Flexor hallucis brevis muscle. It is a fleshy, flat, triangular, and fan-shaped muscle deep in the thenar compartment beneath the long flexor tendons and the lumbrical muscles at the center of the palm. This occurs when the ulnar collateral ligament ruptures from the base of proximal phalanx with proximal retraction of the torn ligament. Figure 2 - Stener Lesion - UCL proximal portion in blue, Add- Adductor Pollicis Aponeurosis, MC - Metacarpal, PP - Proximal Phalanx, DP - Distal Phalanx . Figure 1 - Rupture of Ulnar Collateral Ligament of Thumb. Another muscle that controls movement of the thumb is adductor pollicis. These ligaments are located deep to the adductor aponeurosis of the thumb and stabilize the first metacarpophalangeal (MCP) joint. Theory. The adductor pollicis aponeurosis lies superficial to the UCL, and plays an important role in the pattern of injury and treatment of UCL tears. Fibrosis of the adductor aponeurosis seems to be the main aetiological factor in the development of adduction contracture. - Flexion at interphalangeal (IP) joint will help identification of adductor aponeurosis - Careful thumb abduction during scanning will stress UCL and widen ulnar aspect of MCP joint ; TECHNIQUE: VOLAR HAND • Palm back of hand on examination table or couch with wrist in neutral position, fingers extended Flexor tendon pulleys of fingers - Passively flex and extend of finger while . Trapezoid. The oblique and transverse heads of the adductor pollicis contributed to the ulnar dorsal aponeurosis in 8 and 9 hands, respectively. Anterior oblique ligament. This anatomy is important because if the ligament ruptures, there is a possibility of the distal end of the ruptured ligament becoming trapped lying superficial and proximal to the adductor aponeurosis, leading to a Stener lesion (Figure 2).3 Described in 1962 by Stener,3 the adductor aponeurosis then sits between the . Fig. This action is essential for functions that require pinching and gripping.Additionally, the adductor pollicis aids the later stages of opposition of the thumb. Together they insert on the base of the proximal phalanx of the thumb and the dorsal aponeurosis. Thumb; Adductor pollicis aponeurosis; Carpometacarpal joint; Bennet fracture; Rolando fracture; Pulley injury; MRI; Download chapter PDF Carpometacarpal Joint. Annotated image Annotated image Torn and retracted ulnar collateral ligament (yellow arrows) flipped superficial to the adductor pollicis aponeurosis (red arrows) consistent with a Stener lesion of the thumb. Thumb UCL repair. However, sometimes a complete injury can be difficult to detect7 because the adductor muscle aponeurosis of the thumb can be trapped between the MCP joint and the ligament, which can make the joint seem stable upon clinical examination. Stener Lesion: UCL ligament avulsed above the adductor aponeurosis. Painful, swollen MCPJ . the thumb extrinsic muscles (exten-sor pollicis longus, extensor pollicis brevis, and flexor pollicis longus) and intrinsic muscles (abductor pollicis brevis, flexor pollicis bre-vis, and adductor pollicis). It is important to appreciate that the aponeurosis of the adductor pollicis (thenar) covers the UCL of the thumb superficially. Itemphasises the importanceofaccurate diagnosis of skier's thumb, and . More specifically, the tendon of extensor pollicis longus forms what is referred to as an extensor expansion (or dorsal aponeurosis) as it is joined by the tendon of abductor pollicis brevis laterally and adductor pollicis medially. Physical Examination Abnormal Findings • Tenderness, ecchymosis, and swelling along the ulnar border . Extensor pollicis longus muscle Musculus extensor pollicis longus 1/3. In advanced, long . In the thumb however, the avulsed fragment may displace dorsal to the adductor aponeurosis. Stener lesion symptoms 10.10 Stener lesion with proximal end of UCL visible over adductor aponeurosis. Introduction. The approach involves a straight midaxial incision centered on the ulnar aspect of the thumb MCPJ. S incision, starting dorsally 1cm proximal to MPCJ, heading palmarly and distally, stopping 1cm distal to the joint; Be wary of dorsal branches of radial nerve, and ulnar NV bundle . Options for treatment are lag screw fixation, tension band wiring, or anchor suture for comminuted fractures where the fragments will be excised. The presence and size of a sy-novial recess at the base of all plates was assessed. sensory branch to thumb and mobilize and retract volarly . The MCP joint of the thumb maintains ulnar side stability by means of both static and dynamic mechanisms. Is adductor Pollicis a thenar muscle? Tears can occur if a valgus force is applied to an abducted first MCP joint. Exam: Inspection - May notice swelling at the ulnar side of the . 