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Collateral Ligament Stability and Tenderness

Exams and Signs

The metacarpophalangeal (MP) joints allow flexion, extension, abduction and adduction of the proximal phalanx on the metacarpal head. The collateral ligaments of the MP joints provide stability, and the volar plate prevents hyperextension. The proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints are hinge joint, and the collateral ligaments and the volar plate allow flexion and extension.

Pathophysiology

  • Collateral ligament tenderness may arise from a thumb sprain, which is commonly known as skier’s thumb or gamekeeper’s thumb.1
  • Ligamentous injuries of the PIP joint are typically categorized into one of the following three groups:
    • Grade 1: involves asymmetric swelling and tenderness over the collateral ligament without instability on the lateral stress test
    • Grade 2: involves partial disruption of the collateral ligament, but the volar plate remains intact.  There is some instability, but stress testing reveals a definite soft tissue endpoint indicating that the collateral is not completely torn.
    • Grade 3: involves total collateral ligament disruption and volar plate rupture, with clinical examination depicting evidence of potential subluxation or dislocation on active extension.4,5  Stress testing reveals no soft tissue endpoint indicating that the collateral is completely torn.

Instructions

  1. Stabilize the patient’s metacarpal with the index finger and thumb
  2. Apply valgus/varus stress to the proximal phalanx, first in 30° flexion at the MP joint and then in complete extension
  3. Compare the end point and the degree of joint opening with the contralateral hand

Variations

  • To test the integrity of collateral ligaments of the MP joint, place the MP joint in flexion to keep the collateral ligaments taut. Testing the collateral ligaments in extension will not provide a proper assessment.
  • To diagnose the tissue between torn ligament and bone, imaging may be necessary.1

Related Signs and Tests

  • Collateral ligament stress testing
  • Volar plate stress test
  • Ultrasound
  • MRI
Presentation Photos and Related Diagrams
  • PIP Joint Stress Test of normal ring finger ulnar collateral ligament(UCL)
    PIP Joint Stress Test of normal ring finger ulnar collateral ligament(UCL)
  • PIP Joint Stress Test of injured ring finger radial collateral ligament(RCL). Note PIP swelling.
    PIP Joint Stress Test of injured ring finger radial collateral ligament(RCL). Note PIP swelling.
  • Palpation of PIP joint radial collateral ligament (RCL) for tenderness
    Palpation of PIP joint radial collateral ligament (RCL) for tenderness
  • PIP joint volar plate stress test
    PIP joint volar plate stress test
  • Stress testing index MP joint radial collateral ligament . MP in flexion to keep collateral tight while ulnar deviation force applied.
    Stress testing index MP joint radial collateral ligament . MP in flexion to keep collateral tight while ulnar deviation force applied.
  • Stress testing index MP joint ulnar collateral ligament . MP in flexion to keep collateral tight while radial deviation force applied.
    Stress testing index MP joint ulnar collateral ligament . MP in flexion to keep collateral tight while radial deviation force applied.
Definition of Positive Result
  • A positive result occurs when the patient experiences tenderness when the examiner palpates the MP, PIP and/or DIP joints. One may also observe an increased degree of opening with either radial or ulnar deviation at the MP, PIP and DIP joints compared to the contralateral side. 
Definition of Negative Result
  • A negative result occurs when the patient does not experience tenderness when the examiner palpates the MP, PIP and/or DIP joints. There will be no difference in the degree of opening with either radial or ulnar deviation at the MCP, PIP and DIP joints compared with the contralateral side. 
Comments and Pearls
  • To test the integrity of collateral ligaments of the  finger MP joint, place the finger MP in flexion to keep the collateral ligaments taut. If you test index, long, rong or little finger collateral ligaments of the MP joint in extension, you will find that the joint is quite lax and will not to assess whether the ligament is ruputure of not.
  • To test the integrity of proper collateral ligaments of the thumb MP joint, place the thumb MP in flexion to keep the proper collateral ligaments taut thus allowing their assessment. In this position intact proper collaterals will not allow ulnar or rradial devaition andd ruptured proper collaterals will allow these motions.
  • To test the integrity of accessory collateral ligaments of the thumb MP joint, place the thumb MP in extnsion to keep the accessory collateral ligaments taut thus allowing their assessment. In extension intact accessory collaterals will not allow ulnar or rradial devaition andd ruptured proper collaterals will allow these motions.
  • It is always important to check the contralateral hand, because patients may have varying degrees of natural hyperextension. 
Diagnoses Associated with Exams and Signs
Videos
Collateral ligament stress testing. Accessory collateral tested in extension and proper collateral tested in mild PIP joint flexion.
Volar Plate Stress Test
Stress testing long finger MP joint collateral ligaments
References
  1. Culp R, Jacoby S. Musculoskeletal Examination of the Elbow, Wrist and Hand: Making the Complex Simple. New Jersey: SLACK Incorporated, 2012
  2. Boyer M. AAOS Comprehensive Orthopaedic Review 2. Illinois: American Academy of Orthopaedics, 2014
  3. Trumble T, Budoff J. Hand, Elbow and Shoulder Core Knowledge in Orthopaedics. Pennsylvania: Mosby, 2006
  4. Kamnerdnakta, S, Huetteman, HE and Chung, KC. Complications of Proximal Interphalangeal Joint Injuries: Prevention and Treatment. Hand Clin 2018;34(2):267-288. PMID: 29625645
  5. Rozmaryn, LM. The Collateral Ligament of the Digits of the Hand: Anatomy, Physiology, Biomechanics, Injury, and Treatment. J Hand Surg Am 2017;42(11):904-915. PMID: 29101974
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