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Skeletal Radiol
https://doi.org/10.1007/s00256-017-2790-7
CASE REPORT
Stener-like lesion of the lateral collateral ligament of the first
metatarsophalangeal joint
S. Braspenningx 1 & W. Rezaie 2 & P. Simons 3
Received: 3 September 2017 / Revised: 2 October 2017 / Accepted: 4 October 2017
# ISS 2017
Abstract 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.
Keywords MRI . First metatarsophalangeal joint . Lateral
collateral ligament . Stener-like lesion . Surgical repair
* S. Braspenningx
stephanie.braspenningx@gmail.com
1
Department of Radiology, Antwerp University Hospital & University
of Antwerp, Wilrijkstraat 10, 2650 Edegem, Belgium
2
Department of Orthopaedic Surgery, Onze-Lieve-Vrouwziekenhuis
Aalst, Moorselbaan 164, 9300 Aalst, Belgium
3
Department of Radiology, Onze-Lieve-Vrouwziekenhuis Aalst,
Moorselbaan 164, 9300 Aalst, Belgium
Introduction
Ulnar collateral ligament (UCL) injury of the
metacarpophalangeal (MCP) joint of the thumb, often referred
to as gamekeeper’s thumb, was originally described in 1955
by Campbell et al. as an occupational injury of Scottish gamekeepers [1]. It is very important to distinguish a non-displaced
ulnar collateral ligament tear from a displaced tear or Stener
lesion. The surgical indication of the latter has well been
established meanwhile, while non-displaced tears are treated
conservatively. The mechanism of injury in a Stener lesion is
described in Fig. 1 [2].
Similar lesions have been described in the UCL of the
proximal interphalangeal joint of the ring finger [3], the
radial collateral ligament of the MCP joint of the thumb
[4], the radial collateral ligament of the MCP joint of the
fifth finger [5–7], the radial collateral ligament of the MCP
joint of the third finger [7], the radial collateral ligament of
the MCP joint of both the third and fourth fingers [8], and
the medial collateral ligament of the knee [9, 10]. Ishizuki
et al. [7] described five distally avulsed collateral ligaments,
in which the torn end was trapped by the open window of the
injured sagittal band (Fig. 2), as well as one proximally
avulsed collateral ligament, in which the torn end was
trapped by the sagittal band.
Stener-like lesions located at the level of the foot, and
more specifically the metatarsophalangeal (MTP) joint,
have never been described before. However, we as radiologists, as well as our orthopedic surgeons, are convinced
early operative treatment is also mandatory in these cases.
Therefore, we would like to raise awareness about their
existence to ensure optimal clinical management of these
injuries.
Skeletal Radiol
Fig. 1 Mechanism of Stener
lesion [2]. a Normal situation: the
UCL (ulnar collateral ligament
proper and ulnar accessory
collateral ligament) is completely
covered by the adductor
aponeurosis. b, c Simultaneous
abduction, supination, and flexion
forces causing the UCL to rupture
(almost always at its distal
attachment), the torn end of the
UCL passes the proximal edge of
the adductor aponeurosis. d The
phalanx has returned to its
original position and the ligament
gets caught by the aponeurosis
and folded over to point
proximally. The interposed
adductor aponeurosis prevents
conservative healing
Case report
A 14-year-old girl presented to the emergency department
with a hyperextension, abduction, and inversion trauma of
the left hallux 1 day before at her taekwondo class. Right away
she noticed severe soft tissue swelling. The ability of weight
bearing was clearly limited. At clinical examination, the first
metatarsophalangeal joint was very tender and mobility was
greatly reduced. Mainly dorsiflexion against resistance was
Fig. 2 Mechanism of Stener-like
lesion [7]. a Normal situation: the
LCL is completely covered by the
extensor hood. b, c Simultaneous
abduction, supination, and hyperextension forces causing the LCL
and extensor hood to rupture, the
torn end of the LCL passes the
proximal edge of the ruptured
extensor hood. d The phalanx has
returned to its original position
and the ligament gets caught by
the ruptured extensor hood, which
prevents conservative healing
very painful. Conventional radiography (Fig. 3) was performed, but did not show any abnormalities. Because of these
reassuring findings, the patient was discharged with adequate
analgesic therapy and the advice of rest, ice application, and
elevation. However, 1 month later the patient still complained
of pain and swelling of first MTP joint, mainly during exercise. Physical examination demonstrated lateral collateral ligament (LCL) instability of the first MTP joint by varus stress
testing. A 3-T MRI of the foot was performed. With the use of
Skeletal Radiol
superficially located torn end of the LCL and the extensor hood.