4. Static stability is provided by the main and accessory UCLs, the volar plate, as well as the dorsal capsule. Hence making it impossible for the loosened ligament to reconnect with the site of insertion, necessitating surgery. A stener lesion is a complete tear of the ulnar collateral ligament (ucl) from the thumb proximal phalanx at the level of the metacarpophalangeal (mcp) joint that is displaced superficial to the adductor pollicis aponeurosis, leading to interposition of the. A sprained thumb may be aggravated by the . Case Discussion The flexor tendon is enveloped by a tendon sheath that usually extends from the wrist area (, Fig 7 ). tissue dorsally (Figure 3). This review details the history, aetiology, epidemiology, anatomy,diagnosis,surgical and conservative treatment regimes l rehabilitation and current advancesin the prevention ofskier's thumb. The oblique and transverse heads of the adductor pollicis contributed to the ulnar dorsal aponeurosis in 8 and 9 hands, respectively. Anatomical study of the dorsal aponeurosis of the thumb demonstrates that the adductor pollicis (AP) tendon is connected to the dorsal aponeurosis with its three components (transverse, oblique . 3. Stabilizers of the Carpometacarpal Joint. Patients with this lesion present with ecchymosis, soft tissue swelling, and focal tenderness of the ulnar aspect of the thumb metacarpophalangeal joint. In the United States, estimates for skiing . (c) Axial PD FSE image shows proper radial collateral ligament (purple arrow) and proper ulnar collateral ligament (yellow arrow), volar plate (white arrow) connecting the radial (light green . Clinically Relevant Anatomy [edit | edit source] The metacarpophalangeal joint of the thumb is a diarthrodial joint . The adductor aponeurosis is in normal position (arrowhead). Depending on the strain applied to the thumb, the injury to the UCL may involve damage to the adductor aponeurosis (thumb muscle), the accessory collateral ligament, bony structures, tendons and neurological tissues. Anatomical study of the dorsal aponeurosis of the thumb demonstrates that the adductor pollicis (AP) tendon is connected to the dorsal aponeurosis with its three components (transverse, oblique . Stability. REF www.anatomylearning. Fig. 2nd proximal phalanx. The first carpometacarpal joint, with a shallow articular surface, allows for wide range of motion of the thumb. Adductor aponeurosis and adductor pollicis muscle now lying between ligament . A Stener's lesion (Fig. Dr. Ebraheim's educational animated video describes the anatomy of the adductor pollicis muscle.The abductor pollicis muscle is a small muscle of the hand an. The UCL is covered by the adductor pollicis aponeurosis, which is composed of transverse and oblique fibers from the tendon of the adductor pollicis muscle and extensor hood of the thumb . Tenderness along UCL . The ulnar collateral ligament (UCL) complex includes the ulnar proper collateral ligament and the ulnar accessory collateral ligament.1 These ligaments are located deep to the adductor aponeurosis of the thumb and stabilize the first metacarpophalangeal (MCP) joint. 