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Radial Collateral Ligament of the Thumb Injury
From WikiSM
Other Names
- RCL Thumb Injury
- Thumb RCL
Background
- This page refers to injuries to the RCL of the thumb
History
- Overall less common than UCL injuries
- Important to consider in unstable MCP injuries
Epidemiology
- Most often found in active populations
- Implicated in 25% of NFL thumb injuries
- Implicated in 32% of unstable MCP injuries
Introduction
Pathophysiology
- Mechanism: usually forced adduction of the thumb
- Injury patterns:
- Proper Collateral Ligament most common cause of clinically significant injury
- Proximal avulsion 55%, distal avulsion 29%, midsubstance tear 16% [7]
Anatomy of the Radial Collateral Ligament of the thumb
- RCL divided into:
- Proper Collateral Ligament: provides stability in flexion
- Accessory Collateral Ligament: provides stability in extension
- Spans from dorsal lateral metacarpal to lateral proximal phalanx
Risk Factors
- Active populations (athletes, military)
Differential Diagnosis
Differential Diagnosis Finger And Hand Pain
- Fractures
- Dislocations
- Tendinopathies
- Ligament Injuries
- Neuropathies
- Arthropathies
- Nail Bed Injuries
- Pediatric Considerations
- Other
Clinical Features
History
- Typically forced MCP adduction
- Sometimes axial load injury
- Pain and difficulty with pinch
Physical Exam: Physical Examination Hand
- Ecchymosis and tenderness of the radial MCP
- Radial MCP laxity (must test at 0 and 30 degrees flexion), evaluate for endpoint
Special Tests
- Key pinch grip (thumb to radial index finger)
Evaluation
Radiograph
- Evaluate for avulsion fractures and volar or ulnar subluxation
- Stress views showing >30 degrees angulation suggest complete rupture
Ultrasound
- Not shown to be beneficial over physical exam
MRI
- Can be used in the setting of inconclusive exam
Classification
- The classification of MCP collateral ligament injuries is critical to the guidance of proper management. RCL and UCL injuries utilize the same three stage classification system as follows {1-4}:
- Grade 1: Incomplete tear of the RCL with only few torn fibers – tenderness to palpation and without laxity present on stressing examination
- Grade 2: Incomplete tear of the RCL with a greater number of torn fibers present – increased tenderness to palpation at the radial aspect of the MCP, more prominent swelling and the presence of laxity on stressing but with a definitive end point.
- Grade 3: Complete tear of the RCL – tenderness to palpation, swelling and prominent instability/laxity with no end point on stressing examination
- Grade 1: Incomplete tear of the RCL with only few torn fibers – tenderness to palpation and without laxity present on stressing examination
Management
Nonoperative
- Grade 1 and 2: thumb spica splint or thumb spica cast for 4-6 weeks
- Grade 3: can consider thumb spica in nonathletes
- With <30 degrees angulation and <3mm subluxation on XR
Operative
- Indications
- Grade 3 injury in athletes
- >30 degrees angulation on stress XR
- >3mm subluxation on XR
- Thumb spica cast for 6 weeks post-op
- Then thumb spica brace for 2 weeks
Rehab and Return to Play
Rehabilitation
- Use thumb spica brace if still symptomatic after 4-6 weeks casting
- ROM and strengthening exercises when pain resolves for nonoperative management
- Early ROM after 6 weeks casting for operative management, then begin strengthening exercises at 3 months
Return to Play
- Nonoperative: when pain has resolved with strength and ROM exercises
- Operative: after completion of strengthening and ROM program, at least 3 months post-op
Prognosis and Complications
Prognosis
- Grade 1 and 2 typically heal within 4-6 weeks
- Grade 3 may develop chronic instability if not surgically repaired
Complications
- Grade 3 injuries may develop chronic instability or subluxation
- May develop MCP osteoarthritis
See Also
Internal
External
- Sports Med Review Hand Pain: https://www.sportsmedreview.com/by-joint/hand/
References
- LM;, Rozmaryn. “The Collateral Ligament of the Digits of the Hand: Anatomy, Physiology, Biomechanics, Injury, and Treatment.” The Journal of Hand Surgery, U.S. National Library of Medicine, 2017, pubmed.ncbi.nlm.nih.gov/29101974/.
- Netscher, David T, et al. “Finger Injuries in Ball Sports.” Hand Clinics, U.S. National Library of Medicine, Feb. 2017, www.ncbi.nlm.nih.gov/pubmed/27886829.
- RG;, Daley D;Geary M;Gaston. “Thumb Metacarpophalangeal Ulnar and Radial Collateral Ligament Injuries.” Clinics in Sports Medicine, U.S. National Library of Medicine, 2020, pubmed.ncbi.nlm.nih.gov/32115093/.
- SK;, Edelstein DM;Kardashian G;Lee. “Radial Collateral Ligament Injuries of the Thumb.” The Journal of Hand Surgery, U.S. National Library of Medicine, 2008, pubmed.ncbi.nlm.nih.gov/18590860/.
- Mitchell TW, Mitchell SA, Wu C. Radial Collateral Ligament Injuries of the Thumb Metacarpophalangeal Joint. Curr Rev Musculoskelet Med. 2022 Dec;15(6):581-589. doi: 10.1007/s12178-022-09805-z. Epub 2022 Oct 28. PMID: 36303098; PMCID: PMC9789250.
- Gluck JS, Balutis EC, Glickel SZ. "Thumb Ligament Injuries." The Journal of Hand Surgery, Volume 40, Issue 4, 2015, Pages 835-842, ISSN 0363-5023, https://doi.org/10.1016/j.jhsa.2014.11.009.
- Coyle MP., Jr Grade III radial collateral ligament injuries of the thumb metacarpophalangeal joint: treatment by soft tissue advancement and bony reattachment. J Hand Surg Am. 2003;28(1):14–20. doi: 10.1053/jhsu.2003.50008.