Interphalangeal Collateral Ligament Sprain

By admin On Sep 22, 2023

Ovid: 5-Minute Sports Medicine Consult, The

Matt Roth

Basics

Description

Injury to a collateral ligament at the interphalangeal joint of the finger, usually the proximal interphalangeal joint (PIP):
- 1st degree: Pain, but no laxity with stress
- 2nd degree: Pain and laxity but firm endpoint with stress
- 3rd degree: Pain and loss of firm endpoint with stress
Mechanisms: Abduction or adduction force applied to the finger, usually while extended
Synonym(s): Mild injuries: Jammed finger

Epidemiology

Incidence

1st- and 2nd-degree sprain much more common than 3rd-degree sprain
Index finger most often affected
Radial collateral ligament (RCL) more often affected than ulnar collateral ligament (UCL)

Risk Factors

Ball-handling and contact sports: Football, basketball, volleyball, wrestling
Prior injury or dislocation of the PIP joint

Diagnosis

History

Finger struck by player or ball during play
Axial trauma causing forced ulnar or radial deviation of joint
Usually presents acutely in 1st few weeks but may become chronic

Physical Exam

Pain and swelling over lateral aspects of PIP joint
Decreased range of motion (ROM) secondary to pain and swelling
Instability in more severe injuries
Confirm neurovascular integrity, especially with on-field assessment.
Ensure that maximum tenderness is over lateral aspects and not dorsal (suggestive of central slip injury, which can have significant consequences if missed).
Stability is best evaluated for with the metacarpophalangeal (MCP) joint kept in 90 degrees of flexion and the PIP joint stressed in both extension and 20–30 degrees of flexion (1)[C].
Compare with uninjured fingers.
Use gentle force to avoid overstressing joint and extending partial tear into a complete tear.
Instability with lateral stress (opening beyond 20 degrees or lack of firm endpoint) suggests loss of integrity.
Assess function of flexor and extensor tendons by isolating MCP, PIP, and distal interphalangeal (DIP) joints separately to rule out tendon injury.
Loss of active ROM may be due to either pain or volar plate/central slip injury, so digital block may be necessary to test ROM (2)[C].

Diagnostic Tests & Interpretation

Imaging

Plain radiographs are generally not required for 1st-degree injuries but may be considered for 2nd- or 3rd-degree injuries or to rule out additional bone injury.
Minimum requirement of posteroanterior, true lateral, and oblique radiographs of involved fingers (2)[C]
May be associated with avulsion fracture at ligamentous insertion
Look for dorsal subluxation to suggest instability
US is an emerging diagnostic tool in the evaluation of finger ligament integrity (1)[C].

Differential Diagnosis

Phalangeal fracture
IP dislocation
Central slip injury
Volar plate injury
Often associated with one or more of above

P.335

Treatment

Immobilization:
- Treatment is guided by which finger is involved, level of activity, and degree of pain and disability.
- In general, finger should be “buddy taped” to finger adjacent to injured ligament, except that the ring finger should be secured to 5th digit (small finger)—regardless of ligament affected— to avoid unprotected 5th digit (3)[C].
- Mild injures may be “buddy taped,” and patient may consider return to play depending of function and sport requirements (1)[C].
- 1st degree: “Buddy tape” continuously for 10–14 days; then during physical activity for an additional 2–4 wks (3)[C].
- 2nd degree: Splint in 30 degrees of flexion acutely; decrease flexion by 10 degrees per week; once full extension, “buddy tape” during physical activity for an additional 4–6 wks (3)[C].
- 3rd degree: Some treat as severe 2nd degree, but surgery may be warranted if “unstressed instability,” tissue interposition limiting joint motion, or lack of joint congruity is observed on radiographs (3)[C].
Rehabilitation: Depending on severity, begin passive ROM exercises in 1st week and active ROM after 1–2 wks, later for more severe injuries (3)[C].

Additional Treatment

Additional Therapies

Displaced intraarticular and large avulsion fractures with displacement may require open reduction and internal fixation (ORIF) (2)[C].
Hyperextension and/or dorsal dislocation injuries and central tenderness over the volar aspect should raise concern for volar plate injuries.
Central tenderness over the dorsal PIP joint suggests central slip injury, which can lead to a chronic boutonniere deformity.

Pediatric Considerations

Collateral ligament injury in children should raise concern for growth plate involvement, and there should be a low threshold for referral to a hand specialist (1)[C].

Surgery/Other Procedures

Generally necessary if instability with active ROM, tissue interposition limiting joint motion, or lack of joint congruity is observed on radiographs (2)[C].
Routine surgical repair for all complete tears is controversial (2)[C].
- Pro: Helps to ensure stability of pinch (especially in radial collateral ligament of index finger), shorter duration of disability
- Con: Most complete tears heal well with conservative treatment; operative trauma may limit joint motion.
ORIF usually necessitates 4 wks of activity limitation following surgery (2)[C].

Ongoing Care

Follow-Up Recommendations

Follow up in 1–2 wks for reevaluation of laxity.
Refer significant fractures for possible ORIF (2)[C].
If uncertain of possible central slip/volar plate injury, refer to surgeon or follow up in 7–10 days for reevaluation (2)[C].
Chronic disability may be seen in athletes with delayed presentation or multiple dislocations (2)[C].
Chronic symptoms may respond to extended splinting and “buddy taping” with protected ROM exercises for several weeks to months (2)[C].
Surgical repair may be indicated if disability and instability persist after a sufficient trial of conservative treatment (2)[C].

Patient Education

Advise patients that some persistent deformity may be noted after injury has healed.

References

1. Leggit JC, Meko CJ. Acute finger injuries: part I. Tendons and ligaments. Am Fam Physician. 2006;73:810–816.

2. Freiberg A, Pollard BA, Macdonald MR, et al. Management of proximal interphalangeal joint injuries. Hand Clin. 2006;22:235–242.

3. Morgan WJ, Slowman LS. Acute hand and wrist injuries in athletes: evaluation and management. J Am Acad Orthop Surg. 2001;9:389–400.

Additional Reading

Alexy C, De Carlo M. Rehabilitation and use of protective devices in hand and wrist injuries. Clin Sports Med. 1998;17:635–655.

Palmer RE. Joint injuries of the hand in athletes. Clin Sports Med. 1998;17:513–531.

Codes

ICD9

842.13 Sprain of interphalangeal (joint) of hand

Clinical Pearls

Ensure active ROM in all affected and surrounding joints to rule out more significant ligamentous injuries.
Return to play depends on finger affected and demands of sport, but frequently, immediate return to play can be accomplished with “buddy taping” and/or splinting with some risk for further injury.
Some residual soreness can be expected for months and sometimes up to a year.
The joint affected may appear permanently enlarged owing to scarring during the healing process.