3 types Bony avulsion . A Stener lesion occurs when the disrupted ligament is displaced superficial to the adductor pollicis aponeurosis, . A thumb spica cast is then applied (Figure 7). Despite its name, its main action is mainly rotation . Flexor pollicis . RESULTS. Adductor pollicis muscle. The adductor pollicis muscle is the primary dynamic stabilizer resisting valgus stress and inserts onto the ulnar tubercle of the proximal phalanx, volar plate, ulnar sesamoid, and the adductor aponeurosis, the latter blending with the extensor hood and inserting on the extensor pollicis longus tendon. Greater than 15 degrees of laxity with radial stress compared to the contralateral thumb. Together, this aponeurosis forms the extensor mechanism of the thumb. Large intra . MRI of 2-mm slice thickness showed minimally retracted fibers of the torn ulnar collateral ligament of the right thumb, but the adductor aponeurosis was intact. Small fragment pulled away from P1 . The adductor aponeurosis is then re-approximated with 3-0 absorbable sutures with the thumb in a slightly ulnar deviated position. Flexor pollicis brevis forms the thenar eminence of the hand. UCL, Ulnar collateral Ligament; AA, Adductor aponeurosis. The torn UCL is "balled up" and retracted proximally, positioned superficial to the aponeurosis (arrow). Interposition of the adductor aponeurosis (Stener lesion), which can be found on MRI or ultrasound. Avulsion fractures of the ulnar corner of the proximal phalangeal base of the thumb are treated in a fashion similar to the other proximal phalanges. This is also known as "skier's thumb" [ 23 ]. Dorsal and Volar Ligaments of the First CMC Joint Expose and identify the adductor aponeurosis (Figure 2). Today more commonly seen in skiers, also known as 'Skiers Thumb,' occurs when the stock or stock strap forcefully abduct the skiers thumb when falling or aggressively planting the pole (acute injury). Be sure to protect the nerve. The dynamic nature of US allows one to image the thumb soft-tissue structures in different positions and to more easily identify subtle structures such as the adductor aponeurosis owing to its dynamic motion. - Flexion at interphalangeal (IP) joint will help identification of adductor aponeurosis - Careful thumb abduction during scanning will stress UCL and widen ulnar aspect of MCP joint ; TECHNIQUE: VOLAR HAND • Palm back of hand on examination table or couch with wrist in neutral position, fingers extended Flexor tendon pulleys of fingers - Passively flex and extend of finger while . The adductor aponeurosis is retracted distally and the dorsal capsule, which is frequently torn, is inspected, after which the proper collateral ligament and the accessory collateral ligaments are assessed. 2. The adductor mechanism is of particu-lar importance as a dynamic stabi-lizer.5 It inserts into the extensor expansion through its aponeurosis, Aponeurosis of adductor pollicis tendon (orange colored structure) and abductor pollicis brevis tendon insertion (red colored structure) overlay the ulnar and radial collateral ligaments, respectively. 1 and 2). The interposed adductor . Ulnar collateral ligament injuries can involve injuries to the dorsal capsule, palmar plate, and adductor aponeurosis. A Stener lesion occurs when the adductor aponeurosis becomes interposed between the ruptured UCL and its site of insertion at the base of the proximal phalanx. While there have been numerous ligaments described at the level of the . Technique. References / Further reading. The RCL arises dorsally from the condyle of the metacarpal head, courses obliquely and inserts distal and volar at the tubercle of the . Post-Operative Care The first cast is kept on for 2 weeks. Adductor pollicus muscle. Flexor pollicis longus tendon. Options for treatment are lag screw fixation, tension band wiring, or anchor suture for comminuted fractures where the fragments will be excised. Skier's thumb is defined as an acute injury to the ulnar callateraI Iigament of the metacarpophalangeal joint of the thumb. C Forced radial deviation to thumb tears UCL. Abduction Stress Test - in full extension and 30° - loss of end point or 30 o > other side - indicates complete rupture . Acute injuries can occur when the strap on a ski pole forcibly abducts the thumb. Clinical Presentation History • History of combined hyperextension and forced abduction to the thumb • Acutely painful MCP joint and swelling . Avulsion fractures of the ulnar corner of the proximal phalangeal base of the thumb are treated in a fashion similar to the other proximal phalanges. 