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The Stener Lesion and Complete Ulnar Collateral Ligament Injuries of the Thumb: A Review.

The Stener lesion was first described by a Swedish physician, Dr. Bertil Stener. (1) In his study published in 1962, he found that 25 of 39 patients who sustained a rupture of the thumb ulnar collateral ligament (UCL) from the first proximal phalanx at the metacarpophalangeal (MCP) joint had interposition of the adductor pollicis aponeurosis. Consequently, a Stener lesion became the eponym for a ruptured UCL from the thumb proximal phalanx at the level of the MCP joint that is displaced proximal and superficial to the adductor aponeurosis resulting in interposition of the aponeurosis between the ligament and the MCP joint. (2) Various studies have estimated the prevalence of these lesions to be between 60% to 88% of complete thumb UCL tears. (1,3,4) The proposed mechanism of injury involves placement of a valgus load against an abducted or radially-deviated thumb MCP joint. The adductor aponeurosis displaces distally, thereby uncovering the UCL, which tears with increasing valgus force. (1) When the thumb returns to a neutral position, the aponeurosis repositions and the UCL is caught superficially. This mechanism is more commonly seen in downhill skiers, football players, and wrestlers. (5)

Anatomy

Understanding the function and normal anatomy of the UCL is crucial for comprehending the pathoanatomy of a Stener lesion. In general, together with the dorsal capsule, radial collateral ligament (RCL), and volar plate, the UCL serves as a static stabilizer of the MCP joint. (6) More specifically, the primary function of the UCL is to provide resistance to valgus stress and volar subluxation of the MCP joint, and it also contributes to pinch strength. The ligament is approximately 12 mm to 14 mm in length and slightly more than 5 mm in width. (7) It is comprised of two distinct bundles or structures: the proper and accessory UCLs (Table 1). (6,8) The "proper" is taut in flexion, while the "accessory" is taut in extension. A certain amount of valgus laxity of the thumb MCP joint is normal, typically 6[degrees] in extension and 12[degrees] in flexion. (8,9)

Evaluating the anatomy more closely, the proper UCL courses in a distal-volar direction from the base of the first metacarpal head to the medial tubercle of the proximal phalanx. (8,10) The accessory UCL is more superficial and volar, and it blends into the fibrocartilaginous region of the volar plate (including the ulnar sesamoid bone). A cadaveric anatomic study performed by Carlson et al. (7) demonstrated that, collectively, the gross center of the UCL origin is 4.2 mm from the dorsal surface of the first metacarpal, and 5.3 mm from the articular surface. The center of the phalangeal insertion is 2.8 mm from the volar surface and 3.4 mm distal to the MCP joint.

Tearing of both the proper and accessory UCLs is needed in order to develop a Stener lesion. (11) A load of approximately 294 N is required to accomplish this. (12) Interposition of the aponeurosis between the torn UCL and its insertion onto the proximal phalanx provides a physical barrier to healing. (13,14) Of note, one cannot sustain a Stener lesion on the radial side of the thumb because the abductor pollicis aponeurosis lies over the proximal RCL, whereas the adductor pollicis aponeurosis inserts more obliquely along the proximal phalanx extensor hood. (6,14)

Skier's and Gamekeeper's Thumb

When discussing this type of pathology, it is important to distinguish between a skier's or gamekeeper's thumb and a Stener lesion. A skier's thumb refers to an acute, whereas a gamekeeper's thumb typically denotes a chronic, UCL injury or insufficiency at the thumb MCP joint. A skier's thumb is named for the valgus moment that a ski pole places onto a thumb when one falls while skiing. (3,15) Gamekeeper's thumb was first described by Campbell in 1955. (16) He observed this condition in a non-traumatic setting among Scottish gamekeepers who would kill a wounded rabbit by exerting a downward pressure on their necks with the thumb and index finger, which placed a valgus stress on an abducted MCP joint. Over time, this repetitive maneuver led to UCL insufficiency. Importantly, neither of these injuries lead to interposition of the adductor aponeurosis, which distinguishes them from a Stener lesion.

