Stener lesion after lateral dislocation of the proximal interphalangeal joint--indication for open reduction

Midterm clinical outcomes of collateral ligament repair of the thumb and lesser digits: a retrospective analysis of 35 cases

Background

Finger collateral ligament injuries are common, and conservative treatment usually works well. However, complete ruptures that lead to instability could cause painful disability. This study presents our clinical experience and a qualitative functional evaluation following the surgical repair of the thumb and proximal interphalangeal (PIP) joint collateral ligament ruptures.

Methods

Thirty-five patients (22 men and 13 women), diagnosed via a physical examination and magnetic resonance imaging (MRI) with a total collateral ligament rupture in the metacarpophalangeal thumb (16) and PIP joints of the lesser digits (19) and treated surgically, were evaluated retrospectively. The limited range of motion; functional score by Saetta; disabilities of the arm, shoulder, and hand (DASH) score; pre- and post-operative pain, deformity level; and post-operative ability to grip keys, buttons, and jars were measured. The significance of the change between the pre and post-operative visual analog scale for pain (VAS) scores were evaluated using the Wilcoxon signed-rank test. The difference between the lesser digits and thumb groups by patient age was evaluated using the Mann–Whitney-U test. All data, such as the mean, range, and standard deviation, were calculated using SPSS.

Results

The mean pre- and post-operative VAS scores were 4.8 (from 3 to 7) and 0.91 (0 to 4), respectively. The mean post-operative limitation in the range of motion was 9.78° (s = 14.47) for lesser digits and 6.87° (s = 12.29) for the thumb. According to Seatta et al., the final functional score was 62.5% excellent, 25% good, and 12.5% moderate for the thumb and 84.2% excellent, 10.5% good, and 5.3% poor for the lesser digits. The mean post-operative DASH score was 13.55 (SD: 8.77) for lesser digits and 14.22 (SD: 8.9) for the thumb. The mean contralateral (healthy) hand DASH score was 0.75 (SD: 1.05) for lesser digits and 0.75 (SD: 1.05) for the thumb. For the thumb and lesser digits, the z-scores were − 3.55 and − 3.787, respectively, and the progress of the VAS score was significant (p < 0.05).

Conclusion

After a 40-month follow-up for 35 acute, subacute, and chronic cases, the results suggest that direct and suture-anchor repairs are feasible, painless treatments associated with good finger function.

Irreducible Dislocations of the Proximal Interphalangeal Joint: Algorithm for Open Reduction and Soft-tissue Repair

Supplemental Digital Content is available in the text.

The “jammed finger” is among the most common hand injuries and may include simple sprains, dislocations, fractures, and fracture-dislocations. In contrast, irreducible dislocations of the proximal interphalangeal joint are rare injuries. However, they must not be overlooked in the primary assessment, because persistent subluxation may lead to joint contracture, severely compromising hand function. Irreducible dislocations are challenging injuries with interposed soft tissues, preventing closed reduction. Thorough preoperative diagnosis and soft-tissue imaging guide the approach to open reduction and repair of injured periarticular structures. We introduce a systematic algorithm with considerations on classification and management of irreducible proximal interphalangeal joint dislocations. The algorithm is useful for the primary assessment and for hand surgeons responsible for open reduction and rehabilitation.

Stener-like lesion of the lateral collateral ligament of the first metatarsophalangeal joint

Displaced ulnar collateral ligament injuries of the metacarpophalangeal joint of the thumb, also known as Stener lesions, are a well-recognized clinical entity, requiring surgical intervention because of the trapped location of the torn lateral collateral ligament superficial to the adductor aponeurosis of the thumb. We report a similar lesion located at the first metatarsophalangeal joint, to our knowledge the first ever described in the literature. In our patient, magnetic resonance imaging showed a full-thickness tear of the lateral collateral ligament of the first metatarsophalangeal joint, as well as a full-thickness tear of the extensor hood, with dislocation of the proximal part of the ruptured lateral collateral ligament to a position superficial to the extensor hood. Analogous to true Stener lesions, we are convinced these patients also need early surgical repair. Therefore, we would like to raise awareness about their existence to ensure adequate management of these lesions, in order to prevent possible long-term complications like chronic pain, instability, and joint degeneration.

Current trends in the management of proximal interphalangeal joint injuries of the hand

Injuries to the proximal interphalangeal joint are commonly encountered by the hand surgeon. Proper diagnosis and treatment are vital for optimal outcomes. Proper treatment of these injuries requires a working knowledge of the anatomy of the joint and an appreciation for principles for reduction, stabilization, and early rehabilitation to provide the best outcomes possible. Injuries can include fractures of the head of the proximal phalanx, dislocations, fracture dislocations, and fractures of the base of the middle phalanx. Similar to other aspects of plastic surgery, there is little high-level evidence guiding treatment and thus most treatment is based on level III or IV evidence. The goal for treatment of any injury around the proximal interphalangeal joint is to establish a congruent joint and allow for early motion. Stiffness and posttraumatic arthritis are common following these injuries. Salvage procedures are limited to arthrodesis and arthroplasty, neither of which can restore the normal function of the hand.

Radial collateral ligament injury of the thumb with a Stener-like lesion

The original Stener lesion, described in 1962, refers to an ulnar collateral ligament tear of the thumb metacarpophalangeal joint with adductor aponeurosis interposition. The adductor aponeurosis serves as a mechanical block to healing by preventing apposition of the torn ends of the ulnar collateral ligament. This article presents a case of a 27-year-old woman with painful swelling of the thumb metacarpophalangeal joint following a car accident. Complete tear of the radial collateral ligament was diagnosed based on physical and radiographic examinations. Radial collateral ligament injuries are reported to be less common than ulnar collateral ligament injuries, and, in the past, radial collateral ligament tears were thought to be innocuous, requiring little intervention. More recently, the significance of these injuries has been well documented, and there is support for acute surgical management of complete radial collateral ligament tears. During surgical intervention in our case, we found an intrasubstance tear of the radial collateral ligament with the proximal portion of the ligament retracted and lying superficial to the abductor aponeurosis, thereby producing a Stener-like lesion on the radial side of the joint. The incidence of a Stener-like lesion to the radial collateral ligament is unknown, but it has only been reported once in the literature. Although a primary radial collateral ligament tear may heal by soft tissue apposition, we felt that conservative management in our patient would unlikely lead to healing due to interposition of the abductor aponeurosis. This case supports current recommendations for surgical intervention of complete radial collateral ligament injuries due to the possibility of a Stener-like lesion with soft tissue interposition recurring in the future.

Palmar dislocation of the proximal interphalangeal joint

Fifteen patients with palmar dislocations of the proximal interphalangeal (PIP) joint were reviewed 6 to 49 months after treatment (average 17.8 months). Disruption of the extensor mechanism, palmar plate, and one collateral ligament was found in all patients. The loss of static and dynamic joint support caused palmar subluxation, malrotation, and a boutonnière deformity. Two dislocations were irreducible, and three were associated with dorsal avulsion fractures from the middle phalanx. The serious nature of the injuries from this dislocation was initially unrecognized, and most patients were casually treated; delay from injury to referral averaged more than 11 weeks. Twelve of the 15 required surgery for joint reduction and tendon and ligament repair; three treated earlier were managed by closed reduction and percutaneous pinning. Joint alignment, comfort, and stability were restored, and all returned to full activities including heavy labor. However, a full range of PIP motion was not recovered in any case.