Complete Tear of the Radial Collateral Ligament of the Third Metacarpophalangeal Joint

■ trauma update

ALAN E. FREELAND, MD; E. RHETT HOBGOOD, MD

plane perpendicular to the head and course distally and long anteroposterior diameter obliquely to insert on the radi- Early repair of complete collateral ligament tears restores of the metacarpal head. The al and ulnar tuberosities on the joint alignment, stability, and full passive range of motion. glenoid cavity of the proximal palmar proximal margins of phalanx covers most of the the base of the proximal pha- metacarpal head articular sur- lanx. The radial collateral liga- he metacarpophalangeal Some rotation and deviation face in the transverse plane, ment originates and attaches Tjoints of the fingers are also occur during flexion and but only approximately one- slightly closer to the joint mar- complex condylar hinge joints with pinching and grasping third of its facade in the sagit- gin and courses less vertically capable of multiplanar motions. tal plane at any point during than its ulnar counterpart. The motion.1-3 The joint surfaces flexion and extension. The accessory collateral ligaments and surrounding capsule and ANATOMY volar plate elongates the gle- originate just palmar to the ligaments provide static stabil- The convex metacarpal ity whereas the intrinsic and head is elliptically shaped and extrinsic muscles are dynamic has a correspondingly variable stabilizers. The normal joint radius of curvature in the mid- Radial and ulnar collateral ligament injuries flexes approximately 90° and sagittal plane, whereas the may extend as much as 20°- base of the proximal phalanx are evenly distributed in the middle finger, 30°. Abduction and adduction has a shallow circular plane the most frequently involved finger... of up to 10°-40°, depending on that conforms to the various the specific finger, is greatest in segments of the articular sur- full extension and increasingly face with which it articulates. constrained throughout flexion. The geometric multiaxial cen- noid cavity and constrains it collateral ligaments and insert ter of rotation of the metacar- throughout extension. on the lateral sides of the volar pophalangeal joints lies on a The collateral and accesso- plate. As a pair, the collateral From the Department of spiraling arc that becomes ry collateral ligaments provide and accessory ligaments are Orthopedic Surgery and Rehabilita- increasingly palmar as flexion lateral stability and guide the fan-shaped. tion, University of Mississippi Medical Center, Jackson, Miss. increases within the approxi- metacarpophalangeal joint The collateral and accesso- Reprint requests: Alan E. mate center of the metacarpal throughout its range of flexion ry collateral ligaments act in a Freeland, MD, Dept of Orthopedic head.1 The glenoid cavity of and extension.1-3 The collater- reciprocal fashion during flex- Surgery and Rehabilitation, the base of the proximal pha- al ligaments originate dorsally ion and extension.1,4 The col- University of Mississippi Medical Center, 2500 N State St, Jackson, lanx is oblong and its greatest from the radial and ulnar lateral ligaments lie just dorsal MS 39216. diameter is in the transverse tuberosities of the metacarpal to the flexion-extension axis

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of the joint and become pro- ing, ecchymosis, and tender- gressively longer and taut ness, but the ligaments remain throughout flexion and shorten aligned and stable. The joint and relax during extension. and finger alignment remains The accessory collateral liga- normal on clinical and radio- ments are positioned palmar to graphic examination and dur- the flexion-extension axis of ing lateral stress testing. An the joint and are tense and undisplaced or minimally dis- longer in extension and relax placed avulsed bone fragment and shorten during flexion. may be seen on radiographs in some cases and alerts the COLLATERAL LIGAMENT examining physician to the INJURIES lesion. Metacarpophalangeal Clinical stress testing to and finger motion may be determine stability of the col- compromised initially, but lateral ligaments of the undis- recovery usually is complete placed finger is performed within a few weeks following with the metacarpophalangeal protective splinting and pro- joint fully flexed, a position in gressive rehabilitation.5 which the normal collateral Complete collateral liga- ligament is fully stretched and ment tears have similar signs lateral deviation of the base of and symptoms, but are unsta- the proximal phalanx is pre- ble, and the finger may deviate vented.5 Lateral stress testing away from the side of the tear of the metacarpophalangeal securing the diagnosis. A dis- 1 joint in full extension tests the placed avulsed bone fragment Figure 1: AP radiograph demonstrates ulnar subluxation and translation of the integrity of the accessory col- may act as a sentinel to the base of the proximal phalanx on the third metacarpal head with the metacarpophalangeal joint fully extended indicating a complete tear of the 5 lateral ligaments. Local anes- lesion. Brewerton radio- radial collateral ligament with probable involvement of the radial accessory thesia may be necessary to graphic views of the meta- collateral ligament. perform this maneuver. Stress carpal head may be helpful in radiographs may be performed identifying displaced avulsion collateral ligament injuries are mon. The accessory collateral in various positions of flexion fractures.6 Clinical stress test- seen collectively only two- ligament may be involved in thirds as frequently, occurring more severe cases. Dorsal in approximately 1 in 1000 interosseous tendon avulsions Failure to initially repair a completely torn hand injuries.5 Radial and may occur.7 An accompanying metacarpophalangeal joint ligament may ulnar collateral ligament overlying transverse or oblique injuries are evenly distributed tear of the sagittal bands of the result in chronic pain, instability, deformity, in the middle finger, the most extensor hood usually is pre- weakness, and arthritis. frequently involved finger, sent. One side of the sagittal whereas ulnar collateral tears band tear may become inter- are more common in the index posed between the two ends of and extension and may reveal ing, stress radiographs, arthro- finger and radial disruptions the torn collateral ligaments, instability directly or by com- graphy, and magnetic reso- are more frequent in the ring similar to the Stener lesion seen parison with similar views of nance imaging have been suc- and small fingers. in some complete tears of the the same finger of the unin- cessful in diagnosing occult The collateral ligament ulnar collateral ligament of the volved opposite hand. undisplaced lesions.5,7,8 may tear from its origin, inser- metacarpophalangeal thumb Injuries that stretch or par- Although thumb metacar- tion, or within its substance.5 joint.5,7,9,10 tially tear one of the collateral pophalangeal joint collateral Tears at the insertion occur ligaments may be accompa- injuries are common, finger most commonly and tears CASE REPORT nied by localized pain, swell- metacarpophalangeal joint from the origin are least com- A 38-year-old woman sustained