These adhesions had to be released. Subsequently, the LCL was
reinserted to the footprint of ligament by a mini Mitek anchor
(Mini Quickanchor, DePuy). Afterwards, the extensor hood was
sutured. Postoperative treatment consisted of weight-bearing
with hallux brace. Gradual return to sports activity was managed
by physiotherapy and full functional recovery was obtained after
6 weeks.
Discussion
Fig. 3 Conventional AP radiographic view of the foot is unremarkable
with no evidence of fracture or first MTP joint space widening
a 3.0-T HD 8Ch foot/ankle coil, long-axis (TR/TE,
3216/56,35), short-axis (TR/TE, 3775/41,29) and sagittal
(TR/TE, 4038/58,41) proton density-weighted images with
fat saturation were obtained, as well as axial T1-weighted
(TR/TE, 406/10,83) images. The short- and long-axis proton
density-weighted images showed a full-thickness tear of the
extensor hood (Fig. 4a–c). A dislocation of the proximal part
of the ruptured LCL to a position superficial to the extensor
hood was noted on the short- and long-axis proton densityweighted images (Fig. 4a and c). There were no associated lesions of the plantar plate. Subsequent stress radiography (Fig. 5)
revealed a lateral diastasis of the first metatarsophalangeal joint
under valgus stress, as expected. Because of the locked position
of the ruptured LCL superficial to the extensor hood, quite similar to a Stener lesion, the patient was admitted for surgical
repair. Intraoperative findings confirmed the ruptured extensor
hood, as well as the superficial position of the ruptured LCL in
relation to it (Figs. 6b and 7). Due to the time delay between
traumatic event and surgery, scar tissue had already been
formed, and there were already some adhesions between the
Lesions of the first MTP joint like acute traumatic hallux valgus deformity (due to a medial collateral ligament tear), turf toe
(hyperdorsiflexion injury to the first MTP capsuloligamentous
complex), and sand toe (hyperplantarflexion injury) are well
known. We describe a unique lesion of the LCL, to our knowledge the first of its kind described in the literature. This lesion
shows strong resemblance to a Stener lesion of the thumb and
presents in an analogous way, as will be discussed later on.
Stener lesions of the thumb occur due to combined abduction, supination, and hyperextension forces. In our patient, a
similar lesion arose from a hyperextension, abduction, and
inversion trauma of the hallux. In Stener lesions, the intact
adductor aponeurosis is interposed between the torn end of
the UCL and the site of its phalangeal attachment. According
to Ishizuki et al. [7], in Stener-like lesions of the little finger, the
sagittal band ruptures at the same level of the joint. The torn
end of the UCL then becomes trapped by the open window of
the ruptured sagittal band (Fig. 2), and prevents spontaneous
healing. We believe the mechanism of the lesion we describe,
in which the LCL of the first MTP joint becomes trapped by
the ruptured extensor hood, is very similar to the one of these
other lesions.
In general, Stener or Stener-like lesions present with local
pain, swelling, and difficulties in movement of the affected
phalanx. If untreated, they may lead to chronic instability.
Stress tests are helpful in differentiating partial from fullthickness collateral ligament tears [11]. It has been described
that palpation of a tender mass at the base of the phalanx can
be a strong indication of a displaced ruptured collateral ligament
[7]. At the level of the metatarsophalangeal joint, this tumor
might not be palpated as easy as at the first metacarpophalangeal
joints, which would make the role of imaging in these cases
more important.
Radiographs are often obtained after these kinds of traumatic events, and may show bony avulsion fractures.
