You are in: eMedicine Specialties > Orthopedic Surgery > HAND AND UPPER EXTREMITY Stener LesionArticle Last Updated: Feb 16, 2007AUTHOR AND EDITOR INFORMATIONSection 1 of 12
  Author: Joseph Rectenwald, MD, Staff Physician, Department of Orthopedic Surgery, Palmetto Richland Memorial Hospital Coauthor(s): John J Walsh IV, MD, Associate Professor, Department of Orthopedic Surgery, University of South Carolina School of Medicine Editors: 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; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Michael Yaszemski, MD, PhD, Associate Professor, Departments of Orthopedic Surgery and Bioengineering, Mayo Foundation, Mayo Medical School; Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital; 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 School of Medicine Author and Editor Disclosure Synonyms and related keywords: gamekeeper's thumb, skier's thumb, insufficiency of the ulnar collateral ligament of the thumb metacarpophalangeal joint, UCL, MCP, thumb injury INTRODUCTIONSection 2 of 12
  In his now classic 1962 article, Bertil Stener described a distinct, surgically correctable anatomic lesion that could account for the chronic instability found in the thumbs of some gamekeepers and skiers. CS Campbell first coined the term gamekeeper's thumb in 1955, when he described insufficiency in the ulnar collateral ligament (UCL) of the thumb metacarpophalangeal (MCP) joint in many Scottish gamekeepers. The proposed etiology of this laxity was related to the method used by gamekeepers to kill wounded rabbits. A gamekeeper would hold the rabbit's legs in one hand and wedge the animal's neck in the cleft between the thumb and index finger of the other hand. By forcefully pulling on the rabbit's legs, the neck was stretched and extended against the ulnar side of the thumb, thus breaking the neck and killing the rabbit. The multiple repetition of this maneuver was thought to be the etiology of the ulnar collateral ligamentous laxity found in 20 of the 24 Scottish gamekeepers examined in Campbell's study. More than a decade earlier, acute rupture of the UCL of the thumb as a result of major trauma was reported in Europe. European authors made the correlation between downhill skiing and this injury, coining the term skier's thumb. The proposed mechanism of injury was a traumatic avulsion of the UCL from forced abduction of the thumb proximal phalanx. Forced thumb abduction occurred from falling on the outstretched hand while still holding a ski pole. Any extreme valgus stress on the thumb can result in a ligamentous disruption of the UCL. The most common mechanism is a fall on the abducted thumb. Stener observed and reported several cases in which a distal rupture of the UCL of the thumb MCP joint occurred, with interposition of the adductor aponeurosis between the distal site of attachment of the ruptured ligament and the detached ligament. The interposed adductor aponeurosis maintains separation between the ruptured ends of the ligament and thus prevents ligamentous healing and restoration of joint stability. ProblemSee Pathophysiology. FrequencyThe true frequency is unknown. PathophysiologyStener described a lesion produced by forced thumb abduction in which the distal attachment of the UCL was traumatically avulsed from the proximal phalanx of the thumb. The severed end would become caught under the adductor aponeurosis and therefore be unable to return to its anatomic position. Consequently, the severed ligament would fold on itself and thus be prevented from healing and restoring stability to the MCP joint (see Image 1). ClinicalA patient with an acute injury to the UCL presents with a painful, swollen, ecchymotic thumb MCP joint. The physician must differentiate between an incomplete rupture or sprain and a complete rupture of the UCL. If a complete rupture is suspected, the physician must differentiate between a complete rupture with adductor aponeurosis interposition (Stener lesion) and a complete rupture with anatomic or near-anatomic position of the severed end of the UCL. Prior to the stress-testing part of the physical examination, plain anteroposterior (AP) and lateral radiographs are obtained. Valgus stress testing prior to radiographic evaluation may be contraindicated in the case of a nondisplaced ligamentous or avulsed bone fragment. Such a maneuver theoretically could turn a nondisplaced disruption into a displaced Stener-type lesion. A protocol and classification system developed by Louis and colleagues (1986) provides for a systematic method of evaluation for the acute UCL injury. Radiographs are used to classify the ligamentous injury into 1 of 5 categories, as follows:
Palpation of a lump (the distal end of the ruptured UCL) on the ulnar aspect of the thumb MCP is highly suggestive of a Stener lesion. However, lack of a mass does not exclude a Stener lesion. Other methods of diagnosis, such as stress radiography, magnetic resonance imaging (MRI), arthrography, and ultrasound scanning, also have been used to aid in diagnosing Stener lesions, with varying accuracy. Further research is needed to delineate the accuracy of these modalities. Early diagnosis of an acute Stener lesion is important, as repair of the UCL is more difficult when treatment is delayed longer than 3 weeks. More complex ligament reconstruction procedures (eg, adductor tendon advancement, arthrodesis) may be necessary when treatment of an acute UCL injury is delayed. Long-term instability may lead to traumatic degenerative joint disease and could require arthrodesis for definitive treatment. INDICATIONSSection 3 of 12