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2 3 Figure 2: This illustration defines the tears of the radial sagittal bands and the conjoined origin of the radial collateral and accessory collateral ligaments seen at surgery. Abbreviation: RCL=radial collateral ligament. Figure 3: The joint alignment has been restored by repair of the conjoined origin of the collateral and accessory collateral ligaments to a bone anchor suture imbedded in the radial side of the metacarpal head.

skeletal polytrauma in a motor Palmar to the sagittal band, com- restored. The adjacent capsule and to deviation of the finger to the vehicle accident. The left middle plete avulsion of the radial collat- overlying sagittal band tears were side opposite the tear on clini- finger was jammed on impact, and eral and accessory collateral liga- repaired in layers with fine cal examination and radio- pain and swelling of the left hand ment conjoined origins from the resorbable sutures. graphs. Radiographic evalua- and ulnar deviation of the left mid- metacarpal head was noted as well The metacarpophalangeal tion may also disclose joint dle finger at the metacarpopha- as some adjacent capsular tearing joint was splinted in 30° of flexion subluxation. Early diagnosis langeal joint were noted on presen- (Figure 2). No Stener-type lesion for 3 weeks and interphalangeal and repair of complete finger tation. Radiographs demonstrated was noted. The second dorsal joint motion was encouraged. The metacarpophalangeal collater- ulnar subluxation and translation of interosseous tendon was intact. index and middle fingers were al ligament tear usually lead to the proximal phalanx on the meta- A mini bone anchor was buddy-taped to protect the repair good to excellent recovery carpal head (Figure 1). Although inserted in the radial surface of the while allowing further recovery of within 12 weeks, provided no manipulation restored the joint metacarpal head at the perceived digital motion. Strengthening problems or complications alignment, the reduction was not center of the radial collateral liga- using a soft, spongy ball was initi- occur.5,11,12 stable. ment origin. The metacarpopha- ated 2 months postinjury. The Complete collateral liga- Surgery was performed within langeal joint was reduced, and the patient recovered uneventfully. ment tears are more likely to a few days of the injury. The torn radial collateral ligament ori- heal uneventfully if repaired lesion was approached through a gin was secured to the bone DISCUSSION initially.5,11,12 One side of the dorsoradial incision over the anchor suture (Figure 3). Joint Complete metacarpopha- torn sagittal band may inter- metacarpophalangeal joint. The alignment, stability, and full pas- langeal collateral ligament pose under the torn ligament, radial sagittal bands were torn. sive range of motion were tears may be apparent owing creating a situation analogous