Thirkannad and Wolff [12] described the Btwo fleck sign^ in
which two separate bony fragments are seen. The largest fragment can be seen at the suspected attachment of the UCL but
was in fact not associated with it, and is part of the attachment
of the adductor pollicis muscle. The more discrete second
fragment is in fact the one attached to the torn and displaced
Skeletal Radiol
Fig. 4 Short- and long-axis proton density-weighted images (TR/
TE, 3775/41,29 and TR/TE,
3216/56,35 resp.) revealing a fullthickness tear of the extensor
hood (white arrow in a, b, and c).
Dislocation of the proximal part
of the ruptured LCL to a position
superficial to the extensor hood
(arrowhead in a and c) as seen on
the short- and long-axis proton
density-weighted images
distal end of the UCL. No bony avulsions could be detected in
our patient. Faivre et al. [6] state that clinical examination and
standard radiographs should be sufficient to provide a correct
diagnosis and distinguish simple sprains from more serious
lesions with important laxity. However, they cannot distinguish non-displaced from displaced ruptures of the collateral
ligament. Some controversy exists about stress radiographs,
because they might worsen the injury. Nevertheless, they
clearly showed instability in this case.
Ultrasound is a very accurate method for demonstrating
lesions of the collateral ligament, but should be performed
by an experienced sonographer [13]. The exact sonographic
approach has been described for lesions of the UCL of the
thumb, but is beyond the scope of this case report and can
Fig. 5 Conventional AP radiographic view under valgus stress
demonstrating a lateral diastasis of the first metatarsophalangeal joint
(white arrow)
be found elsewhere [13, 14]. Potential pitfalls of ultrasound
include shrinkage of the ligament and formation of scar tissue,
starting as early as 1 week after the traumatic event [15].
The accuracy of magnetic resonance imaging may also be
affected by e.g., scar tissue in chronic lesions, but it is still
considered the best method for evaluating collateral ligament
injuries [16–18]. Magnetic resonance imaging is able to differentiate between non-displaced and displaced ruptures of the
collateral ligament. It also visualizes surrounding structures
and is therefore very useful for ruling out mimics of collateral
Fig. 6 Schematic overview of intra-operative findings. a Normal anatomy showing an intact extensor hood. b Ruptured extensor hood and LCL,
with the distal part of the LCL located superficial to the extensor hood.
Some adhesions between them had already been formed
Skeletal Radiol
Informed consent Informed consent was obtained from all individual
participants included in the study.
References
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2.
Fig. 7 Intra-operative findings. The torn end of the LCL (arrowhead)
was found in a position superficial to the ruptured extensor hood (white
arrow). Adhesions between both were already present and had to be
released
3.
ligament injury. Hergan et al. [15] state that magnetic resonance imaging should always be used to check a nondisplaced UCL tear diagnosed by ultrasound before conservative therapy is performed. In our case, magnetic resonance
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granulation tissue was already present 1 month after the event.
Displaced collateral ligaments are a surgical indication.
Their repair should be performed at an early stage to avoid
aberrant adhesion of the collateral ligament, a process that had
already started in our patient, with the torn end of the LCL
located superficial to the extensor hood. Both the primary and
accessory parts of the collateral ligament need to be sutured to
their original attachment [11]. Like in our patients, suture anchors have become quite popular for this purpose. The ruptured extensor hood was also sutured in our patient, and adequate stability of the joint was achieved.
In conclusion, we would like to stress the indication for
early operative treatment in these kinds of displaced collateral
ligament ruptures. Therefore, the main goal of this case report
is to stress the importance of posttraumatic imaging of the
ligaments of the toes and raise awareness about the existence
of this Stener-like lesion of the lateral collateral ligament of
the first metatarsophalangeal joint in order to ensure similar
patients are treated adequately at an early stage, and to prevent
possible long-term complications like chronic pain, instability,
and joint degeneration.
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Compliance with ethical standards
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Conflict of interest The authors declare that they have no conflicts of
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Ethical approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the
institutional and/or national research committee and with the 1964
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