Stener Lesion Treatment & Management

Updated: Aug 22, 2019
  • Author: Joseph P Rectenwald, MD; Chief Editor: Harris Gellman, MD  more...
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Treatment

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. [3]

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. [7, 13, 20]

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Surgical Therapy

Operative exposure and repair

In 1994, Kozin and Bishop [21]  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 (EPL) 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 image below), sometimes with an avulsed bony fragment attached. [13] A midsubstance tear may be repaired with a 3-0 nonabsorbable suture.

Ruptured ulnar collateral ligament. Ruptured ulnar collateral ligament.

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 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.

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. [20]

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. [22]

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 (EPB) tendon, the plantaris, a toe extensor, a slip of the abductor pollicis longus (APL), and a portion of the flexor carpi radialis (FCR) 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.

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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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