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Letter

Collingwood, Ontario, Canada

Dear Editor:

The article entitled "Acute Skier’s Thumb Repaired with a Proximal Phalanx Suture Anchor" (by Zeman et al., September/October 1998, pages 644 to 650) demonstrates the ability to achieve good results in an ideal situation using a suture anchor for repair of the ulnar collateral ligament tears in acute skier’s thumb injuries. This is a very common injury in ski areas; the important question in the management of this common injury then is, what are the results of good nonoperative management?

In my experience, it is impossible to diagnose a Stener lesion on clinical grounds, and the various imaging techniques that have been described are simply not practical in a busy ski-area practice. Before the development of the suture anchor, it was my practice to perform direct surgical repairs on all unstable ulnar collateral ligament injuries. I did find, however, that a significant portion of these repairs left the patient with a rather stiff, painful, metacarpophalangeal joint. It has therefore been my practice over at least the last 10 years to manage all of these injuries nonoperatively with a carefully applied thumb spica cast followed by a period of protective splinting. I have found that this form of treatment will generally provide a pain-free, mobile, stable metacarpophalangeal joint in the majority of cases.

It is true that some of these thumbs managed conservatively will remain unstable and clinically problematic. In those cases, a secondary repair, using a tendon graft, can provide a satisfactory solution and indeed, since the advent of the suture anchors, I have been able to find enough tissue in some of these unstable thumbs to effect a direct repair without the requirement of using a graft.

There is no doubt that the tissue anchor has expanded our ability to perform soft tissue repairs on ligaments and tendons, and this has been well documented in the article by Zeman et al.

Author’s Response

Aspen, Colorado

We have the advantage of being able to examine and diagnose the large majority of our acute ulnar collateral ligament injuries within 1 to 2 hours after injury. Thus, we are dealing with patients with minimal-to-mild swelling and relatively little muscle spasm or pain. In that environment, we have been able to palpate the Stener lesion in most cases as a palpable mass proximal to the metacarpophalangeal joint. When the mass is palpable and is associated with gross instability, we are very confident that acute open reduction and repair is the preferred method.

In a previous review, we found that in our population the incidence of Stener lesion was 86% of all acute ulnar collateral ligament injuries. This probably reflects the fact that this is a relatively high-speed mechanism of rupture for the ulnar collateral ligament, as opposed to the traditional injury patterns. Because of that high incidence, we prefer to approach these as an acute issue rather than casting first to see if they will heal.

I have not been as successful as Dr. McCall in doing chronic reconstructions and find that, in that setting, I am not as capable of restoring good stability. In addition, the chronic reconstructions invariably have more scar tissue and a thickened joint that restricts motion.

This Article Full Text (PDF) Free Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Request Reprints Citing Articles Citing Articles via Google Scholar Google Scholar Articles by McCall, J. Articles by Hunter, R. E. Search for Related Content PubMed PubMed Citation Articles by McCall, J. Articles by Hunter, R. E.