41 year old women with thumb hyperextension injury. On the ulnar aspect of the metacarpophalangeal (MCP) joint of the thumb are seen the transverse and oblique fibers of the adductor pollicis aponeurosis (and some muscle fibers), inserting into the extensor pollicis longus (EPL) tendon, and all overlying the ulnar collateral ligament. The adductor aponeurosis is then incised longitudinally, parallel and just palmar to the extensor pollicis longus tendon. Lack of a solid end point when stressing the MCPJ at 30 degrees of flexion. Prepare the UCL for Reattachment. Extensor . Stener Lesion.The adductor tendon shifts also at the time of injury and shifts down the. Approach. This prevents healing and is an indication for surgical repair. The Stener lesion occurs when the aponeurosis of the adductor pollicis muscle is interposed between the torn UCL and its original site of insertion at the base of the . Surgical findings revealed a nondisplaced ulnar collateral ligament tear near the proximal margin of the adductor aponeurosis . Stener lesion is where adductor aponeurosis is interposed between UCL and bone ; Technique Approach. Stener lesion of the thumb metacarpophalangeal joint, initially described in 1962, is a complete ulnar collateral ligament avulsion with the adductor aponeurosis interposed within the tear. Thumb flexor anatomy labelled. Thumb: Pulleys: 2 annular pulleys and an oblique pulley (which arises from the aponeurosis of the aDductor pollicis muscle (thenar eminence) Tendons: Flexor pollicis longus(FPL) runs through the carpal tunnel and thenar eminence to insert on the distal phalanx. CONCLUSIONS:This investigation provides a detailed anatomic study of the dorsal aponeurosis of the thumb with observation of both intrinsic and extrinsic . The total . The ligament is retracted and is flipped superficial to the adductor pollicis aponeurosis consistent with a Stener lesion. This cast is removed, the skin sutures are removed and . Figure 1 - Rupture of Ulnar Collateral Ligament of Thumb Figure 2 - Adductor muscle insertion onto D1 Proximal phalanx that can obstruct proximal portion of UCL ligament . This anatomical module of e-Anatomy is dedicated to the anatomy of the thumb with the normal MRI appearance of the phalanx bones, the MCP and IP joint with ligaments including volar plates, extensor and flexor mechanisms of the thumb, the thenar muscles and annular pulleys and synovial sheaths of the thumb on a high-resolution 3T MRI of the fingers (multiplanar T2-FS and T1 images). Associated lesions might include injury to dorsal capsule, a rent in adductor aponeurosis, extensor expansion, volar plate or avulsion fracture. D, Thumb returned to neutral position resulting in UCL occupying superficial position to . The implications of these injuries can be detrimental as the thumb controls grasping, which comprises 50% of the functions of the hand. Displacement of the UCL greater than or equal to 3 mm visualized on MRI. Skiers and those who play ball-handling sports, such as baseball, football and basketball, have a greater risk of sustaining such an injury. This stretches or tears the ulnar collateral ligament depending on how far the thumb moves. Fig. Relations. the adductor aponeurosis, to the ulnar aspect of the metacarpal head. Diagram showing the progression to a Stener lesion, with continued radial deviation (hyperabduction ) of the thumb. The ligament can displace superficially to the adductor pollicis aponeurosis, which is referred to as "Stener lesion" [ 16 ]. The fibers of the intrinsic apparatus were composed of 3 major types: transverse, oblique, and long. The extensor tendons of the thumb are situated in the 1 st (abductor pollicis longus and extensor pollicis brevis - APL and EPB) and 3 rd (extensor pollicis longus - EPL) extensor compartments on the dorsal aspect of the wrist. ulnar sesamoid. The fibers of the intrinsic apparatus were composed of 3 major types: transverse, oblique, and long. 1 The . Simply following the adductor aponeurosis proximally on the axial images provides a useful landmark for identifying displaced ligamentous tissue, which is readily seen protruding beyond the plane of the aponeurosis Gamekeeper's thumb (chronic injury) and skier's thumb (acute injury) are two similar conditions involving the UCL References Jump to: Theory. Once good hemostasis is noted, running or interrupted 4-0 nylon suture can be used to close the skin. Test proper UCL with thumb flexed to 30 degrees at MCP joint; Test accessory