Ultrasound of Normal and Injured Ligaments and Retinacula of the Hand

Clinical diagnosis of ligament and retinacular injuries of the hand may be challenging. Ultrasound (US) enables detailed high-resolution, dynamic, and real-time evaluation of these structures. This article is a comprehensive review of the intricate anatomy, optimal imaging technique, and normal US appearances of these ligaments and retinacula. The US features, pertinent biomechanics, clinical presentation, and differential diagnosis of injuries affecting the annular pulleys, differentiating from climber's finger; extensor hood including sagittal band and central slip rupture; proximal interphalangeal and metacarpophalangeal collateral ligaments including the Stener lesion and associated volar plate injury; and the anterior oblique or beak ligament of the trapeziometacarpal joint are reviewed. Emphasis is placed on optimal transducer positioning, value of dynamic US, injury severity, surgical indications, and other US findings with important management implications. US facilitates a timely accurate diagnosis of hand ligament and retinacular injury to ensure optimal patient management and minimize the risk of functional impairment of the hand.

Ultrasound of the Wrist and Hand

Chapter 122 covers US of the wrist and hand. US is gaining popularity as a useful modality for imaging wrist and hand pain, providing soft tissue resolution superior to MRI, with the additional benefits of real-time imaging, ease of comparison to the contralateral side, and dynamic imaging. US provides excellent visualization of tendons and the small joints of the hand. Peripheral nerves are easily identified and assessed with US with resolution surpassing MRI. Median nerve entrapment can be quickly and easily evaluated when carpal tunnel disease is suspected. Dynamic evaluation allows further assessment for the presence of Stener lesion, sagittal band and annular pulley injuries, and for tendon subluxation. US easily shows joint effusions, osteophytes, erosions, and synovial hypertrophy when arthritis is suspected. Soft tissue masses, such as ganglion cysts or giant cell tumor of the tendon sheath, are accurately imaged with US.

Can Physical Examination Create a Stener Lesion?

Background: The purpose of this study is to determine whether a Stener lesion can be created while testing stability of the ulnar collateral ligament (UCL) of the thumb. Testing was performed in a manner that reproduced clinical examination. Methods: Six fresh frozen hand and forearm specimens underwent sequential sectioning of the accessory UCL, the proper UCL, and the ulnar sagittal band. Measurements of radial deviation of the metacarpophalangeal (MCP) joint were taken with the thumb in neutral rotation, pronation and supination, both with 0 degrees and with 30 degrees of flexion of the MCP joint. Visual examination was performed to assess the presence of a Stener lesion. Results: No Stener lesion was created in any position as long as the fascial origin of the ulnar sagittal band at the adductor pollicis longus remained intact. After creating a defect in the ulnar sagittal band, a Stener lesion was created in two specimens, but only when the thumb was flexed and supinated. Pronation provided more stability, and supination provided less stability, with one or both components cut, especially when testing at 30° of flexion. Compared to both components cut without flexion or rotation, there was a statistically significant difference in angulation with the 30 degrees of MCP joint flexion in both neutral rotation in supination. Conclusions: Performing a physical examination to assess the amount of instability of an ulnar collateral ligament injury did not create a Stener lesion if the exam was performed in a controlled, gentle manner with the thumb held without rotation. If the thumb is held in neutral rotation during the exam, an iatrogenic Stener lesion should not be created.

The Stener Lesion: Historical Perspective and Evolution of Diagnostic Criteria

Background: In 1962, Bertil Stener first described the anatomy and treatment of the displaced ulnar collateral ligament of the metacarpophalangeal joint, later called the Stener lesion. Since Stener’s publication, treatment algorithms for ulnar collateral ligament rupture have aided in preoperative diagnosis, yet the best diagnostic method to assess ligament displacement remains largely undefined. Methods: An extensive literature search was performed to explore the treatment evolution of the Stener lesion and explore how technical development has influenced Stener lesion diagnosis. We also sought to illuminate the life and work of Bertil Stener. Results: Studies evaluating the use of magnetic resonance imaging (MRI) and ultrasound (US) technology have suggested that these modalities have improved Stener lesion diagnosis. Conclusion: Despite the utility of developing MRI and US technology, consensus for one superior diagnostic tool for Stener lesions does not currently exist.