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Stener Lesion Treatment & Management

  • Author: Joseph P Rectenwald, MD; Chief Editor: Harris Gellman, MD  more...
 
Updated: Aug 10, 2015
 

Approach Considerations

Stener was able to identify a subgroup of individuals with a ulnar collateral ligament (UCL) injury who required operative intervention for the restoration of UCL integrity and, therefore, metacarpophalangeal (MCP) joint stability.[1] If the adductor aponeurosis is interposed between the ruptured ends of the UCL, only operative intervention will allow apposition and healing of the traumatically displaced ligament in an anatomic position. If a Stener lesion is not present, splinting of the thumb in such a way that the torn ligament ends are reduced may lead to ligamentous healing and restoration of joint stability in select patients. The ligamentous injuries may also require surgical treatment.

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Medical Therapy

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.[5, 11, 15]

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Surgical Therapy

Operative exposure and repair

In 1994, Kozin and Bishop[16]  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 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 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 the first image below), sometimes with an avulsed bony fragment attached.[11] A midsubstance tear may be repaired with a 3-0 nonabsorbable suture. If the UCL is 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 with a suture anchor or a pullout suture with a nonabsorbable suture (see the second image below). The MCP joint then is pinned with a 0.045-in. Kirschner wire (K-wire) in approximately 20° of flexion and with slight ulnar deviation prior to suture tying.

Ruptured ulnar collateral ligament. Ruptured ulnar collateral ligament.
Completed repair using suture anchors for fixation Completed repair using suture anchors for fixation.

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-eight fashion through a predrilled hole in the proximal phalanx and at the collateral ligament insertion into the bony fragment. Tightening of the figure-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 (<3 weeks from injury), a good-to-excellent result can be expected in more than 90% of cases, regardless of ligament repair technique.[15]

Chronic ligamentous injuries (>3 weeks from injury) are difficult to repair primarily. If significant arthritis is present, arthrodesis of the MCP joint 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.[17]

Ligament reconstruction with a free or local tendon graft has been described using various ligaments. The palmaris longus is the most common choice; other, less common choices include the extensor pollicis brevis tendon, the plantaris, a toe extensor, a slip of the abductor pollicis longus, and 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

Complications associated with surgical repair of an acute UCL injury include radial sensory nerve neurapraxia, stiffness of the thumb interphalangeal (IP) and MCP joints, and, infrequently, recurrent instability.

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Contributor Information and Disclosures
Author

Joseph P Rectenwald, MD Orthopaedic Associates of Augusta, PA

Disclosure: Nothing to disclose.

Coauthor(s)

John J Walsh, IV, MD Professor and Chairman, Department of Orthopedic Surgery, University of South Carolina School of Medicine

John J Walsh, IV, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Christian Medical and Dental Associations, American Society for Surgery of the Hand

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Michael Yaszemski, MD, PhD Associate Professor, Departments of Orthopedic Surgery and Bioengineering, Mayo Foundation, Mayo Medical School

Disclosure: Nothing to disclose.

Chief Editor

Harris Gellman, MD Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami, Leonard M Miller School of Medicine, Clinical Professor, Surgery, Nova Southeastern School of Medicine

Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, Arkansas Medical Society

Disclosure: Nothing to disclose.

Additional Contributors

A Lee Osterman, MD Director of Hand Surgery Fellowship, Director, Philadelphia Hand Center; Director, Professor, Department of Orthopedic Surgery, Division of Hand Surgery, University Hospital, Thomas Jefferson University

Disclosure: Nothing to disclose.

References
  1. Stener B. Displacement of the ruptured ulnar collateral ligament of the metacarpophalangeal joint. J Bone Joint Surg Am. 1962 Nov. 44B(4):869-79.

  2. Campbell CS. Gamekeeper's thumb. J Bone Joint Surg Br. 1955 Feb. 37-B(1):148-9. [Medline].

  3. Heyman P, Gelberman RH, Duncan K, et al. Injuries of the ulnar collateral ligament of the thumb metacarpophalangeal joint. Biomechanical and prospective clinical studies on the usefulness of valgus stress testing. Clin Orthop Relat Res. 1993 Jul. 165-71. [Medline].