Clinical Evaluation

The clinical evaluation for a Stener lesion includes a thorough history, which often involves a hyper-radial deviation injury to the thumb. Patients will typically endorse pain along the ulnar aspect of the thumb MCP joint. On examination, swelling, ecchymosis, and tenderness along the ulnar aspect of the thumb is often noted. A palpable mass may also be present on the ulnar aspect of the proximal phalanx base which may represent the torn UCL, indicative of a Stener lesion. (17,18) This finding is typically absent in patients with chronic UCL insufficiency, but its absence does not necessarily mean that a Stener lesion is not present. (2,4,19) While most Stener lesions result from a tear at the UCL's distal insertion, proximal or mid-substance tears (as well as bony avulsions) can also occur, leading to variable locations of this finding. (10)

Stress examination of the MCP joint is perhaps the most important clinical evaluation of stability of the UCL. However, stressing an acutely-injured MCP joint may be painful, with guarding and muscle spasms potentially yielding a false-negative result. Consequently, some surgeons advocate administering an intra-articular lidocaine injection prior to testing in order to increase accuracy. (2,10,20) To that end, a study by Cooper et al. (20) suggested that diagnostic accuracy increases from 28% to 98% when an intra-articular injection is given. To perform the test, one hand should stabilize the metacarpal neck while the other grasps the proximal phalanx and controls rotation, because rotation of the phalanx can masquerade as valgus laxity (Fig. 1). A valgus force should be applied with the thumb in both full extension and at 30[degrees] of flexion, and it should be compared to the contralateral thumb.

Generally, instability to valgus stress in flexion indicates an injury to the proper UCL, instability in extension suggests an accessory UCL injury, and instability in both positions indicates injury to both bundles. (10) Defining instability parameters more specifically, the traditional diagnosis of a complete UCL rupture is made if there is over 35[degrees] of valgus laxity in either flexion or extension and there is a greater than 15[degrees] difference compared to the uninjured thumb. (4,11) Pain at the UCL with symmetric laxity is generally considered to be a ligament sprain, while a difference between 10[degrees] to 15[degrees], but with a firm endpoint, is considered a partial tear. (11,21) With regards to a Stener lesion, valgus instability greater than 35[degrees] in both flexion and extension has been shown to be 94% sensitive and 57% specific for detection. (4,18) However, rather than strictly adhering to this numerical classification, many surgeons assert that the absence of a firm endpoint on stress testing is the best indicator of a complete UCL tear. (10,22)

Diagnostic Studies

Several imaging modalities are available for detecting a Stener lesion. Radiographs of the thumb are typically obtained to assess for metacarpal fractures or fractures at the base of the proximal phalanx, as well as for volar subluxation and squaring of the metacarpal head. Radiographs may also reveal a "two fleck sign." (23) This phenomenon occurs when a larger, more obvious fracture fragment seen lying adjacent to the expected location of the attachment of the UCL is, in fact, part of the attachment of the adductor pollicis and not the UCL. A second, smaller fleck of bone is attached to the displaced UCL, identifying this as a Stener lesion. In general, bony avulsions can be seen in up to 30% of complete UCL ruptures. (24) Evidence of an exostosis at the metacarpal neck may denote a chronic, rather than acute, UCL tear. (25) Moreover, stress views can be obtained to better assess the degree of laxity in patients who have an equivocal clinical exam. Although not typically performed and despite concerns by some surgeons that valgus stressing the MCP joint could worsen an underlying UCL injury, a cadaveric study by Adler et al. (26) demonstrated that a properly performed stress view cannot cause a Stener lesion.

Additionally, ultrasound can be a relatively fast, costeffective, and non-invasive imaging option. An intact UCL will appear as a continuous echolucent convex structure along the ulnar aspect of the thumb. (13) An ill-defined, heterogeneous, echolucent mass identified proximal to the MCP joint with absent UCL fibers at the proximal phalanx, referred to as a "tadpole" sign, indicates a Stener lesion. Results from three Level 1 studies indicate that ultrasound has a 76% sensitivity and 81% specificity and accuracy for detecting a Stener lesion. (27-29) However, as with many ultrasound studies, these figures vary significantly depending upon the skill of the technician. Moreover, ultrasound diagnosis can be challenging in the setting of chronic tears and intrinsically thin UCLs.

