What’s the Diagnosis – Case 118
1
What’s the Diagnosis – Case 118
2
What’s the Diagnosis – Case 118
3
What’s the Diagnosis – Case 118
4
What’s the Diagnosis – Case 118
5
What’s the Diagnosis – Case 118
6
What’s the Diagnosis – Case 118
7
What’s the Diagnosis – Case 118
8
What’s the Diagnosis – Case 118
9
What’s the Diagnosis – Case 118
10
What’s the Diagnosis – Case 118
11
What’s the Diagnosis – Case 118
12
What’s the Diagnosis – Case 118
13
What’s the Diagnosis – Case 118
14
What’s the Diagnosis – Case 118
15
What’s the Diagnosis – Case 118
16
What’s the Diagnosis – Case 118
17
What’s the Diagnosis – Case 118
18
What’s the Diagnosis – Case 118
19
What’s the Diagnosis – Case 118
20
What’s the Diagnosis – Case 118
21
What’s the Diagnosis – Case 118
22
What’s the Diagnosis – Case 118
23
What’s the Diagnosis – Case 118
24
What’s the Diagnosis – Case 118
25
What’s the Diagnosis – Case 118
26
What’s the Diagnosis – Case 118
27
What’s the Diagnosis – Case 118
28
What’s the Diagnosis – Case 118
29
What’s the Diagnosis – Case 118
30
What’s the Diagnosis – Case 118
31
What’s the Diagnosis – Case 118
32
What’s the Diagnosis – Case 118
33
What’s the Diagnosis – Case 118
34
What’s the Diagnosis – Case 118
35
What’s the Diagnosis – Case 118
36
What’s the Diagnosis – Case 118
37
What’s the Diagnosis – Case 118
38
What’s the Diagnosis – Case 118
39
Findings The patient has sustained a disruption of the entire ulnar collateral ligament (UCL) of the thumb MCP from the attachment to the base of the metacarpal with the ligament now lying superficial or outboard to the adductor aponeurosis (AA). This configuration has been termed a yo-yo on a string. The yo-yo being the UCL and the string the AA. A partial disruption has been sustained of the proximal attachment of the radial collateral ligament (RCL) and edema is present of the metacarpal head related to the recent trauma. No chondral shearing injury has been sustained but a reactive effusion is present of the thumb or 1st MTP.
What’s the Diagnosis – Case 118
40
What’s the Diagnosis – Case 118
41
What’s the Diagnosis – Case 118
42
What’s the Diagnosis – Case 118
43
What’s the Diagnosis – Case 118
44
What’s the Diagnosis – Case 118
45
What’s the Diagnosis – Case 118
46
What’s the Diagnosis – Case 118
47
What’s the Diagnosis – Case 118
48
What’s the Diagnosis – Case 118
49
What’s the Diagnosis – Case 118
50
What’s the Diagnosis – Case 118
51
What’s the Diagnosis – Case 118
52
What’s the Diagnosis – Case 118
53
What’s the Diagnosis – Case 118
54
What’s the Diagnosis – Case 118
55
What’s the Diagnosis – Case 118
56
What’s the Diagnosis – Case 118
57
What’s the Diagnosis – Case 118
58
Diagnosis: Stener Lesion Perhaps not a diagnostic dilemma on this case but a nice representation of a Stener lesion. The UCL is torn when a valgus force is imparted to the thumb as when holding a ski pole when falling and hence the term skier’s thumb. When gamekeepers would break the necks of small animals such as rabbits the repetitive motion would cause scarring of the UCL and hence a chronic analagous process is now often referred to as gamekeeper’s thumb. The architecture of the collateral ligaments in the hand and foot are complicated with proper and accessory components. In the Stener lesion typically both components are disrupted although typically on imaging we do not separate the individual components. In a Stener lesion, the adductor aponeurosis or the slip of tissue of the adductor pollicis that continues distal to the proximal phalangeal attachment to join the extensor apparatus, lies inward or deep to the UCL.
What’s the Diagnosis – Case 118
59
The aponeurosis blocks the ligament from apposition to the underlying bone and hence does not allow ligament healing. Without repair there is a loss of strength of the thumb and typically precipitated early arthritis. As in this case, the injury is often not a simple valgus moment and the RCL is frequently injured. Additionally, the adductor myotendinous unit is often frequently injured. Stener lesions or UCL ligament injuries with clinical and radiographic evidence of instability are indicated for surgery.
What’s the Diagnosis – Case 118
60