What is your diagnosis?

Grade III radial collateral ligament sprain 

• Pearl: When examining patients with pain in their hands, it is also important to assess the patient’s dominant side and how the injury affects the patient’s job, hobbies, and activities. 

• Pearl: Collateral ligament sprains of the fingers usually result from direct trauma to the finger, often in sports such as baseball.

What do you expect on the physical exam?

If the patient is presenting acutely (<4 weeks after injury), they may present with swelling and tenderness of the affected finger at the site of injury. Should the sprain be chronic, the patient may present no pain or swelling but with laxity still present upon stressing the joint.

• Pearl: In finger collateral ligament sprains, there may or may not be increased laxity when applying stress to the affected joint. Sprains are graded based on the amount of laxity present and whether or not there is an endpoint present. Grade I: pain without laxity, Grade II: laxity with an endpoint when stress is applied, Grade III: no end point to laxity present when stress is applied.

What imaging modality could be used to aid in diagnosis in the ED?

Ultrasound, especially with stress views, and plain films. Plain radiographs are needed in order to rule out fracture or avulsion injury, especially when the patient is presenting acutely.

Image 2 (same as above). Plain films showing no fracture or dislocation. Author’s own images.

Image 3A. Ultrasound imaging of the affected finger at the PIP joint showing increased laxity when valgus stress is applied. Author’s own media.

Image 3B. Ultrasound images of the unaffected contralateral side showing no laxity. Author’s own media.

• Pearl: With bedside ultrasound modalities, it is possible to evaluate the valgus laxity of the affected joint in a dynamic manner and to compare it with the unaffected finger. 

What do you do in the ED?

Stabilize the finger with buddy taping or a metal brace for static splinting in order to prevent future disability. 

• Pearl: Special consideration should be given to the patient’s dominant side, their job, and regular activities in order to provide proper treatment and follow up considering the possible rate of disability if the injury is not treated properly.

When do you call Orthopaedics?

Emergent operative treatment is generally not needed for collateral ligament sprains of the hand. However, patients should be referred to an orthopaedic surgeon if there is the suspicion of a complete tear as they may require operative management.

• Pearl: Patients should be provided with proper outpatient follow up in order to reassess the patient’s functionality over time and possible operative management if conservative management is unsuccessful. This patient was evaluated by hand surgery who recommended taping and OT. He recovered completely.