Arthrography can also be utilized to visualize a retracted or folded UCL either directly by joint distension or indirectly via extravasation of contrast or visualization of the heads of the adductor pollicis. (13,30) This technique, however, is invasive and is unable to assess other surrounding structures. Moreover, its efficacy is limited in the setting of an intact capsule.

Magnetic resonance imaging (MRI) has shown variable accuracy for detecting a Stener lesion based upon Level III evidence, with some studies reporting poor specificity, sensitivity, and interobserver reliability, while others report up to 100% sensitivity and 94% specificity, especially when combined with an arthrogram. (21,31,32) An acute Stener lesion will appear on an MRI as edema around the rupture site and an identifiable gap in the ligament, described as a "yo-yo on a string" appearance (Fig. 2). (13,21) A chronic rupture will manifest as decreased signal intensity and a less identifiable gap due to scarring. Also, false positives on dorsal MRI cuts may result due to the relatively volar course of the UCL. In a head-to-head comparison of MRI and ultrasound, Hergan et al. (33) found MRI to be superior, with a sensitivity and specificity of 100%, compared to 88% and 83%, respectively, for ultrasound. Nonetheless, the cost-effectiveness of routine MRI use has not yet been established.

Overall, there is no single imaging standard for the detection of Stener lesions, with most of the reports in the literature revolving around predominantly smaller studies of lower-level evidence with a high degree of variability. Consequently, the physician must often rely on the patient's history and clinical examination to make a diagnosis.

Management

Once diagnosed, the management of a Stener lesion typically includes an operative intervention since the interposition of the adductor pollicis aponeurosis prevents healing. Non-operative management is reserved only for patients with significant comorbidities that preclude medical clearance. In these patients, the thumb is immobilized for 4 to 8 weeks through spica casting or functional hinged bracing in slight ulnar deviation and flexion at the MCP joint. (3,10) This is then followed by a graded occupational therapy program. However, persistent pain and instability have been reported in 15% to 100% of patients with Stener lesions treated nonoperatively in several case series. (34-36)

The goal of surgery is to reproduce the anatomic position of the UCL and restore MCP joint stability, and surgical options vary depending upon the chronicity of the injury. Although the timing of "acute" and "chronic" lesions is debated within the literature and serves only as a guide for treatment, "acute" injuries are generally considered to be those occurring within the past 3 to 6 weeks and which can usually be treated with repair of the UCL. (10,11,14) However, cases where the UCL is retracted and scarred may be unable to be repaired. While this may be found earlier, this is typically seen in injuries that are more than 6 weeks old, and when present these cases can be treated with tendon transfers or graft reconstruction using palmaris longus or EPB autografts, among others. (14) In cases where chronic instability has led to MCP joint arthritis, an arthrodesis or arthroplasty can be performed.

Reviewing the management more closely, the general surgical approach typically involves a dorsal-ulnar skin incision, dissection which protects the branches of the radial sensory nerve, and making a longitudinal incision over the adductor aponeurosis and the MCP joint capsule.

Acute Lesions

A variety of procedures exist for repairing acute Stener lesions. Direct suture repair can be performed if distal ligamentous remnants of the UCL are still attached to the proximal phalanx, as in a mid-substance tear. (13) A strong 3-0 or 4-0 non-absorbable suture, such as FiberWire (Arthrex, Naples, Florida, USA), is used. (37) If a bony avulsion is present, larger bony fragments are incorporated into the fixation, while smaller fragments (which are more common) are excised as stable bony fixation is difficult. (3) Additionally, although not always performed and highly surgeon-dependent, surgeons have the option of immobilizing the MCP joint with a pin for 4 to 6 weeks to protect the joint from stress during the healing phase. (3,10) The MCP joint is held in a reduced position with mild flexion, and a 0.045-inch K-wire is introduced.

When viable ligamentous remnants are not present, the lesion is treated with reattachment of the ligament to the bone. One option to accomplish this is to use transosseous pull-out sutures through bone tunnels. (2,3,10,11) With this technique, a suture is passed through the proximal stump of the UCL and then passed through two transverse, slightly divergent bone tunnels in the proximal phalanx. These tunnels are centered around the isometric point at an angle of 45[degrees] from the MCP joint surface. The suture ends are subsequently tied down over a bony bridge or button on the dorsoradial aspect of the phalanx. Alternatively, suture anchors can be inserted into the metacarpal or proximal phalanx while the sutures are tensioned and secured to the UCL stump through a Bunnell or Kessler stitch to lie in contact with the bone. (8) In most repairs, the MCP joint is held in 15[degrees] of flexion and slight ulnar deviation.

