposed to x-rays.

4. The bandage roll is thick enough to generate forced valgus in a patient with large hands. The nonrigid roll makes the examination more tolerable and avoids overforced valgus, eliminating the need for anesthetic blockade.

5. The technique is accessible and simple. In fact, there is no need to remove the roll from its wrapping.