UCL with thumb in extension at MCP joint; Assess for Stener Lesion (associated with Grade III injuries) Displaced distal end of ruptured ligament; Proximal UCL trapped outside adductor aponeurosis; Presents as tender mass at UCL, and joint instability; Requires surgery Regarding this, what muscle does thumb abduction? Care should be taken to preserve the dorsal capsule layer. The adductor pollicis aponeurosis inserts to the dorsal thumb tendons and capsule of the MCP joint. This aponeurosis is a thin layer superficial to the UCL joining dorsally with fibers of the extensor hood [5, 14, 20]. Coronal and axial PD FS images at the MCP show a Stener lesion. It is seen with a traumatic injury, called the "gamekeeper's thumb," in which there is a tear of the ulnar collateral ligament (UCL) at the level of the metacarpophalangeal joint. Examination Technique The hand is placed flat on the table. Function. Its main function is the adduction of the thumb which is the movement of the thumb towards the index finger from an abducted position. Injury Mechanism: A valgus stress to the 1 st metatarsal phalangeal joint resulting in the stretching force to the . Adductor aponeurosis. Fig. A lesion of the UCL is commonly called skier's thumb. Repair. Mobilize soft tissues to allow for retraction of the . The abductor pollicis brevis provided fibers to the radial dorsal aponeurosis in all 10 specimens. 10.8 After the final repair, the thumb is showing no laxity on valgus stress test. A Stener lesion is a displaced tear of the ulnar collateral ligament in the metacarpophalangeal joint of the thumb in which the adductor pollicis aponeurosis is positioned between the retracted . This activity . In human anatomy, the adductor pollicis muscle is a muscle in the hand that functions to adduct the thumb. A Stener lesion is characterized by slippage of the torn end of the ulnar collateral ligament superficial to the adductor aponeurosis/ adductor pollicis muscle such that now there is interposition of the adductor pollicis muscle between the ulnar collateral ligament and the MCP joint. Ultrasound is a cost-effective and accurate method to evaluate the UCL, allowing dynamic imaging and contralateral comparison in the setting of acute injury. On intermediate-weighted fat-saturated images, the ulnar collateral ligament of the metacarpophalangeal joint (reader 1, 79%; reader 2, 62%) and the adductor pollicis aponeurosis (reader 1, 50%; reader 2, 82%) commonly had a striated . Abstract Adduction contracture of the thumb in rheumatoid arthritis is a common complication which should be diagnosed in its early stages. or dorsally. Figure 1 - Rupture of Ulnar Collateral Ligament of Thumb. Release of the adductor aponeurosis in mild or moderate cases may prevent the advancement of the contracture. Post-op. If the ligament tears completely, then the ligament is prevented from reattaching to the bone through superficial tissue or muscle (also called adductor aponeurosis). It lies deeper and more distal to flexor pollicis brevis. Adductor pollicis is the most powerful of the intrinsic muscles of the hand. The separation of the proximal and distal ligament segments by the adductor aponeurosis prevents healing. A Stener lesion occurs when a complete distal, thumb ulnar collateral ligament tear results in the interposition of the aponeurosis of the adductor pollicis muscle between the metacarpophalangeal joint and torn ligament. Incise the adductor aponeurosis leaving a 2-3 mm cuff of . abductor pollicis brevis, flexor pollicis brevis, adductor pollicis ulnar-sided tendinous/aponeurotic insertions more robust than radial Classification Presentation History fall on outstretched hand and abducted thumb ball or racquet strike Symptoms common symptoms pain at ulnar aspect of MCP joint worse with pinch or grasp most common for UCL tear Divisions of the dorsal sensory branch of the radial nerve lie superficially in the subcutaneous tissue of this To correct the adductor contracture, the insertion of the adductor pollicis was incised, and the 1st dorsal interosseous muscle, as well as a part of the palmar aponeurosis, was excised. A 12-13-MHz linear probe is used. The UCL is strengthened by the aponeurosis of the adductor pollicis muscle (Fig. 10.7 Repair of the adductor aponeurosis with a 6.0 PDS running stitch. In the thumb however, the avulsed fragment may displace dorsal to the adductor aponeurosis. Avulsion fractures of the ulnar base of the proximal phalanx occur 20% to 30% . A control study of the normal left thumb well delineated the course of the intact ulnar collateral ligament. Opponens pollicis muscle (Middle) The transverse and oblique heads of the adductor pollicis are seen together with the proximal portion of the adductor aponeurosis. The separation of the proximal and distal ligament segments by the adductor aponeurosis prevents healing. A Stener lesion is a type of injury to the thumb. Adductor aponeurosis - superficial to UCL - inserts into ulna border thumb extensor mechanism - via the ulna sesamoid . The UCL is absent at the proximal attachment (arrow). Fig1. As dissection is carried down to the adductor aponeurosis, care is taken to preserve and protect the dorsal cutaneous branch of the radial nerve which is typically in the dorsal half of the incision. In these cases, magnetic resonance . Stener's lesion can occur 64 - 87% of UCL injuries. abductor pollicis longus . dorsal plates, adductor pollicis aponeurosis, and annular pulleys. "Shaky thumb" •1943: Watson-Jones examined the importance of the ulnar collateral . - Adductor Aponeurosis: - identify the adductor aponeurosis (superficial expansion of adductor pollicis), which is continguous with the extensor mechanism which overlies the EPL; - if a Stener lesion is present, it should be visible at this point, and can be seen as a mass of tissue just proximal to the adductor aponeurosis; - longitudinal incision is made thru aponeurosis volar to edge of EPL . Thumb ligament injuries usually occur from a forced radial deviation (abduction) of the thumb during a high-velocity activity. X-ray . It has two heads: transverse and oblique. Injuries to the radial collateral ligament of the metacarpophalangeal joint are less common and account for 10-42% of collateral ligament injuries [ 5 ]. accessory collateral ligaments inorder for the ligament to be displaced above the adductor aponeurosis; - ruptured end of ligament is no longer in contact w/ its area of insertion of the phalanx, & therefore healing can not occur; - reference: Displacement of the ruptured ulnar collateral ligament of the metacarpo-phalangeal joint of the thumb - Gamekeeper's Fracture: - even slightly displaced . 10.9 Final skin closure with subcuticular 5.0 Monocryl. Intrinsic muscles contributing to the dorsal aponeurosis of the thumb The flexor pollicis brevis superficial head, flexor pollicis brevis deep head, abductor pollicis brevis, opponens pollicis, oblique head of the adductor pollicis, and transverse head of the adductor pollicis were identified and followed from their muscu-lotendinous junction distally to observe insertion sites. 2) results from interposition of proximal aspect of adductor aponeurosis between proximally retracted ulnar collateral ligament and the 1 st MCP / bone. Sonographically, the adductor aponeurosis appears as a thin and uniform echogenic band overlying the UCL, which may also appear slightly hypoechoic relative to the overlying echogenic connective tissue (Fig . Figure 2 - Stener Lesion - UCL proximal portion in blue, Add- Adductor Pollicis Aponeurosis, MC - Metacarpal, PP - Proximal Phalanx, DP - Distal Phalanx . UCL Function Extension (Normal = 6° Valgus coronal joint angulation) 30° Flexion (Normal = 12° Valgus coronal joint angulation) Stener Lesion (1962) Epidemiology •Annual . 1. The separation of the proximal and distal ligament segments by the adductor aponeurosis prevents healing. Exam: Inspection - May notice swelling at the ulnar side of the . Examination . •Adductor aponeurosis •Superficial to UCL •Palmar insertion into sesamoid Distal Adductor Aponeurosis Proximal aUCL pUCL. UCL normally lies deep to AA. fibers of the adductor pollicis aponeurosis (and some muscle fibers), inserting into the extensor pollicis longus (EPL) tendon, and all overlying the ulnar collateral ligament. Static and dynamic mechanisms identify the adductor aponeurosis 3 major types: transverse, oblique, and ulnar of... 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