In order to assess the robustness of these repair techniques, several biomechanical studies have been performed. Firoozbakhsh et al. (12) conducted a cadaveric study in which they compared the biomechanical properties of intact UCLs to those repaired with mini suture anchors. While repair with suture anchors yielded a lower load to failure and less joint rigidity, these investigators concluded that the repaired UCLs may be able to withstand forces produced by moderate MCP range of motion. Harley et al. (38) performed a comparable cadaveric investigation whereby they induced an acute UCL rupture through controlled valgus loading and repaired it with a mini suture anchor. While the strains at failure were similar between intact and repaired UCLs, repaired specimens had a significantly lower load to failure. However, the reported maximum strain at failure was three times greater than the strain typically seen in active thumb motion. To evaluate the relative fixation strengths of different types of suture anchors, Jarrett et al. (39) conducted a cadaveric study of iatrogenic UCL injuries repaired with either traditional suture anchors or PushLock anchors, which allow the surgeon to approximate the UCL to its insertion by passing sutures prior to securing the anchor to bone. They showed that the PushLock anchor has a significantly higher resistance to gap formation and is less likely to fail at the interface between the UCL and the suture.

In addition to the aforementioned repair strategies, less commonly used techniques, such as condylar shaving, have been described. Haddock et al. (40) described this technique in 2009 for the treatment of both challenging acute and chronic complete UCL injuries. Using the standard incision over the thumb, they elevated proximally-based and distally-based rectangular flaps containing the UCL remnants and exposed the MCP joint. Then, the condyles along the ulnar aspect of both the first metacarpal and proximal phalanx were shaved with a burr until the bone contour was flush. A K-wire was used to stabilize the joint, and then a 2 mm suture anchor was introduced into the footprint of the resected condyle in the proximal phalanx. The proximally-based flap was secured down first, and the distal flap reinforced on top with the same sutures. This technique provided a shorter course for the UCL remnants, thereby facilitating an easier primary repair.

Like condylar shaving, arthroscopy-assisted UCL repair has been described but is less commonly performed. (41) In this technique, 2 mL of normal saline is injected into the thumb MCP joint, and two portals (one radiodorsal portal and one radiopalmar portal just volar to the RCL) are introduced. A small probe passed through the radiopalmar portal is then used to reduce the distal remnant of the UCL back underneath the adductor aponeurosis. The joint is immobilized with a K-wire and the UCL is allowed to scar in.

Of all the described techniques for acute repair, suture anchors are the most commonly used. However, regardless of the repair method, re-creation of the UCL's anatomic footprint is crucial, because non-anatomic re-positioning of the UCL leads to abnormal motion at the MCP joint that can predispose to post-traumatic osteoarthritis or increased stiffness.

Chronic Lesions

In the setting of a chronic Stener lesion, or if a prior repair has failed, the UCL may be retracted or attenuated. (11,42) This makes primary repair challenging, with historically poor outcomes. (14) Consequently, alternative management strategies need to be implemented.

In the absence of first MCP joint osteoarthritis, treatment with either dynamic or static stabilization is performed. (11,13,43) Dynamic stabilization confers joint stability via tendon transfers. The first of these techniques was described by Kaplan (44) originally for chronic complete UCL tears. He advocated transferring the extensor indicis proprius (EIP) to the extensor pollicis longus (EPL) at the level of the sagittal band in addition to repairing the dorsal capsule. Later, Sakellarides and DeWeese (45) described transferring either a split or full extensor pollicis brevis (EPB) tendon to the ulnar side of the proximal phalanx to restore stability. Additionally, Neviaser et al. (46) reported adductor pollicis advancement to a location 1 cm distal to the MCP articulation with capsulorrhaphy. Modifying Neviaser's technique, McCue et al. (5) performed an adductor advancement combined with UCL advancement in a series of 25 athletes.

