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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?
PCL is primary restraint to radial deviation with MCPJ in flexion, ACL provides restraint to radial deviation with MCPJ in extension
PCL is primary restraint to radial deviation with MCPJ in extension, ACL provides restraint to radial deviation with MCPJ in extension
ACL is primary restraint to ulnar deviation with MCPJ in flexion, PCL provides restraint to ulnar deviation with MCPJ in extension
ACL is primary restraint to radial deviation with MCPJ in flexion, PCL provides restraint to radial deviation with MCPJ in extension
PCL is primary restraint to ulnar deviation with MCPJ in flexion, ACL provides restraint to radial deviation with MCPJ in extension
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The proper ulnar collateral ligament(PCL) runs from the metacarpal head to the volar aspect of proximal phalanx and resists radial stress with the thumb MCPJ in flexion. The accessory ulnar collateral ligament(ACL) lies palmar to the proper ligament, and inserts onto the volar plate. The volar plate and ACL function as the principle restraints to radial 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.
Thirkannad S, Wolff TW
J Hand Surg Eur Vol. 2008 Apr;33(2):208-11. PMID: 18443066 (Link to Abstract)
Orthop Clin North Am. 1992 Jan;23(1):41-8. PMID: 1729668 (Link to Abstract)
HPI - This patient is an 18 year-old RHD male high school student who injured his thumb after falling on his radially abducted right thumb. He ignored his injury to play through the football season, and sought care 12 weeks after his injury. He complained of thumb instability, pain, and difficulty pinching. The patient never had a trial of casting/splinting.
How would you treat this patient's chronic thumb metacarpophalangeal joint UCL instability?
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This is an example of a patient with severe chronic UCL instability. The examin...