‣Which term is for chronic?Gamekeeper = chronicSkier = acute‣Components of the Ulnar Collateral Ligament?UCL proper – tight in flexionUCL accessory – tight in extension‣Usually injury is on which side?Rupture of the ulnar collateral ligamentAvulsion fracture of the ulnar–volar base of the proximal phalanx (displaced or not) or both‣Thumb UCL Injury tests?Stress both at extension and 30° of MCP flexionradial instability in 30° of flexion indicates injury to proper UCLradial instability in extension indicates injury to accessory and proper UCL +/- volar platePalpate for Stener Lesion = avulsed ligament/ bone displaced above adductor pollicis aponeurosisWill not heal without surgery‣How do you grade this injury?Based on extent of valgus laxityGrade 1 = sprainGrade 2 = < 15 ° relative to contralateral thumb with firm end point ( Partial)Grade 3 = > 15 ° without firm end point (complete)‣How do you check for Palmaris Longus PL tendon? Which other conditions should you check for PL tendon?Bunched finger test ➔ bunch fingers together and wrist flexedCheck in:Carpal tunnel syndrome - for Camitz PL to APBRadial nerve palsy - for Jones or Brand's transfersAll tendon injuries for chronic recon - Tendon lacerations, Jersey Finger, Mallet finger (SORL recon)Elbow - to reconstruct ruptured PLRIThumb UCL injury - for chronic reconstructionFlexor pulley rupture - loop method of reconstructionChronic mallet finger - for reconstruction of oblique retinacular ligamentSwan neck deformity - for SORL reconstruction‣What is a stener lesion? Significance?Complete tear of UCL from proximal phalanxAnd interpositon of the adductor tendon between the torn UCL and the footprint ➔ Healing is impossible‣What invx?XR - looking for avulsion and extent of displacementUS - look for stenerMRI - stener‣Acute Mx?Partial Grade 2 - Non op with thumb spica splintGrade 3 Complete - Consensus is for surgical managementHowever, option is still available to treat non operativelyOlder studies found that up to 85% can heal with conservative thumb spica Op - stener/ displaced avulsion‣Surgical Approach to skier thumb?Dorsoulnar approach to MCPJDanger - Sensory branch of SRNIncision - start dorsally 1cm proximally to MCPJ, extended in palmar direction around ulnar aspect of joint in oblique or S-shape fashionIdentify and protect dorsal sensory branch of SRNLongitudinal incision to divide adductor aponeurosis close to its insertion into EPL tendon, leaving a 3-5mm fringe for later reattachmentUCL is below the adductor aponeurosis‣Management of Chronic thumb UCL injury?Reconstruction with PL tendon or suture anchors. Single vs double bundles