As an alternative to dynamic stabilization methods, static stabilization refers to reconstruction with a tendon graft. (11,13) A variety of graft choices and bone tunnel configurations for placement of these grafts have been described in the literature. Of these, perhaps the most commonly used tendon graft is the palmaris longus (Fig. 3). (8) With this graft, Glickel et al. (43) reported their technique of reconstructing the UCL through three bone tunnels: two in the proximal phalanx and one in the first metacarpal (Fig. 4). This is known as the apexproximal triangular tunnel configuration. More specifically, after resecting the UCL remnants, two proximal phalanx tunnels are created at the 1 o'clock and 4 o'clock positions 5 mm distal to the MCP articulation. These tunnels are created at a 45[degrees] angle from one another at the insertional footprint of the UCL and converge in the intramedullary canal. Then, a single ulnar-to-radial tunnel is made in the metacarpal at the UCL origin. The palmaris longus graft is subsequently passed first through the proximal phalanx tunnels, and its ends are then passed from ulnar to radial through the metacarpal tunnel with the aid of a suture passer or steel wire (Fig. 5). After appropriately tensioning the graft, the graft ends are tied over a metacarpal button, sutured together in a knot, or secured to the metacarpal with an interference screw.

Several other tendon graft and bone tunnel combinations have been reported. Strandell47 described the use of a split EPB graft in a small series of patients, while Fairhurst and Hansen (48) demonstrated the utility of a full EPB tendon in an apex-distal, or reverse, triangular bone tunnel configuration. Moreover, Alldred (49) used a fourth toe extensor autograft in a figure-of-eight weave for three patients, and Osterman et al. (50) described a rectangular, or parallel, configuration. Also, Frykman and Johansson (51) reported UCL reconstruction with a slip of the abductor pollicis longus (APL), which they passed through a transverse metacarpal tunnel from radial to ulnar and secured to the base of the proximal phalanx ulnarly.

As with acute repair, various cadaveric studies have attempted to analyze the biomechanical characteristics of chronic reconstruction techniques. In a UCL tendon graft reconstruction simulation, Lee et al. (52) compared the valgus stability and range of motion conferred by four common bone tunnel configurations: apex-proximal, apex-distal, cruciate, and parallel. Each tunnel configuration produced a similar degree of valgus load stability, but only the apexproximal method restored a flexion-extension range of motion similar to the native UCL. Consequently, the investigators recommended that apex-proximal bone tunnels be used for UCL reconstruction. Hogan et al. (53) compared the strength and stiffness of the intact UCL with the Strandell, modified Glickel, Osterman, and Fairhurst reconstruction techniques. While none of the techniques matched the rotational stiffness or failure moment of the intact UCL, the modified Glickel procedure (using interference knot fixation) had a significantly higher failure moment and stiffness compared to the other three methods.

If, due to chronic instability, the MCP joint has developed osteoarthritis, repair or reconstruction techniques may lead to persistent pain. In this situation, MCP joint arthrodesis or arthroplasty is recommended. (8) To accomplish this, a dorsal incision over the extensor interval is made. If an arthrodesis is to be performed, the articular surfaces are debrided and fused with a plate-and-screw construct, K-wires and tension band, or cannulated screws.

Postoperative Care

Following repair of Stener lesions, the postoperative rehabilitation protocol is often surgeon-dependent. While a variety of protocols exist, one common practice for acute repairs is to immobilize the MCP joint for 4 to 6 weeks followed by an additional several weeks of protected or supervised therapy and a return to full activity by 10 to 12 weeks. (6) However, several cadaveric biomechanical studies have shown that the maximum load-to-failure with suture anchor repair exceeds the force typically encountered with active thumb motion. (12,38) Given these findings, there has been a recent trend toward earlier mobilization to prevent thumb stiffness in the setting of acute repairs. One proposed protocol by Crowley et al. (54) immobilizes the MCP joint for approximately 2 weeks, after which the patient is placed into a removable splint which allows them to perform active range of motion exercises four times daily. This splint is then discontinued at 4 weeks when strengthening exercises are introduced, and the patient is permitted to return to their full activities by 3 months. Patients treated with reconstruction or arthrodesis follow a similar progression but with a longer period of initial immobilization and a slight delay before permitting therapy and full activity. (6)