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to the Stener lesion sometimes may result in chronic pain, Chao EY. Three-dimensional geal joints of the fingers. J Bone geometric analysis of the meta- Joint Surg Br. 1989; 71:388-389. observed in ulnar collateral instability, deformity, weak- carpophalangeal joint. J Hand 12. Kato H, Minami A, Takahara M, ligament tears of the ness, and arthritis. Late liga- Surg Am. 1988; 13:521-529. Oshio I, Hirachi K, Kotaki H. metacarpophalangeal thumb ment repair or reconstruction, 4. Minami A, An KN, Cooney WP Surgical repair of acute collater- joint.5,7,11,12 It is important to although not as reliable as III, Linscheid RL, Chao EY. al ligament injuries in digits with Ligamentous structures of the the Mitek bone suture anchor. J restore the collateral ligament early repair, usually provides metacarpophalangeal joint: a Hand Surg Br. 1999; 24:70-75. in these instances. Bone substantial improvement, if quantitative anatomic study. J 13. Beauperthuy GD, Burke EF. Orthop Res. 1984; 1:361-368. anchor sutures have been not full recovery, provided no Alternative method of repairing 7,15-17 5. Delaere OP, Suttor PM, Degolla collateral ligament injuries at the effective in achieving ligament arthritis exists. R, Leach R, Pieret PJ. Early sur- metacarpophalangeal joints of repair at the origin or insertion Repair of the torn sagittal gical treatment for collateral lig- the thumb and fingers. Use of the of the ligament. Substance bands, accomplished by direct ament rupture of the metacar- Mitek anchor. J Hand Surg Br. 18 pophalangeal joints of the fin- 1997; 22:736-738. tears are repaired by direct suture, is also important. gers. J Hand Surg Am. 2003; 12,13 14. Doyle JR, Atkinson RE. Rupture suture. The re-establish- Failure to repair a sagittal 28:309-315. of the radial collateral ligament ment of radial collateral liga- band tear may result in loss of 6. Gross DL, Moneim M. Radial of the metacarpo-phalangeal ment stability is particularly centralization of the extrinsic collateral ligament avulsion frac- joint of the index finger: a report ture of the metacarpophalangeal of three cases. J Hand Surg Br. important for the metacar- extensor tendons of the meta- joint in the small finger. 1989; 14:248-250. pophalangeal joint of the carpophalangeal joint, result- Orthopedics. 1989; 21:814-815. 15. Hsieh YF, Draganich LF, index finger, owing to the con- ing in chronic pain, swelling, 7. Ishizuki M. Injury to collateral Piotrowski GA, Mass DP. ligament of the metacarpopha- Effects of reconstructed radial siderable forces placed on this extensor lag, finger deviation, langeal joint of a finger. J Hand collateral ligament on index fin- joint during pinch, grasp, and snapping at the metacarpopha- Surg Am. 1988; 13:444-448. ger mechanics. Clin Orthop. with the use of tools.14,15 langeal joint, and ultimately, 8. Clavero JA, Alomar X, Monill 2000; 379:270-282. Intra-articular bone frag- arthritis. Reconstruction may JM, et al. MR imaging of liga- 16. Riederer S, Nagy L, Buchler U. ment and tendon injuries of the Chronic post-traumatic radial ments are removed. Small also be necessary for the resid- fingers. Radiographics. 2002; instability of the metacarpopha- avulsed bone fragments may be uals of this lesion alone, if left 22:237-256. langeal joint of the finger. Long- resected from the ligament. The unattended. 9. Stener B. Displacement of the term results of ligament reconstruction. J Hand Surg Br. 1998; ligament is then anchored as ruptured ulnar collateral ligament of the metacarpopha- 23:503-506. outlined above. Larger avulsion REFERENCES langeal joint of the thumb. A 17. Oka Y, Harayama H, Ikeda M. fragments are repaired with 1. Dubousset JF. The digital joints. clinical and anatomical study. J Reconstructive procedure to wires or mini screws to restore In: Tubiana R, ed. The Hand. Bone Joint Surg Br. 1962; repair chronic injuries to the col- Philadelphia, Pa: WB Saunders; 44:869-879. lateral ligament of the meta- the ligament. Associated inter- 1981:191-201. 10. Wolf BA, Cervino AL. Rupture carpophalangeal joints of the hand. Hand Surg. 2003; 8:81-85. osseous tendon avulsions 2. Schultz RJ, Storace A, of the radial collateral ligament should also be repaired by Krishnamurthy S. Metacarpo- of the fifth metacarpophalangeal 18. Doyle JR. Extensor tendons- joint. Ann Plast Surg. 1988; acute injuries. In: Green DP, direct or bone anchor suture. phalangeal joint motion and the role of the collateral ligaments. 21:382-387. Hotchkiss RN, Pederson WC, Failure to initially repair a Int Orthop. 1987; 11:149-155. 11. Schubiner JM, Mass DP. Opera- eds. Green’s Operative Hand Surgery. 4th ed. New York, NY: completely torn metacar- 3. Tamai K, Ryu J, An K, tion for collateral ligament rup- tures of the metacarpophalan- Churchill Livingstone; pophalangeal joint ligament Linscheid RL, Cooney WP, 1999:1978-1981.

Section Editor: Alan E. Freeland, MD

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