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Dr. P here with Dr. Stern,

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3 00:00:01,950 --> 00:00:05,170 Orthopedic Surgeon and Wrist Surgeon,

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par excellence, and we're talking about a 44-year-old

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man who sustained an injury a year ago and

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complains of pain and quote-unquote arthritis.

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This was sent to us indirectly through a

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primary care doctor and a coronal T1, a

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coronal 3D gradient echo, and a short axis T1.

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One point to make is look at the

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angle that they acquired this at.

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Uh, probably not the optimal angle for,

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uh, for assessing the, uh, UCL and RCL.

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We kind of like to be straight across.

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It doesn't have to be orthogonal.

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So if the thumb is positioned this way, we look at

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the box or rectangle of the thumb, then we want our

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coronal to be exactly perpendicular to this axis.

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Nevertheless, the study is diagnostic and we're

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interested in the ulnar collateral ligament.

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And we're going to show you a series of

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these cases in the upcoming vignettes.

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So anatomically we can see the more

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superficial adductor aponeurosis.

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And then the UCL sits underneath

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this adductor aponeurosis.

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And some of it is actually kind of trapped

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inside the joint or folded inside the joint.

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You can see that on the 3D GRE.

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Uh, so this would be classified as a

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non-stenotic ulnar collateral ligament.

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So what, what determines whether

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the patient gets an operation?

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Because, you know, I've noticed over the years that

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you're pretty conservative about operating on these.

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Well, we're fairly conservative, uh, there are a lot

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of clinical decision-making if you don't have an MRI.

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An MRI will, uh, really help the clinician, uh, seal

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the deal in terms of therapeutic decision-making.

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Uh, so first we would examine the patient

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and usually there's asymmetric, uh, swelling,

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more on the ulnar side of the MP joint,

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none on the radial side of the MP joint.

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We would look at static alignment, oftentimes,

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uh, in a, uh, UCL injury which is complete,

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uh, there will be some radial deviation of

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the proximal phalanx and you can see that

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both clinically and on plain radiographs.

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Uh, and then of course we'll examine for

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tenderness if the patient has a so-called Stener

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lesion where the, uh, ulnar collateral ligament

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actually flips back 180 degrees on itself.

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Uh, and the, uh, more distal portion of

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the native ligament is now proximal and

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is trapped under the adductor aponeurosis.

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Uh, that's a Stener lesion

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and sometimes that is palpable.

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And that would be a definite surgery.

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The difficult ones are things like this and, uh,

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in general, uh, like this, because the ligament

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is certainly not in the greatest of shape.

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There's intermediate signal and edema there.

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Uh, if the patient was clinically tender, uh, even

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if there were signs, if there were not signs of gross

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instability, we may very well operate on the patient.

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This, and, and in this case, you would

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have to do a ligament substitution, harvest

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something like the palmaris longus tendon

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to substitute for the collateral ligament.

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If you look just at plain films, and I don't want to

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go on too long, if, uh, you do stress radiographs,

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which we'll often do, and, uh, the, uh, MP joint

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opens up more than about 15 to 20 degrees, in

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comparison to the contralateral side, that would be

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another, uh, indication for surgical intervention.

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So if you have a Stener lesion, does

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that automatically mean you operate?

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Uh, it would be pretty much an automatic

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operation unless there was some medical

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contraindication, which would be unlikely.

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These injuries in general are

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in younger, more active people.

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Now, one thing we try and do, and maybe, you know,

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we're chasing some false hope for you guys here,

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is we try and assess kind of the health of the

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ligament, because sometimes, you know, it'll pull

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off, and it'll look like a pretty reasonable ligament.

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Maybe it'll take a little piece of bone,

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maybe not, and it'll stay right here.

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We try and tell you whether the ligament

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looks shredded or whether the ligament kind

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of looks healthy, but it's just pulled off.

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Does that, does that in any way influence

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what you'll do as far as a graft?

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Yeah, so, yeah, if the ligament, if the

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native ligament is repairable like, like you

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drew, on the left side, there's

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no question I would make every effort to

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bring it back to the bone and hold it

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there with a suture anchor or something similar.

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Well, the health and wellness of the ligament

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does matter then, and then in the next,

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vignettes we're going to talk a little bit

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about the position of the proximal phalanx.

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Because a lot of these UCL injuries, you know,

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we see the proximal phalanx kind of sag forward.

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And that's been an enigma to many

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radiologists who don't do a lot of wrist

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and hand and finger imaging for a long time.

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So, let's move on, shall we?

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Dr. P and Dr. Stern, out.