Outcomes

Acute Repair

Several studies have demonstrated successful patient outcomes with acute repair of UCL and Stener lesions through the pull-out suture and suture anchor techniques. One such study by Zeman et al. (55) prospectively followed 58 patients who sustained a complete, acute UCL rupture repaired with a suture anchor. Forty-five patients had a minimum of 1 year of follow-up and completed a subjective functional outcomes questionnaire. Of these patients, 98% were satisfied with the surgery, felt that they had a stable repair, were not impaired in their activities of daily living, and had a functional range of motion. Only 17% of the patients reported persistent mild discomfort. Additionally, Weiland et al. (56) prospectively evaluated 30 patients who underwent repair with suture anchors and showed that there was no difference in valgus stress test measurements or pinch strength between the repaired and uninjured thumbs. Moreover, 29 out of the 30 patients reported "good" or "excellent" satisfaction with their surgical result. Although both the pull-out suture method and suture anchor technique have shown successful patient outcomes, a retrospective study of 60 patients by Katolik et al. (57) showed that suture anchor fixation results in improved pinch strength, better range of motion, reduced tourniquet time, and fewer complications compared to pull-out sutures.

Chronic Reconstruction and Arthrodesis

Similar to acute repair, reconstructive and arthrodesis techniques have shown good outcomes in the setting of a chronic lesion. As previously noted, McCue et al. (5) described a dynamic stabilization technique involving adductor pollicis tendon advancement combined with UCL advancement or reattachment. Their series of 25 athletes with chronic lesions that occurred an average of 9 weeks prior to surgery demonstrated that 96% of the patients had either "good" or "excellent" outcomes. The patients exhibited 7[degrees] more laxity on valgus stress testing. However, all patients were ultimately able to return to sport at the same position. In the report by Glickel et al. (43) of their apex-proximal tendon graft reconstruction technique, they retrospectively reviewed 26 patients with an average follow-up of 4.5 years. The static reconstruction restored 90% of the MCP joint stability in 92% of the patients and maintained an average of 85% of the range of motion. Moreover, the postoperative key pinch strength was restored by 95%. These investigators also developed a grading system for outcomes that is now commonly used. Based upon this system, 92% of patients had "good" or "excellent" outcomes.

Evaluating outcomes following MCP arthrodesis, Hagan and Hastings (58) retrospectively assessed 10 patients who underwent arthrodesis due to chronic UCL instability resulting in osteoarthritis. All patients were fused with either percutaneous K-wires or a tension-band construct. There was a 100% fusion rate, and every patient had a postoperative pinch strength similar to the uninjured thumb.

Overall Outcomes

In order to more globally assess outcomes following the treatment of thumb UCL ruptures, Samora et al. (59) conducted a systematic review of 14 clinical studies reporting outcomes for non-operative management, acute repair, and chronic reconstruction. They demonstrated that non-operative treatment often failed. However, management with repair of acute lesions and reconstruction of chronic ruptures consistently led to excellent outcomes with no appreciable difference between the two groups.

Complications

As with every operation, complications are always possible. The complications associated with the treatment of Stener lesions include failure of the primary repair or reconstruction with recurrence of instability, infection, paresthesias on the ulnar border of the thumb due to irritation of the dorsal radial sensory nerve, and decreased range of motion. (2,3,14)

Illustrative Case

The following is a case illustrating the typical presentation and treatment of a patient with a Stener lesion.

The patient is a 35-year-old, right-hand-dominant male who presented with left thumb pain after falling off of his motorcycle 1 week prior. Since the low-speed fall, he noted pain predominantly over the base of his thumb with limited range of motion. His past medical history was significant for gastroesophageal reflux disease (GERD) and an appendectomy. He had no known drug allergies or toxic habits.

On physical examination, his skin was intact, but he had swelling, ecchymosis, and tenderness to palpation ulnarly at the thumb MCP joint. His thumb range of motion was limited secondary to pain, there was a palpable mass along the ulnar aspect of his thumb, and his thumb MCP joint demonstrated gross instability with radial deviation stress without an endpoint. His left upper extremity was otherwise neurologically intact.

Plain radiographs of the thumb were obtained but revealed no fractures or dislocations. The patient presented with an MRI from an outside facility that demonstrated a proximally-displaced tear of the MCP joint UCL with interposition of the adductor pollicis aponeurosis (a Stener lesion).

