http://upload.orthobullets.com/topic/6040/images/ucl avulsion.jpg
http://upload.orthobullets.com/topic/6040/images/stener lesion.jpg
Introduction
  • Thumb collateral ligament injuries include
    • radial collateral ligament
      • rare
    • ulnar collateral ligament
      • most common
      • eponyms for ulnar collateral ligament  (UCL) injury are
        • Gamekeeper's thumb for chronic injury
        • skiers thumb for acute injury
        • Stener lesion 
          • avulsed ligament with or without bony attachment is displaced above the adductor aponeurosis
          • will not heal without surgical repair
  • Epidemiology
    • UCL more common than radial collateral ligament
  • Mechanism
    • hyper abduction or extension at the MCP joint
Anatomy
  • UCL is composed of 
    • proper collateral ligament 
      • resists valgus load with thumb in flexion
    • accessory collateral ligament and volar plate 
      • resists valgus load with thumb in extension
      • valgus laxity in both flexion and extension is indicative of a complete UCL rupture 
Presentation
  • History
    • hyperabduction injury
  • Symptoms
    • pain at ulnar aspect of thumb MCP joint
  • Physical exam
    • inspection and palpation
      • mass from torn ligament and possible bony avulsion may be present
    • stress joint with radial deviation both at neutral and 30° of flexion
      • instability in 30° of flexion indicates injury to proper UCL  
      • instability in neutral indicates injury to accessory and proper UCL and/or volar plate
      • compare to uninjured thumb MCP joint

Imaging
  • Radiographs  
    • recommended views
      • AP, lateral and oblique of thumb
      • valgus stress view may aid in diagnosis if a bony avulsion has already been ruled out
  • MRI
    • can aid in diagnosis if exam equivocal

Treatment
  • Nonoperative
    • immobilization for 4 to 6 weeks
      • indications
        • partial tears with < 20° side to side variation of varus/valgus instability
  • Operative
    • ligament repair
      • indications
        • acute injuries with
          • > 20° side to side variation of varus/valgus instability
          • >35° of opening
        • Stener lesion  
          • avulsed ligament with or without bony attachment is displaced above the adductor aponeurosis
          • will not heal without surgical repair
      • technique
        • can use suture, suture anchors, or small screw to repair ligament
    • reconstruction of ligament with tendon graft, MCP fusion, or adductor advancement
      • indications
        • chronic injury
Radial Collateral Ligament Injury
  • Rare
  • Treatment
    • nonoperative
      • immobilization
        • indicated in most cases
        • Stener's lesion does not occur
 

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Questions (1)

(OBQ10.213) Creation of a Stener lesion, as found in Gamekeeper's thumb, requires combined tears of the proper and accessory ulnar collateral ligaments in order for the ligament to be displaced by the adductor aponeurosis. Which of the following most accurately describes the role these ulnar collateral ligaments (PCL/ACL) play in thumb MCP joint stability? Review Topic

QID:3306
1

PCL is primary restraint to radial deviation with MCPJ in flexion, ACL provides restraint to radial deviation with MCPJ in extension

57%

(1043/1828)

2

PCL is primary restraint to radial deviation with MCPJ in extension, ACL provides restraint to radial deviation with MCPJ in extension

9%

(161/1828)

3

ACL is primary restraint to ulnar deviation with MCPJ in flexion, PCL provides restraint to ulnar deviation with MCPJ in extension

9%

(170/1828)

4

ACL is primary restraint to radial deviation with MCPJ in flexion, PCL provides restraint to radial deviation with MCPJ in extension

17%

(316/1828)

5

PCL is primary restraint to ulnar deviation with MCPJ in flexion, ACL provides restraint to radial deviation with MCPJ in extension

6%

(115/1828)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

The proper ulnar collateral ligament(PCL) runs from the metacarpal head to the volar aspect of proximal phalanx and resists ulnar stress with the thumb MCPJ in flexion. The accessory ulnar collateral ligament(ACL) lies palmar to the proper ligament, and insets inserts onto the volar plate. The volar plate and ACL function as the principle restraints to ulnar stress with the thumb MCPJ in extension.

The function of the ulnar collateral ligaments is shown in Illustration A.(Please note the distal phalanx of the thumb has been removed in Illustration A.) A Stener lesion is described by displacement of the distal end of the completely ruptured UCL such that it comes to lie superficial and proximal to the adductor aponeurosis. This is shown in Illustration B.

Thrikannad and Wolff report a case of distal pull-off of the ulnar collateral ligament (UCL) of the thumb MCPJ with two fracture fragments. They identify the need to look for a second fragment of bone in these injuries, where an apparently undisplaced fracture is noted at the base of the proximal phalanx. They suggest that this second fragment probably indicates the location of the distal end of the UCL and may identify a Stener lesion. A radiographic example from their paper is shown in Illustration C.

Newland, in his review article on Gamekeeper's Thumb, states that criteria for judging what constitutes a complete tear vary from 15 deg to 45 deg difference with respect to the opposite side. He goes on to state, however, that many authors choose an absolute value of >35 degrees of joint laxity compared to the contralateral side when judging a tear to be complete or incomplete. When an complete tear is identified, surgical repair is recommended.

ILLUSTRATIONS:

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