Stener was able to identify a subgroup of individuals with a UCL injury who required operative intervention for the restoration of UCL integrity and, therefore, MCP joint stability. 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 such 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. RELEVANT ANATOMYSection 4 of 12
The clearest and most eloquent anatomic depiction of the Stener lesion can be found in Stener's aforementioned article. Most of the material included here is adapted from his original work. Important structures around the MCP joint include the adductor aponeurosis and tendon, the dorsal aponeurosis, the collateral ligament proper, and the accessory collateral ligament of the thumb. The adductor aponeurosis serves as an active restraint to thumb abduction but has no passive role in MCP stability. Severance of the adductor aponeurosis has no effect on lateral stability. The UCL of the thumb is composed of 2 discernible components, the accessory and the proper. In his cadaveric dissections, Stener found that the UCL proper was taut in flexion and loose in extension, while the opposite was true for the accessory UCL. Transection of the UCL proper resulted in increased abduction with the MCP flexed but not when the MCP was held in the extended position. This instability was found to be slight and did not become severe until the accessory UCL was severed as well. The volar plate restricted abduction when the MCP was extended, even when both the UCL proper and accessory ligaments were severed. The UCL provides lateral support and prevents volar subluxation of the MCP joint. Stability of the thumb MCP to abduction is vital for key pinch, tip pinch, and thumb opposition. Stener described a lesion of the UCL in which the distal attachment was traumatically avulsed from the proximal phalanx of the thumb. Caught beneath the adductor aponeurosis, the severed end was unable to return to its anatomic position. The severed ligament consequently folded on itself and therefore was prevented from healing and restoring stability to the MCP joint (see Image 1). With a Stener lesion, a situation exists in which the MCP joint of the thumb is rendered permanently unstable because the UCL is prevented from healing by the interposed adductor aponeurosis. The resultant chronic instability significantly impairs function in the injured hand. CONTRAINDICATIONSSection 5 of 12
No absolute contraindications to surgical intervention exist for a true Stener lesion. WORKUPSection 6 of 12
Imaging Studies
TREATMENTSection 7 of 12
Medical therapyClosed 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. Surgical therapyKozin and Bishop (1994) have described the following operative method of exposure and repair of the Stener lesion:
The UCL frequently is torn from the insertion site at the proximal phalanx (see Image 3), sometimes with an avulsed bony fragment attached. A midsubstance tear may be repaired with a 3-0 nonabsorbable suture. If 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 using a suture anchor or a pullout suture with a nonabsorbable suture (see Image 4). The MCP joint then is pinned with a 0.045-inch Kirschner (K) wire in approximately 20° of flexion and with slight ulnar deviation prior to suture tying. 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-of-eight fashion through a predrilled hole in the proximal phalanx and at the collateral ligament insertion into the bony fragment. Tightening of the figure-of-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 (within 3 wk of injury), a good-to-excellent result can be expected in more than 90% of cases, regardless of ligament repair technique. Chronic ligamentous injuries (those > 3 wk from injury) are difficult to repair primarily. If significant arthritis is present, arthrodesis of the MCP 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. Ligament reconstruction with a free or local tendon graft has been described using various ligaments. The palmaris longus is utilized most commonly. Other, less commonly used choices include the extensor pollicis brevis tendon, the plantaris, a toe extensor, a slip of the abductor pollicis longus, or 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. COMPLICATIONSSection 8 of 12
Complications associated with surgical repair of an acute UCL injury include radial sensory nerve neurapraxia, stiffness of the thumb interphalangeal and MCP joints, and, infrequently, recurrent instability. OUTCOME AND PROGNOSISSection 9 of 12
Stener's original article was a significant contribution to the treatment of acute disruptions of the UCL of the thumb MCP joint. Stener described a lesion in which the thumb UCL is disrupted and prevented from healing in its original anatomic position by the interposed adductor aponeurosis. If recognized early, the UCL may be reduced operatively and secured in its anatomic position. Early recognition and anatomic reduction can result in excellent functional outcome in the vast majority of cases. Late presentation or a delayed diagnosis of a Stener lesion may produce a need for more involved surgery, with less desirable results. FUTURE AND CONTROVERSIESSection 10 of 12
Little controversy exists regarding the need for operative intervention for a true Stener lesion. Like any surgical procedure, however, surgeon-dependent variations exist in operative technique and postoperative protocol. MULTIMEDIASection 11 of 12
REFERENCESSection 12 of 12
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