Given the presence of a Stener lesion, the patient was taken to the operating room for surgical intervention. A dorsal-ulnar incision was made over the left thumb at the ulnar aspect of the MCP joint (Fig. 6). The branch of the dorsal radial sensory nerve was identified and protected volarly. The UCL was found to be torn and retracted proximal to the proximal edge of the adductor aponeurosis, identifying the Stener lesion (Fig. 7). The aponeurosis was then incised and elevated from the MCP joint. The UCL was then tenolysed, and the MCP joint was reduced and pinned with a single 0.045-inch K-wire. The proximally-based UCL was then repaired to its distal ligamentous remnants with 4-0 interrupted sutures. The adductor aponeurosis was subsequently repaired ulnarly with centralization of the tendon at the MCP joint with interrupted sutures (Fig. 8). Five weeks after this index procedure, the K-wire was removed, and the patient recovered well.

Summary

A Stener lesion refers to a ruptured UCL from the thumb proximal phalanx at the level of the MCP joint that is displaced proximal and superficial to the adductor pollicis aponeurosis, resulting in interposition of the aponeurosis between the ligament and the MCP joint. A careful clinical examination is crucial to the diagnosis, with valgus stress testing of the MCP joint being a vital aspect of the assessment. In cases where the clinical examination is equivocal, however, adjunctive imaging studies including ultrasound or MRI can be performed. The interposition of the adductor aponeurosis, which distinguishes the Stener lesion from other UCL injuries, provides a physical blockade to healing, thereby necessitating surgery. Acute Stener lesions can be treated with repair of the UCL primarily through direct suture, suture anchor, or pull-out suture techniques. More chronic injuries can be treated with reconstruction, while arthrodesis can be reserved for cases where MCP joint arthritis is present. Overall, patient outcomes are generally good with operative treatment of Stener lesions and complete UCL injuries of the thumb.

Disclosure Statement

None of the authors have a financial or proprietary interest in the subject matter or materials discussed in the manuscript, including, but not limited to, employment, consultancies, stock ownership, honoraria, and paid expert testimony.

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Bryan G. Beutel, MD, Eitan Melamed, MD, and Michael E. Rettig, MD

Bryan G. Beutel, MD, Eitan Melamed, MD, and Michael E. Rettig, MD, Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, New York, USA. Correspondence: Bryan G. Beutel, MD, 10 Waterside Plaza, Apt 10B, New York, New York, 10010, USA; bryanbeutel@gmail.com.

Caption: Figure 1 Valgus stress test of the thumb at the metacarpophalangeal joint.

Caption: Figure 2 A, T2, B, T1, and C, axial MRI views of the thumb demonstrating a Stener lesion.

Caption: Figure 3 Palmaris longus autograft harvest.

Caption: Figure 4 Apex-proximal bone tunnel configuration. One tunnel is placed through the first metacarpal, while two tunnels are introduced into the proximal phalanx. To view this figure in color, see www.hjdbulletin.org.

Caption: Figure 5 Reconstructed ulnar collateral ligament with palmaris longus autograft passed through the bone tunnels. To view this figure in color, see www.hjdbulletin.org.

Caption: Figure 6 Dorsal-ulnar incision for Stener lesion repair and reconstruction. To view this figure in color, see www.hjdbulletin.org.

Caption: Figure 7 Stener lesion with ruptured ulnar collateral ligament and interposed adductor pollicis aponeurosis. To view this figure in color, see www.hjdbulletin.org.

Caption: Figure 8 Directly-repaired ulnar collateral ligament and adductor aponeurosis. To view this figure in color, see www.hjdbulletin.org.
Table 1 Anatomic Characterization of the Ulnar Collateral Ligament of
the Thumb

Bundle     Dynamic Tension      Course

Proper     Tight in flexion,    Distal-volar direction from base of
           loose in extension   first metacarpal head to medial tubercle
                                of proximal phalanx
Accessory  Tight in extension,  Superficial or volar to proper bundle,
           loose in flexion     blends into fibrocartilaginous of volar
                                plate


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Author:Beutel, Bryan G.; Melamed, Eitan; Rettig, Michael E.
Publication:Bulletin of the NYU Hospital for Joint Diseases
Article Type:Report
Date:Jan 1, 2019
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