Stener Lesion Treatment & Management

Closed treatment is satisfactory for type I, III, and V injuries. Immobilization in a thumb spica cast for 4 weeks usually is sufficient. Type II and IV injuries are unstable and require operative treatment.^{[10, 11, 13]}

Kozin and Bishop^[14] (1994) have described the following operative method of exposure and repair of the Stener lesion:

• A chevron or S-shaped incision is made over the dorsum of the thumb metacarpophalangeal (MCP) joint, with the apex at the thumb-index webspace.
• The skin flap is elevated, with care taken to preserve any superficial radial nerve branches.
• At this point in the dissection, the displaced ulnar collateral ligament (UCL) may be observed at the proximal edge of the adductor aponeurosis. If the ligament is disrupted and displaced, it should be seen in cross section, held in a displaced position by the proximal edge of the adductor aponeurosis.
• The adductor aponeurosis is incised longitudinally, parallel and just ulnar to the extensor pollicis longus tendon, and then elevated from the underlying capsule.
• The adductor aponeurosis then is retracted distally, and a longitudinal capsulotomy is performed if one did not occur at the time of the avulsion injury.

The UCL frequently is torn from the insertion site at the proximal phalanx (see first image below), sometimes with an avulsed bony fragment attached.^[11] A midsubstance tear may be repaired with a 3-0 nonabsorbable suture. If avulsed from the distal insertion site, the distal insertion site on the proximal phalanx is roughened and prepared for reattachment of the ligament. The ligament is reattached using a suture anchor or a pullout suture with a nonabsorbable suture (see second image below). The MCP joint then is pinned with a 0.045-inch Kirschner (K) wire in approximately 20° of flexion and with slight ulnar deviation prior to suture tying.

The volar plate is repaired to the reinserted UCL to restore accessory UCL function. The pin is removed at 5 weeks, when the thumb spica cast is removed, and active motion is instituted. Abduction stress is avoided for approximately 3 months. Surgical exposure is similar when a substantial fracture fragment (type II) is identified with the avulsed UCL. Tension band fixation of the small fragment then is used so that the fracture fragment is reduced but not fragmented. Blood supply to the fragment is maintained and prominent hardware is avoided with this fixation method.

A 26- or 28-gauge steel wire is passed in a figure-of-eight fashion through a predrilled hole in the proximal phalanx and at the collateral ligament insertion into the bony fragment. Tightening of the figure-of-eight tension band construct provides for secure fixation, reconstitution of articular congruity, and restoration of normal ligament length. Other authors have described tying the suture over a button on the radial side of the MCP joint with a pullout suture technique, but this method leaves exposed suture and a looser repair than does the aforementioned method.

The most critical aspect of the repair, regardless of the technique utilized, is anatomic restoration of the ligamentous attachment in the proper orientation. In thumbs treated acutely (within 3 wk of injury), a good-to-excellent result can be expected in more than 90% of cases, regardless of ligament repair technique.^[13] Chronic ligamentous injuries (those > 3 wk from injury) are difficult to repair primarily. If significant arthritis is present, arthrodesis of the MCP decreases pain, increases stability, and improves thumb function. If arthritis is not present, adductor tendon advancement or ligamentous reconstruction may be attempted for reconstruction of the unstable MCP joint. An adductor advancement consists of relocating the adductor insertion distally to increase stability. The UCL also may be mobilized, and an attempt at repair can be made as well.^[15]

Ligament reconstruction with a free or local tendon graft has been described using various ligaments. The palmaris longus is utilized most commonly. Other, less commonly used choices include the extensor pollicis brevis tendon, the plantaris, a toe extensor, a slip of the abductor pollicis longus, or a portion of the flexor carpi radialis tendon. In the case of a palmaris longus free-tendon graft, the tendon is harvested and then passed through a tunnel in the metacarpal head from dorsal to palmar. Finally, it is attached to the proximal phalanx. Analysis of outcome using this technique has indicated that it provides adequate stability with some loss of motion.

Complications associated with surgical repair of an acute ulnar collateral ligament injury include radial sensory nerve neurapraxia, stiffness of the thumb interphalangeal and metacarpophalangeal joints, and, infrequently, recurrent instability.

Stener's original article was a significant contribution to the treatment of acute disruptions of the ulnar collateral ligament (UCL) of the thumb metacarpophalangeal (MCP) joint. Stener described a lesion in which the thumb UCL is disrupted and prevented from healing in its original anatomic position by the interposed adductor aponeurosis. If recognized early, the UCL may be reduced operatively and secured in its anatomic position. Early recognition and anatomic reduction can result in excellent functional outcome in the vast majority of cases. Late presentation or a delayed diagnosis of a Stener lesion may produce a need for more involved surgery, with less desirable results.

Little controversy exists regarding the need for operative intervention for a true Stener lesion. Like any surgical procedure, however, surgeon-dependent variations exist in operative technique and postoperative protocol.