  4. Louis DS, Huebner JJ, Hankin FM. Rupture and displacement of the ulnar collateral ligament of the metacarpophalangeal joint of the thumb. Preoperative diagnosis. J Bone Joint Surg Am. 1986 Dec. 68(9):1320-6. [Medline].

  5. Glickel SZ, Malerich M, Pearce SM, et al. Ligament replacement for chronic instability of the ulnar collateral ligament of the metacarpophalangeal joint of the thumb. J Hand Surg [Am]. 1993 Sep. 18(5):930-41. [Medline].

  6. Lohman M, Vasenius J, Kivisaari A, et al. MR imaging in chronic rupture of the ulnar collateral ligament of the thumb. Acta Radiol. 2001 Jan. 42(1):10-14.

  7. Shinohara T, Horii E, Majima M, Nakao E, Suzuki M, Nakamura R, et al. Sonographic diagnosis of acute injuries of the ulnar collateral ligament of the metacarpophalangeal joint of the thumb. J Clin Ultrasound. 2007 Feb. 35(2):73-7. [Medline].

  8. Gherissi A, Moussaoui A, Liverneaux P. [Is the diagnosis of Stener's lesion echograph-dependent? About a series of 25 gamekeeper's thumb.]. Chir Main. 2008 Sep 29. [Medline].

  9. Heyman P. Injuries to the ulnar collateral ligament of the thumb metacarpophalangeal joint. J Am Acad Orthop Surg. 1997 Jul. 5(4):224-9. [Medline].

  10. Thirkannad S, Wolff TW. The 'two fleck sign' for an occult Stener lesion. J Hand Surg Eur Vol. 2008 Apr. 33(2):208-11. [Medline].

  11. Rochet S, Gallinet D, Garbuio P, Tropet Y, Obert L. [Rupture of the thumb ulnar collateral ligament of the metacarpophalangeal joint: is it possible to operate according to the position of sesamoides on dynamic Xray]. Chir Main. 2007 Aug-Oct. 26(4-5):200-5. [Medline].

  12. Ebrahim FS, De Maeseneer M, Jager T, et al. US diagnosis of UCL tears of the thumb and Stener lesions: technique, pattern-based approach, and differential diagnosis. Radiographics. 2006 Jul-Aug. 26(4):1007-20.

  13. Melville D, Jacobson JA, Haase S, Brandon C, Brigido MK, Fessell D. Ultrasound of displaced ulnar collateral ligament tears of the thumb: the Stener lesion revisited. Skeletal Radiol. 2013 May. 42 (5):667-73. [Medline].

  14. Milner CS, Manon-Matos Y, Thirkannad SM. Gamekeeper's thumb--a treatment-oriented magnetic resonance imaging classification. J Hand Surg Am. 2015 Jan. 40 (1):90-5. [Medline].

  15. Gerber C, Senn E, Matter P. Skier's thumb. Surgical treatment of recent injuries to the ulnar collateral ligament of the thumb's metacarpophalangeal joint. Am J Sports Med. 1981 May-Jun. 9(3):171-7. [Medline].

  16. Kozin SH, Bishop AT. Gamekeeper's thumb. Early diagnosis and treatment. Orthop Rev. 1994 Oct. 23(10):797-804. [Medline].

  17. Neviaser RJ, Wilson JN, Lievano A. Rupture of the ulnar collateral ligament of the thumb (gamekeeper's thumb). Correction by dynamic repair. J Bone Joint Surg Am. 1971 Oct. 53(7):1357-64. [Medline].

  18. Puhaindran ME, Cheah AE, Yong FC. Re: "Stener lesion" after collateral ligament rupture of the proximal interphalangeal joint of the index finger. J Hand Surg Eur Vol. 2008 Oct. 33(5):678-9. [Medline].

 
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Displacement of the ulnar collateral ligament by the adductor aponeurosis during hyperabduction of the thumb.
Stress view of ulnar collateral ligament.
Ruptured ulnar collateral ligament.
Completed repair using suture anchors for fixation.
 
 
 
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